Amendment No. 1 in the name of Deputy McManus is out of order and cannot be moved.
Health (Amendment) Bill 2005: Committee and Remaining Stages.
I was not informed that amendment No. 1 is out of order.
It has been ruled out of order because it involves a potential charge on the Revenue.
I am sorry but I must protest because it does not. I am entitled to comment on this.
I will look into the matter and communicate with the Deputy.
I am sorry but this is the only chance I have. Legislation is being rushed through.
The amendment is out of order.
I must dispute that because I do not believe it.
The Chair has ruled on the matter and the Deputy must accept that ruling.
My legal advice states that this does not involve a charge on the State.
The Chair has ruled on the matter and if the Deputy has a problem with it she should come to the office of the Ceann Comhairle to discuss it.
It was carefully crafted to ensure that I could table it in this House on Committee Stage and I am very disappointed that I will not be able to do this.
I call Deputy Twomey to move amendment No. 2.
I must protest. We do not have an explanatory memorandum, we do not have time to deal with this and now amendments are being ruled out of order without prior warning. It is not even noted in the grouping list of amendments.
It is out of order because it involves a potential charge on the Revenue. There is nothing to stop the Deputy speaking on the amendment when we come to deal with the section.
Amendment No. 1 not moved.
NEW SECTION.
I move amendment No. 2:
In page 3, before section 1, to insert the following new section:
"1.—The Health Act 1970 is amended by inserting the following new section after section 44, but in Part IV:
‘44A.—Within three months of the passing of this Act, the Minister shall lay before each House of the Oireachtas, a statement of strategy detailing its plans for the funding of the care of the elderly in both public and private nursing homes.'."
We have been waiting since 2002 for the Government to publish a report on funding for the care of the elderly. Publication has been repeatedly postponed even though many submissions were made to the Department and correspondence was received from organisations involved with the elderly. People want to see Government action in the form of legislation or a report on how we will fund this care. The Tánaiste commented on this in the past and the issue has been raised in parliamentary questions and on Second Stage of this Bill, but we are getting no information whatsoever and it is important, considering the number of people aged over 65 will increase dramatically over the next few decades.
We have been waiting for some time for a Government report — it was even mentioned in the health strategy that was published in December 2001. Does the Tánaiste have plans to let us know Government policy on funding care for the elderly? It is a major issue. Given that all these charges have been made legal, we should look to the future.
During the course of much of the debate we have looked at the Government's lack of concern for the issue of nursing home charges. It is vital that we address this issue, given that it has been outstanding for many years. The Tánaiste should look around the Department and ascertain what the submissions contain and if a report is ready for publication. Will she tell the House the reason for the delay? Does she agree this matter should be enshrined in legislation to enable us have something to explain to the numerous organisations who come to meet us on a regular basis asking what is the Government's policy on care of the elderly?
I support this amendment which addresses an important and central issue. We need clear Government policy on long term care of the elderly. Given that the population is greying it is becoming a growing issue and it is important there is a clear strategy, long term and short term, to deal with the major issues that have not been dealt with in the area of funding. Even allowing for the fact that people will be charged and have their pensions taken from them for the cost of public care, and allowing for a certain amount of pocket money, this only constitutes approximately one tenth of the actual cost of public nursing home care.
When it comes to private nursing home care a real problem is emerging that even with the enhanced subvention there are those on medical cards who cannot afford to pay the difference between what the enhanced subvention allows for, the pension add-on and the private nursing home charge. This is a real issue given that contract beds are being phased out. Therefore, there is no protection or security for these people, some of whom are extremely frail and vulnerable. The idea of forcing a person to move out of a nursing home because the costs are beyond their reach is unsavoury.
If this is to mean anything, it is bound to impose a potential charge on the State, unless we accept the idea that appears to have grown up because of practice, that one can have a strategy, as in the case of the health strategy, with no money provided. The health strategy was launched by the former Minister for Health and Children, even though the Minister for Finance had told him there was no money to support it. He went ahead with it and we all know what happened — it disappeared in a puff of smoke like a conjurors' trick. It appears that kind of mindset has percolated into this issue, where a strategy dealing with a huge area of costs, the funding of nursing home care for the elderly, is somehow deemed not to have a potential charge on the State.
I tabled an amendment which contains a modest suggestion that "the Minister and the Health Services Executive shall have regard to the targets announced by the Government" where money has already been allocated and there is a commitment by the Minister that 30,000 extra medical cards and 200,000 doctor only cards will be provided. Why should there be a charge on the State if that commitment has already been made? This is undermining any promise made by the Minister. If I accept what the Ceann Comhairle has said that my amendment is out of order, the implication is that the promise made by the Minister is worthless and that we will not get the 30,000 additional medical cards and the 200,000 general practitioner cards for financial reasons. That is a serious situation in which to find ourselves because I would have thought one could take the Minister at her word, include an amendment in the legislation providing for these targets and be mindful of them. It was not the Opposition who set these targets, rather it was the Minister. She made the commitment and must find the money to pay for it. How in any sane person's view this creates a potential charge on the State is hard to concede.
I cannot understand how an amendment which potentially means the imposition of a massive charge on the State, if we are to have full public nursing care paid for by the State — we are talking big bucks — is allowed while an amendment which simply holds the Minister to account for her own promises is not allowed. The reason I tabled this amendment is that the record is markedly different from the promise made by the Minister when she announced this in November. The record shows she promised 30,000 new medical cards. What has happened is that approximately 11,000 fewer people are covered by medical cards. I am fearful that pattern will persist. Promises have been made but nobody has to implement them. God knows, enough promises were made in the area of health care that never materialised. The promise of 200,000 medical cards did not materialise, we now have 30,000 medical cards, and when we try to include in the legislation a provision to ensure the Minister for Health and Children has regard to it, somehow it is found to be unacceptable because it might incur a charge on the State. That tells much about the Government and its approach.
I have no doubt that if the Minister had been willing to accept the amendment there would not have been any problem. Is it that she is like her predecessor in that she does not want to be reminded of promises she has made? She does not want anybody to point the finger and ask, "Minister, you said in November there would be 30,000 new medical cards and 200,000 general practitioner only cards and why has it not been delivered?". All that is being asked for is to have regard to the commitment which she made — nobody else made it — and yet that is deemed to be out of order. That is disturbing for those who are waiting for medical cards and it is undermining the credibility of the Minister if what is being stated here is that we cannot include this in the Bill, even though it concerns a commitment she made.
I support amendment No. 2 in the name Deputy Twomey, which seeks to address the issue of long term care for the elderly and the need for the Minister to prepare over a three month period a plan for the funding of care for the elderly in public and private nursing homes. We should look at access to long term care on the basis of need. I regret that throughout the Bill we see a reflection of financial consideration as the primary consideration, which shows the heavy influence of the Department of Finance continues under her Ministry as it was clearly intrusive in decision-making by the former Minister, Deputy Martin.
Like Deputy McManus, I too have had amendments disallowed on the basis allegedly that, in the opinion of the Ceann Comhairle, they involve — there is no might about it — a potential charge on the Revenue. I was seeking to include the words "the state of health of the person", as one of the critical reasons that should be taken into account in assessing a person's entitlement in any regard under any of our health Acts, yet section 1 of this Bill provides that the Health Service Executive shall have regard to the person's overall financial situation.
There is no mention of a person's state of health or his or her health needs. Clearly, financial considerations are predominant and the prevalent thought on the part of the draftees of the Bill and, with respect, the Minister and her colleagues who are failing to take on board the state of health of the person concerned. Some of my amendments included this but they have been deemed by the Ceann Comhairle to involve a potential charge on the Revenue. We are talking about the provision of health care, either medical cards or access to long-term nursing care. It is surely not on the basis of financial considerations that we should make these judgments but on the basis of the health needs of an individual citizen. Until such time as need alone becomes the guiding principle in the determination of future health policy, there will be a serious dichotomy in this Chamber. The difference between the Government's position and that of the collective Opposition has been demonstrated on many occasions.
Deputy Twomey's amendment proposes a timeframe of three months for plans for funding the care of the elderly. I referred to a case on a previous occasion in the House when the Minister was absent but the Minister of State, Deputy Power, was present. He may recall I instanced what I regarded as a grossly unfair and wounding decision in respect of an elderly lady and her family. Her children were forced by the North Eastern Health Board to sell her house because she was not in a position to make that decision. They were forced to sell their small terraced home in my home town of Monaghan in order to finance her stay in a private nursing home.
I wish to recap on the detail of this case because Deputy Twomey's proposition would require that the Minister and her colleagues take into account the reality ordinary people are facing by virtue of the strict and uncaring code applied by health boards and now the HSE. The lady concerned had small life savings and was advanced in years. Her savings amounted to €11,000. She was a mother who had brought up two families in a small terraced home. She had sought access to the State-run nursing home available in County Monaghan but she was refused subvention and access because she was the owner of this small home.
The lady concerned has four children. While none of them lives with her, it has always been their home. They have visited it from the day they left to go out into the world. It is where they grew up and all their childhood things are kept in their respective shared rooms. They have come back either from England where some are now domiciled or other parts of Ireland to visit their mother on a regular basis.
The lady concerned stayed for more than 100 days in a local hospital as the health board argued her care was her family's responsibility. This was outrageous. The poor woman and many like her would be described by those who give little thought to the circumstances in which she found herself as a "bed-blocker". It is outrageous to shift the blame and responsibility to the poor elderly person concerned who seeks, deserves and has every right to access long-term nursing home care. I reject that term because it quite clearly removes the focus from where the blame deserves to be placed, on the failure of the system to recognise the need of the woman concerned and the needs of all other women and men. That is where the blame must rest.
The family concerned has been forced to sell their home, valued at €150,000 in today's terms. This money has been set aside to pay for her care in a private nursing home. While their mother is alive, the family members have been forced to go through the entire grieving process. They have been forced to dispose of their home, all of their personal effects from their childhood, everything that was dear and important to them in coming home to visit their mother. It is all gone. When their mother does pass away, they will have nowhere to bring her in order to grieve, mourn and wake her, which is still very much a part of the culture of rural Ireland, not only in small towns and rural locations but also in a greater part of Irish society. They will have nowhere to go but an impersonal nursing home facility and perhaps one of the new funeral homes in advance of requiem Mass and burial. This is absolutely awful. I can only imagine how any of us would react if we were faced with the same set of circumstances.
There is a bounden responsibility on the Government to take such situations on board. I have to recount the case in the House again because it hurts and pains the family concerned and the wider community, the members of which know the hurt and pain the family have suffered.
I hope the Minister will adopt Deputy Twomey's amendment which is reasonable. I ask that she take into account the circumstances of the dear lady concerned and her family and many countless others throughout the jurisdiction. The widest concentration possible is necessary for the Minister and her colleagues, the Ministers of State in the Department of Health and Children, and their officials to be fully cognisant of the reality with which people in our communities are dealing. I have only given the House one example. I can only say the hurt and pain caused in this case have been quite severe.
I have a reasonable proposition for the Tánaiste. I ask her to undertake within a reasonable period such as the three months suggested in the amendment — I have no doubt the matter could be revisited — to carry out a study and report back to the Houses of the Oireachtas on her plans for the future funding of the care of the elderly. That is what the House needs to hear, discussion and debate in order to produce a set of regulations or commitments — Government policy in the main — to ensure we can erode the injustices which people continue to suffer on a daily basis. The situation, as it stands, is based on financial considerations, not on the needs of individual patients and applicants for residential care in public nursing homes.
I support Deputy Twomey's strong amendment because it would have teeth and contains common-sense proposals. It would deal with the long-term care of the elderly.
The funding of care for the elderly is a subject that has slipped off the agenda of some who have an attitude about it. This is a crisis for our elderly people.
From listening to people on the ground, the so-called care plans are not adequate. I receive complaints concerning elderly people who have been released from hospital, return home alone and receive only two hours per day of care support when they may need five or six hours of care per day. Recently, I dealt with a case of an elderly woman who was released from hospital and received two hours of care per day. She had to go down to a local centre for lunch, needed to be washed and clothed and required support at night. The care plans need to be beefed up.
This morning I visited the CARE project in my constituency, an excellent initiative which provides meals on wheels and home helps for people in the Artane, Raheny and Killester areas. The two issues on the organisation's agenda were funding and stability. It needs our practical support but the system for obtaining funding is inadequate. Its grants appear to fluctuate monthly. When one considers the services it provides, including 290 home helps and meals on wheels, it is incumbent on all of us, particularly the Tánaiste and the Minister of State in her Department, Deputy Power, to support this and similar projects which provide an excellent service.
The issue of day care services and places needs to be tackled and while we have some examples of good practice, we need to develop the area. On the broader issue, we are losing sight of many positive aspects of the elderly and their vital contribution to society. Many of those present at the meeting I attended this morning were elderly retired people who were involved in providing meals on wheels. I support them and commend them for their work.
This important amendment proposes that the Minister provide a statement of strategy detailing plans to fund care for the elderly in private and public nursing homes. It is correct that we can blame and challenge Ministers but society at large shares responsibility. Although we have done well economically, we have lost our sense of community and family. Issues are often misrepresented and people are too busy to take time to support the elderly in their communities. We must examine our own position, develop strategies and create a more caring society. I support the amendment.
I support the amendment to require the Minister to have a strategy to deal with funding for the care of the elderly. The Tánaiste will accuse me of repetitiveness but it is urgent that the issue of nursing homes is addressed. This is highlighted above all by the differences in the level of subvention being paid in the different health board areas. The enhanced subvention, for example, varies from €50 to several hundred euro between health boards. The wording of a reply I received from a health board in response to a parliamentary question I tabled indicated that the enhanced subvention could be as much as €650, although this figure may have related to total subvention.
We must have a policy on dealing with people who become infirm. Too often, as public representatives, we are contacted by families in difficulties because an elderly member has become infirm as a result of hospitalisation and the hospital wishes to force a decision on his or her future. Often, the family and the person's consultant or the hospital authorities will discuss a range of matters, including whether the person should move to a public or private nursing home, and the elderly person concerned is the last to be consulted. Elderly people in this position should be consulted on their preferences, even if they may not always obtain them, because their wishes must be taken into consideration.
Seven or eight years ago the then Minister for Health and Children issued a special code of practice on dealing with patients in hospital. Demographic changes caused by people living longer due to advances in medicine and an increase in the number of elderly people require that we introduce a code of practice on taking decisions about the future of elderly people, some of whom will have lived in an area or house for 50, 60, 70, 80 or 90 years. This code should apply to consultants and hospitals and should require them to ensure that elderly people in this position are put at ease, informed, understand what is happening and are assisted in every possible way.
The nursing home subvention needs to be urgently revisited. Public representatives are being contacted by an increasing number of families who have loved ones in nursing homes and can no longer afford to make up the difference between the subvention and pension, on the one hand, and the nursing home charges, on the other. Finding the balance, which is becoming ever greater, is causing increasing difficulties for the families concerned.
The State has recognised that the calculation of a person's means relates to the income of the person in question, rather than his or her family. Families also have a degree of responsibility to take care of an elderly person in accordance with their means. However, I know of a person in receipt of old age pension who must contribute €60 or thereabouts per week towards the cost of nursing home care for her husband. In another case, a couple in receipt of a British pension faced extreme pressure to survive because one spouse had to contribute towards the cost of nursing home care for the other. The husband, who was in care, has since died.
I wish briefly to voice my concern about an issue unrelated to the amendment. The Tánaiste must ensure the Department of the Environment, Heritage and Local Government takes action on the special housing aid for the elderly scheme. I have spoken to elderly people who applied two or three years ago for grants to do work on their houses, for example, to stop rain leaking into the house. I have to explain to them that they are listed as priority 2 or 3 and the local health board only deals with emergencies. Last year, my health board did not deal with cases listed as priority 1, 2 or 3. Those in question are elderly people who live alone, which is a condition of the scheme. When elderly people live alone, the least that should be done is to provide them with decent windows and doors, preventing the rain and wind from coming in and ensuring some level of comfort. Many request heating in their homes. It is difficult to understand why individuals, many of them up to 90 years of age and living alone, do not have some form of heating. Rural Members encounter elderly people living alone in such circumstances. The sooner the various special grants such as those for essential repairs, disabled persons and special housing aid for the elderly are rationalised the better. A decent scheme that will take care of the needs of the elderly living alone must be introduced.
I appreciate difficulties arise with certain cases. However, the worst situation I encounter is when an elderly person, looking for repairs to his or her house, is taken off the grant list because his or her daughter gave up employment to come home and take of care of him or her. The individuals concerned are deemed not to be living on their own. This is a difficult rule to explain to an 80 year old who was promised the work would be carried out. We expected this issue to be resolved because of promises to examine the process made by several Ministers for the Environment, Heritage and Local Government. However, the examination has continued for four years. This is an area where elderly people can receive care in their homes, allowing them to remain there for longer periods.
My problem with the amendment is that its statement of strategy, detailing plans for funding the care of the elderly in both public and private nursing homes, omits care in the community and in a person's own home. Elderly people want to continue living in their own homes. Who wants to spend his or her life in a community only to have to go in retirement to a far away place where he or she knows no one and, like the old Indian, loses heart and dies? I have seen too many elderly people having to leave their communities and homes because no one can look after them. The most vulnerable in our communities who deserve support and care are those older persons who must leave them. The migration of older people into institutions is both sad and silent. Sad because it need not happen; silent because no one discusses it.
The amendment should include the giving of support to older people at home. Instead, it only concentrates on public and private nursing homes. I accept these are only available in the absence of a community alternative. People in nursing homes do good work. However, it is more important that support is given to those elderly people who want to remain in their own communities. Any strategy that does not address the need to support older people in their own communities is deficient in providing the means to allow them to stay at home. So many policy statements have been written with lip service paid to this concept. The Years Ahead, a wonderful review, found no progress had been made on the issue.
Support for the elderly in the community has no statutory basis. Funding has not been made available. What funding is available for the 5% of the older persons' population maintained in nursing homes is begrudged to it. Why should this be if it only affects 5% of the elderly population? This is the group that by definition cannot look after itself and needs total nursing care. We need to reflect seriously on what we are saying and doing. Institutionalisation is not the right direction to take. The health strategy refers to consultation, eligibility and entitlement, nursing home subvention scheme improvements and other important matters that need to be addressed. Again, lip service when an adequate response is needed.
A means by which older people can be maintained in their communities, particularly in their own homes, must be introduced. The difficulty has been that some older people have had to go nursing homes because they did not receive a home help service. If they had, they could have been sustained for longer in their homes. Older people must be assessed quickly for grants to ensure repairs to their houses are completed in a short period. However, they could be dead and buried by the time their houses are assessed. Supports such as physiotherapy and speech therapy for those who have suffered strokes are not available. Is it any wonder people end up in institutions?
The emphasis must be on maintaining the individual in his or her home for as long as possible. Where that is not possible, the next best stage is care in the community. There are communities prepared to support older people and which have the potential to do so but it is not being realised. Sheltered housing is the next best option for an individual who cannot be maintained in his or her own home. The difficulty is that the Government's targets for sheltered housing are not being honoured due to the lack of necessary funding and planning problems.
Some communities have been proactive in supporting older people in sheltered housing. However, when an older person needs more support, there is often nothing for him or her but institutionalisation. The community which has saved the older person from a far away institution ends up hanging its head in shame as the older person is forced into a profit driven, non-community nursing home, mainly provided by the private sector.
The alternative is for communities to supply the high support needed by the individual who has the continuum of care and support to which health policy documents constantly refer. The continuum extends from support at home to low and then high support sheltered housing, guaranteeing no matter how old or disabled the person is, he or she can be maintained in the community. This happens in the St. Brendan's village scheme. However, it is not, particularly the high support end, being replicated elsewhere because of inadequate funding. If communities are to achieve similar schemes, legislative changes must be made. For people to be supported in low support housing, there is a need for a defined revenue scheme. However, it is not in place; instead there is a penny wise and pound foolish approach. The introduction of such a scheme would allow those communities which build and manage sheltered houses to employ the staff needed to support those elderly persons who become more disabled in time. When a person needs a higher degree of support, instead of going to a far away institution, he or she moves sideways into a high support unit within the community. However, for this to happen, a capital funding provision must be in place. It is available for profit driven, non-community nursing homes. Why should it not be available for communities to do this? It is wrong that it is not because communities do not want to lose their older people. It could be done quite easily if funding was made available. For instance, it could be done under the capital assistance scheme but there are rules stating it should not be done. If it is done, it should be possible for a community to be able to register because under the law, it is obliged to register if looking after disabled people. There should be a provision to enable communities to build under the capital assistance scheme and register under the Nursing Homes Acts. That would ensure the standards needed. Standards are not being tested in State institutions, which an inspectorate would ensure.
People talk about the problem of older people; it is not a problem but a challenge. Older people should not be segregated. We are all getting older and older people need to be included in society and not excluded. The way forward is to support older people at home, if at all possible. To do that, funding is need which has never been properly provided. If a person can no longer be supported in their own home, low support and high support sheltered housing should be provided. In that way, there is a guarantee that no matter how old or disabled the person, he or she can be maintained in his or her community. I have yet to meet anyone who wants to leave his or her own community.
I, too, support the amendment. As outlined, there is a crisis with the old and I would not blame them for feeling like a burden on society or on their families. When people feel they are a burden on society or on their families, the only thing they want to do is die. I often hear that sentiment expressed. These old people feel they will drain the family finances or will see the family home sold from under them. The family home is something for which they have worked all their life and they do not want to see it evaporate.
We talk about giving subvention to people and enhanced levels of subvention. I do not know if it is the best value for money. Carers could do a lot of work if they received something akin to the amount of money it costs to subvent somebody in a nursing home. The figure of €700 per week was mentioned. Carers could do a lot in the community if they got that amount.
People want to live and to die at home. They do not want to move to an institution. There is a mindset that when somebody assesses the elderly person, it is not to see how the person's situation in the home can be enhanced but to see how soon he or she will have to go into an institution. It is often considered that people cannot be discharged from general hospitals to their own homes because they are not suitable. If people send out a distress signal that they need a grant or a few euro to put in a shower or heating, it should be considered, yet it seems as if every hurdle possible is put in their way, including the requirement that visits must be made by people from the county council and the health board, including an occupational therapist. For a long time in the south Monaghan area, there were no occupational therapists to carry out assessments on people's homes. A little common sense is required. An assessment by a doctor and a visit from somebody from the county council is required even if only a shower or a downstairs toilet is required or to make life a little more comfortable for people.
It is not always a case of the money not being there or of it not being spent. It is a case of how well targeted is the spending. I do not believe it is always targeted in the right direction. If a person could remain at home if provided with a shower or a downstairs toilet, one would avoid that person taking up a bed in a nursing home. It would also avoid that person having to sell the family home to finance that bed. One could avoid many problems in that regard.
Health boards should re-examine their way of thinking. They should stop thinking they must put someone into an institution. There is no scarcity of policy in respect of care of the aged but those policies are not being translated into action. Will the Minister target the money a little better and try to give it back to the community? There should be an ethos within the health service to enable people to go back to their homes. In many cases, their homes may not be as tidy or as nice as a nursing home but it is often the place where they want to die and many people know when their time is up.
The contributions reminded me of the Second Stage debate. Although the Deputies opposite had some of their amendments ruled out of order, they managed to talk to the subject of those amendments. Perhaps I can address some of the issues raised.
In regard to Deputy Twomey's amendment, I agree it is important to have clear policy directions on long-term care and issues around the elderly. We have the Mercer and the O'Shea reports on nursing home subvention. We have an aging population and each year 12,000 more people reach the age of 65 and 1,500 more people reach the age of 80. Over the next 20 years, with expected trends, the demographic profile of our population will change quite dramatically. Clearly, immigration will play a part in perhaps addressing some of the imbalance but there will be a lot more older people.
I am a strong fan of care in the home and the community. It is the wish of the majority of older people to remain in their own homes, or certainly in their own communities, for as long as they can. Many of the long-term care issues must deal with housing related issues as well. The traditional family home in urban environments is not conducive to somebody who has become partially disabled. The two storey home with the conventional bathroom is not suitable for people who might be wheelchair bound or who suffer from certain mobility issues. In other countries, there is much thinking on this particular subject. I recently met some people from the United Kingdom who are involved in the planning of new housing developments not specifically for elderly people but which will incorporate adaptation more easily than the traditional home.
The Government is anxious to bring some certainty to the issues involved. Many of the strategies have dealt with these but I suppose because of other pressures, we have not been able to resolve some of the outstanding problems in this area — mainly the financing ones. How do we finance long-term care into the future in the context of demographic changes? The Minister for Social and Family Affairs, the Minister for Finance, the Minister of State, Deputy Sean Power, and I held a meeting in January with senior officials on this issue. We have put together a group of officials to report back to us by the summer so we can bring finality and certainty to this issue from a policy perspective. It is certain that unless we know the road map, we will not make the right decisions.
The creation of the Health Service Executive — a unified system nationally — will bring uniformity to some of the issues raised by the Deputies opposite. In a country of four million people, it should be clear what citizens are entitled to as far as support is concerned, yet it varies a lot while market conditions change from one place to another. It is more expensive in some places to access nursing home accommodation than in others. Even if that is discounted, there are huge discrepancies. Although it is not easy from a financing perspective — we spend approximately €1.2 billion annually in this area — to find the resources required, we must at least have uniformity countrywide.
The same applies to another issue I want to address, that is, the medical card issue and the concept of hardship enshrined in legislation. A medical card is given at the discretion of the CEO of the health board but when discretion is given to a large number of people, there are differences in interpretation. Again, we need greater uniformity in this area. I have already spoken to the HSE and it is intended to have further discussions. Already approximately 70,000 people have medical cards on this basis.
Deputy Ó Caoláin suggested that medical rather than financial need should be the criterion on which a medical card was granted. There is some merit in that perspective. Some have medical cards on the basis of medical need. We recently made a decision that chronically ill children who have a medical card by virtue of their illness should not have to reapply each year to have the card renewed because their illness is such that they are not going to recover. The idea of placing the burden and sometimes trauma on their families of applying for the renewal of the medical card is unnecessary and not desirable. Measures are being implemented in this regard.
I have a problem with somebody who is very rich and has an illness, perhaps a minor one but one nonetheless that requires ongoing medication, having a medical card while somebody who is less well off has not, unless one accepts the principle of universal application. I do not support it.
I am a strong fan of making choices and having priorities. If we were to give everyone a conventional medical card, it would cost approximately €4 billion a year. The full medical card, if I may use that term, costs approximately €1,000 a year. It is in order to extend at least the doctor part to the widest number within the resources available that we decided to introduce this new concept of the doctor only card. I am conscious that many people, particularly families with young children, may often need only a doctor's reassurance. It may not be necessary subsequently to get medication. Deputies Twomey and Cowley would know more about this than I. Perhaps one third of those who visit the doctor do not require a prescription or medication. The idea that parents in less well off circumstances should have access to a doctor without worrying about the cost, particularly where children are concerned, is one I support. That is why we have introduced this new concept.
I agree that it is always better to have graduated benefit than to have a severe cut-off point whereby if all the criteria are met, one gets full benefit but if one is just above the threshold, one gets nothing. There is a band in the middle and that is what this provides for. Obviously, it is decided on income grounds. It is difficult to get accurate income data in Ireland because incomes are rising very fast. In the past it was easy to predict what it would cost if the threshold were increased by 7.5%, which has been done in respect of the conventional card, and by 25% in respect of the new card. One could estimate accurately the number who would benefit. Because incomes are changing quite rapidly and the method of calculating who is entitled to the medical card, rent or mortgage allowance, the cost of travel to work, the number of children and so on, it is a complicated task to have a fairer system. I would love to be able to have a global figure but that might militate against those in particular circumstances, particularly if a mortgage, high rent or a big travel to work bill is concerned in the case of those who must travel long distances.
We estimate, based on the data available from Revenue and Indecon, that 200,000 people will qualify on the basis of the new threshold to which we have agreed. If there are not 200,000, we will further adjust the threshold. Perhaps we are sometimes conservative regarding where we set the threshold but we are setting it based on income, not numbers. It is not a case of deciding we must have a certain number of medical cards. We are trying to move along an income route in which those who earn a certain income and are in certain circumstances should qualify for the doctor only or conventional card. If our income data are wrong, I will be more than happy to adjust the threshold later this year because we have €60 million assigned for the additional cards.
It is intended that the cards will be issued during the month of April. Originally we thought that legislation would not be necessary. Subsequently it proved it was necessary. In the light of what has happened recently, we must be cautious and conservative and at least have the law right rather than take a chance with all of the consequences of doing so.
Deputy Neville referred to the various grants to assist people to stay in their own homes. I had some discussion with the Minister for the Environment, Heritage and Local Government recently. He informed me that if one were entitled to a disabled person's grant of €8,000 to adapt one's home, it would cost approximately the same in bureaucracy to provide the grant. That seems crazy and the Minister intends examining the whole area of grants to make it much easier. We have a very complicated system under which one must get at least three quotations and ensure the applicants are tax compliant. In addition, in our society when people see that a grant is involved, an additional premium is demanded. In the meantime one must wait a long time for anything to happen. For the relatively small amount it costs to take out a bath and put in a shower that is wheelchair friendly, people should not have to go through this plethora of bureaucracy. The Minister for the Environment, Heritage and Local Government is examining this whole issue. The grant could play a very important part in helping people to stay in their own homes and be given subject perhaps to certification by a geriatrician that the adaptations are needed.
Occupational therapists could be involved.
Yes. Many people in hospital who are medically fit to be discharged must often wait there quite a while until their homes are adapted before they can return home. This does not make sense when it costs approximately €5,000 to €6,000 a week to be in an acute hospital bed while others are on trolleys. It is an important area. Although it is under the remit of another Minister, the Minister of State, Deputy Power——
We need special housing for the elderly.
All of the areas I mentioned need to be brought together in order that access is simpler for those who are most in need, particularly the elderly, but also for families where somebody becomes disabled and there is a need to adapt the home.
Unfortunately, I am not in a position to accept the amendment for a number of reasons. It is not a good idea to have a statutory requirement to bring forward a particular strategy. I undertake that in the autumn of this year the Government will be in a position to bring forward its policy in this area and it is hoped to bring greater certainty and uniformity to the range of supports available to individuals. Clearly, the focus, because of the recent decision of the Supreme Court, is on repayment of charges. This will consume a huge amount of energy and resources and an amount of effort on the part of many, including those running long-term care institutions. Notwithstanding this pressure, policy based on honest analysis of the issues and clear thinking as to the solutions is particularly important at a time like this. We are committed to doing this as quickly as possible.
Will the Minister refer to the type of case about which I talked? She did not refer to it specifically.
The health spend amounts to approximately 25% of what the Government spends on a day-to-day basis. There are still huge deficiencies in our health service right across the board. Resources are not unlimited. They are finite. If the economy was not doing so well, we would not be able to spend even the kind of resources we are spending. We must make choices. Clearly, in that context, choices are made in terms of the supports given and where people can assist in helping to meet the cost of their care. There is a problem, not easily solved, regarding the need to sell a basic family home in advance of the passing away of an individual. This causes considerable trauma for the kinds of reasons that Deputy Ó Caoláin has suggested. Issues might arise subsequent to the death where a sum of money might be paid in lieu of the care given as a contribution, which we need to consider and needs to form part of our policy thinking. There is a big difference between those with considerable resources and those with the basic family home. Circumstances differ. In some cases people have let their homes in the Dublin area and are receiving substantial rent each month.
In that case they would not qualify for subvention.
Some are making the contribution; others are not. We are paying approximately €120 million in subvention, which is not an inconsiderable amount. However, making up the gap between the subvention and the cost can be a burden on many families. Tax relief also applies. We all accept the system is not easy to fund which is why the concept of making a contribution towards shelter and maintenance has been supported here for the past 50 years.
In future we will face greater issues because lifestyles have changed. In the past women stayed at home and looked after their parents or their parents in-law. Women are now out working and society has changed enormously. Notwithstanding the huge commitment to supporting the elderly in society, because of issues relating to lifestyle, career, commuting etc., people are not in a position to do what they did in the past. Notwithstanding what I have said, I believe we can give more support to families and individuals to stay in their own homes. The home care package, which is part of the accident and emergency package we introduced this year, will greatly help people to remain at home who otherwise would need institutional care. In recent weeks I visited many people in institutional care. In the past three weeks in particular I have been in many long-term care facilities in counties Meath and Kildare. A high standard of care is given in both the public and private sector. Most of the people I have met would not be in a position to live at home. In many cases they are severely disabled and it would be impossible for them to live on their own and even living with the family would be particularly difficult. We need to provide more resources and to target them to families where they are needed most.
Many people remain unsure about their future, which is why we need clear Government policy on the matter. Elderly people are often more concerned about their future than are younger people. While young people know they can work, elderly people may be living on a pension or their resources. Only 3% of elderly people end up in nursing homes. As with Deputy Cowley, I fully support keeping people in the community, which is what we would all like to see.
We need clarification on the ten point plan as many points in the plan focus on the elderly, for example, the 100 places for high dependency beds, the step-down facilities and the home care package. The Tánaiste should clarify how people can avail of the home care package and how much money is available to individuals. While we get inquires on the package, we can get no information on it. Considerable fudge and bureaucracy are associated with it, which is the point of my amendment. People should know the Government policy regarding what future holds for the elderly. While this applies to those in the community, it is far more expensive for those who end up in private nursing home care. I accept that we should try to keep people in the community, as it is the easier and cheaper option. However, when patients end up needing more high-dependency care it is a huge cost.
Like Deputy Ó Caoláin, I have come across two cases of patients selling their houses and using those resources to fund their own private nursing home care. It has more or less taken political intervention to resolve their problems when they ran out of funds. This is not the way forward for caring for the elderly. No elderly person should need to come cap in hand to any politician to look after them in their old age. For those who spend their own resources to the degree that they sell their houses, when their money runs out we should have an automatic switchover period with more help from the State. This was not forthcoming in the cases with which I dealt. They relied on me as a politician. While I have some expertise in the area, many politicians do not have such expertise in the care for the elderly. This should not be the case now. As this amendment has not been ruled out of order, it should be agreed in order to allow us to have a policy on the elderly. I have included private nursing homes in my amendment as they are either more difficult to attain or very expensive for the individual, which is why I wish to press the amendment.
I ask the Tánaiste to clarify some of the points she made. I understand the point she has made about the discretionary allocation of medical cards resulting in unevenness across the country. A discretionary scheme would not work properly if it were absolutely uniform as people's experience will vary in different parts of the country. For example, some counties have no hospital and people may have great difficulty in accessing services. It is important to retain a discretionary element in whatever scheme is devised. The relationship of the director of community care — I am not sure if that title is still used — in the old community care areas is appropriately close to both the service and the population. We need the local knowledge of directors of community care.
It is not always possible to define a scheme that will not discriminate unfairly against somebody who may qualify for a medical card on grounds of sheer hardship and suffering, but if required to comply to a particular rigid scheme simply cannot access the card when needed. The scheme that allows disabled drivers grant aid and assistance uses extremely discriminatory criteria, which are grossly unfair on people who just fail to meet the particular requirements. The Minister should ensure that such rigidity is not included in this system, which seems to work pretty well at the moment. The only difficulty is that medical cards are available to so few people. While approximately 700,000 cards have been issued, many more people are covered.
Since the Tánaiste was in a position to increase the income eligibility limits, everybody presumed increasing the limits would result in additional medical cards reaching the point of the 30,000 new ones. However, while she has increased the income limit, it is clearly not enough. I do not want to debate that people are working, etc. We know that medical bills, the cost of drugs and hospital charges have increased hugely. The increased cost per patient is very steep compared with the increase in the income eligibility limits. Clearly the new limits are too low to enable the additional 30,000 cards to be issued. What is the Tánaiste doing about that matter? I ask her to give some more detail about the 200,000 cards. How can she avoid a time lag resulting in these cards not being issued as a result of income changes? I accept her observation that incomes are changing. However, people's needs are unchanging and there is a significant cohort above the limit who simply cannot access a doctor. It is to be hoped this need will be partially addressed through this measure.
In regard to the ten point plan, Deputy Twomey spoke about the specific commitments and arrangements that were to be in place to address the issue of elderly people or those in rehabilitation who were still inappropriately located in acute hospitals. How many have moved under this plan and how many will be moved in the future? I hate to use the term but there has been a significant number of "bed-blockers", or those inappropriately placed, especially in the large Dublin hospitals where there are particular problems. My colleague, Deputy Costello, has raised the case of a 73 year old who was on a trolley in the Mater Hospital for five days, long after the ten point plan was published. Such a situation is difficult for anybody to endure and it is inexcusable in the case of an elderly person. What has been the success rate on the commitments made under the ten point plan?
The Government recognises the principle of free access for all to GP and hospital care and medication, which the Tánaiste and Minister for Health and Children referred to as the principle of universality, but only for those over 70 years of age. I am of the view that health care should be free for all citizens at the point of delivery. Under the current approach, however, financial rather than health considerations are the primary factor in providing access to free treatment for the sector of the population below 70 years of age.
For the community welfare officer making an assessment, "undue hardship" refers to financial hardship. What about a person's medical condition and the hardship he or she suffers as a result? Only some categories of long-term illness are covered, for example. What about those who suffer from asthmatic conditions, some of them struggling to draw breath? Some persons with disabilities are covered while others are not. Health should be the primary consideration in this regard.
Given that the principle of universality has been conceded, will the Government grant full medical cards or, as a first step, GP-only cards to all children under the age of 18 years? This would be a significant step which would have an enormously positive impact on the daily lives of ordinary people and the health of countless generations of young people, leaving them in a much better position through their adult and later life. Many young people are not getting the medical care and attention they require, principally because their unfortunate parents cannot afford it and are excluded by the outrageously low income threshold for qualification.
There are provisions in the community to support older people, even those not fit to go home, whether on a short or long-term basis. There is also provision for respite services. However, these provisions are only available in particular situations and locations. Under the old system, the health boards provided what were known as welfare homes, now referred to as community nursing units. These facilities are only available in particular areas and location was often a reflection of the strength of the political representation in an area.
I have spoken to the Minister of State, Deputy Seán Power, about the proposed community facility in Ballinrobe in south County Mayo. Older people are on trolleys or in beds in Castlebar Hospital who should be in the Ballinrobe facility for which €400,000 is required in order for the project to advance to design stage this year. I hope the Tánaiste will address this issue. A consistent approach must be adopted in centres throughout the country. As I said, it involves support at home through the day centre, low support and high support housing.
Such an approach could provide all the necessary facilities. The Tánaiste should be looking to communities rather than private enterprise to provide these facilities. There are several hundred housing associations which have built low support, sheltered housing. Such developments could be expanded to a major degree if there were a defined revenue funding scheme. High support units could also be provided in a similar manner. This would mean that older people who require such care would not be "bed-blocking", a term which, like Deputy McManus, I dislike. Such inappropriately placed persons could be placed in their own community. Those who are not fit to return to their own homes could be cared for in such high support facilities.
Housing associations are prevented from providing high support facilities because of the existing legislation. They can provide housing but not the full support facilities required by those in need of full nursing care. People often go through a continuum whereby an initially minor disability may develop into a condition which requires greater support. The idea is that no matter the degree of support required, people should receive it in their own community in a facility akin to that in St. Brendan's village in Ballinrobe.
For this to happen changes are required in legislation. However, it is possible to adopt such an approach and it would not require any payment to private enterprise. It could be done by working in partnership with communities. This is what older people want. Such arrangements allow people to have a greater say in the running of the facilities in which they reside. There is no need to pay the shilling to the private operator for whom the primary objective is profit. The agenda is not to make money but to support older people in their own communities and this can be done by empowering communities. The community model is a better option than private nursing homes which are necessary only in the absence of community facilities.
For those in receipt of a medical card, one of their most significant fears is that they will lose it, particularly if they are on the cusp of the qualification threshold. Possession of a medical card may also act as a disincentive in taking up employment. When a full medical card is withdrawn from an individual, might some consideration be given to providing him or her with a GP-only card for a minimum period of, say, six or 12 months? This would remove some of the fear associated with losing one's medical card and ease the transition to a situation where one must cope without it.
Will the Tánaiste consider pricing the provision of prescription plus doctor only medical cards? I do not know what such a provision would cost. We have a costing for the provision of doctor only medical cards but need to go a step further to make them more acceptable. We all would prefer the provision of a full medical card but in the absence of this it would be useful to have such a costing. Perhaps we could examine introducing such a card at a later date.
If the income threshold in the guidelines for the issuing of a medical card was strictly adhered to, I am sure there would be 50,000 to 70,000 fewer medical card holders. If it were not for the common sense of community welfare officers in ignoring the income threshold guidelines, a small number would have a medical card. Community welfare officers are frustrated by the way they have to dispense medical cards.
I received a telephone call yesterday from a young woman who had tried to access the doctor on-call service and had been told to come but to make sure she had a medical card or a sum of €50. If this is the direction in which we are moving, we are bringing medicine to a new low. We talked at one time about the system in America, that one should not get sick unless one had money. If we keep moving in this direction we could shortly send people to America to give them lessons. That is not the response I would have expected from the on-call doctor service.
There is the giving of grants to make houses disability or wheelchair friendly. Has the Tánaiste had talks with the Minister for the Environment, Heritage and Local Government to consider changing the planning laws to ensure planning permission will only be granted for houses that will be disability or wheelchair friendly? This might not solve all our problems but down the line when we are old, we might catch up in this regard. Eventually every house in the country should be wheelchair friendly.
With regard to the points made by Deputy McManus, I am not seeking to eliminate the element of discretion because the purpose in having a medical card based on hardship is to ensure there is such an element. However, my understanding is that there are huge disparities from one place to another. There are places where it seems a high proportion of the population have medical cards but this does not seem to relate to socio-economic circumstances. In a unified system one would have as good a chance of getting a medical card in Dublin as in County Donegal or elsewhere. That is the point I was seeking to make. I do not want to use the word "guidelines" in this regard because there is an element of inflexibility. Obviously, we want flexibility in this arrangement. That is why we have the capacity to do this.
I more or less answered the other points earlier. We want to make sure houses are as wheelchair friendly as possible. All new houses must be wheelchair friendly but one wonders if that is necessary. On the other hand, if we want to ensure people do not have to move from their home if a member becomes disabled, it makes sense but there are associated costs. We will pay initially in the cost of housing.
I welcome the fact that there is huge interest in this issue across parties. That is positive and has generally been the case. It is becoming a bigger issue for society because of the increasing numbers involved but with these increasing numbers we must not lose sight of the current situation.
Deputy McManus asked about the accident and emergency ten point plan that has been implemented. Many of the provisions relating to the acquisition of step-down facilities and high dependency beds were subject to tender. The tenders are being examined and I understand the beds will be in place this month.
A number of home care packages have been put in place while a number of others have been approved but not yet executed. The home care package is customised to meet the needs of the individual concerned. It is not subject to strict criteria but customised to meet the needs of a person who wishes to live in his or her home but cannot because the schemes in place do not facilitate this. I hope that the acquisition later this month of step-down facilities will facilitate up to 500 patients to move from the acute hospital system to a more appropriate setting, perhaps within six to eight weeks after the acute hospital experience. That is the idea.
The high dependency beds are meant for those who cannot be suitably cared for in the traditional long-stay institution and those who cannot return home as they need a high level of care. These beds have been tendered. I understand the tenders are being examined and I hope they will come on stream soon.
Three weeks ago when I met geriatricians, the number of long-stay patients or patients who could be medically discharged in the six Dublin hospitals was 350. These were patients who could have been cared for in more appropriate settings, whether in a rehab facility, a high dependency bed, a nursing home environment or a home care setting. That is a considerable number which does not vary much from week to week. This is a major issue which is exerting enormous pressure on the acute hospital system. Dr. Conor Burke, a respiratory physician attached to James Connolly Memorial Hospital and the Mater Hospital, recently stated in a newspaper article that if hospital beds were used differently, in other words, if people could leave the acute hospital system when they were medically fit to do so, there would not be a problem in the accident and emergency departments of the hospitals concerned. There were patients there who could have been discharged but there was no place to which they could have been discharged. This had led to a blockage in the accident and emergency departments of the hospitals concerned. The problem in accident and emergency departments is a symptom of the problem in the wider hospital setting.
What about the possibility of issuing medical cards to all children under the age of 18 years? Has the Minister given consideration to this proposal which has been mooted previously as an interim measure?
What is the Minister's view of a proposal to introduce a lesser medical card, so to speak, to provide a soft landing on the withdrawal of a full medical card?
I am not a great fan of the concept of universality.
The Minister was a party to this measure.
It is not affordable and countries which have it are quickly trying to withdraw from such schemes because of the difficulty in funding them. Apart from the funding issue, there is the issue of equity and fairness. If everybody has something, it means others cannot have something that they need. I accept that when a benefit has been introduced, it is a different story to withdraw it. We all know the history of political parties which withdrew measures and the consequences. People feel cheated by such action because they make plans based on decisions that have been made. They are entitled to do this and certainty. I am not a fan of giving a medical card to the children of the very well-off when those who are not so well off do not have a medical card for their families.
The Deputy's party gave a medical card to millionaires over the age of 70 years.
That happened but we must move on.
One should not exclude the other.
My philosophy is that we have to make choices and have priorities. As we cannot do everything, we must decide what is the fairest and best way of using the resources available in the health care system. It is about giving benefits to those who need them most rather than giving them to those who may not need them at the expense of others who could do with them more. That is the consequence of the concept of universality.
In the event of withdrawal of a medical card, would the Minister consider issuing the person concerned a doctor only medical card for a specified period to soften the landing?
If one wins the lotto or inherits €2 million and one's medical card is withdrawn, what about softening the landing in such circumstances? Income criteria apply. We factor in the cost of mortgages, rent, travel to work and the number of children involved. We have to stick to the criteria. As I said in response to a question from Deputy McManus, we have the hardship based medical card where there are particular needs to be met that are not income related. There might be an illness in the family or circumstances of a temporary nature that necessitate the giving of a medical card. It is right that we should adopt such a flexible approach.
A couple with two children earning €290 per week do not qualify for a medical card.
They do but it also depends on factors such as the cost of the rent or mortgage.
As it is now 7 p.m., I am required to put the following question in accordance with an order of the Dáil of this day: "That the amendments set down by the Tánaiste and Minister for Health and Children for Committee Stage and not disposed of are hereby made to the Bill and, in respect of each of the sections not disposed of, the section or as appropriate the section, as amended, is hereby agreed to in Committee, the Title, as amended, is hereby agreed to in Committee, the Bill, as amended, is accordingly reported to the House, Fourth Stage is hereby completed and the Bill is hereby passed."
Question put and agreed to.
It is another guillotine.