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Dáil Éireann debate -
Thursday, 24 Sep 2020

Vol. 998 No. 1

Health (Amendment) (Professional Home Care) Bill 2020: Second Stage [Private Members]

I move: "That the Bill be now read a Second Time."

In 2011, the Law Reform Commission published a report, entitled Legal Aspects of Professional Home Care. It set out clear recommendations in this area. To implement these recommendations, it is necessary to introduce legislation to amend the Health Act 2007, which is exactly what this Bill does. The new Bill is necessary and is designed to provide regulation in the area of professional home care. It provides an appropriate regulatory framework and legal standards to be put in place for professional carers, as opposed to informal carers, engaged in the provision of care for people who live in their own home.

The number of people aged over 65 has increased in the past four years, from 629,000 to 720,000. This is an increase of 90,000. By 2030, there will be 1 million people over 65 in this country. Over recent years, the number of people over 80 years of age has increased. In fact, their number in 2016 was 149,000. Based on the figures available to the Central Statistics Office, CSO, it is predicted that by 2036, which is only 16 years away, their number will be 338,000. The majority of older people live active lives. A minority require assistance to live independently, and the increase in the older population is likely to result in a greater need for community-based health and social care services. Government strategy signifies a clear preference to maintain elderly people in their own homes, and yet despite this commitment, there is an absence of a regulatory framework. Home care is not confined to older people. It also involves those who develop a chronic illness, those who have a physical or mental disability or those who are recovering at home after a serious car or work accident.

The Bill provides for the extension of the function of HIQA to include the setting of standards in services provided by professional home care providers. It gives power to the Minister for Health to put in place regulations dealing with all aspects of home care, including the requirement to prepare a home care plan. It also allows the Minister to put regulations in place which provide that standards are set for detailed training requirements for those providing these services. The change in legislation provided for in this Bill is necessary if we want to guarantee safe, secure home care for all members of society who need it.

This is the third time I have introduced this Bill. I introduced it in 2014, in 2016 and now in 2020. This is not a criticism of the Minister of State, Deputy Butler, or anyone previously. I fully understand that the Department has a heavy work schedule, but this was first discussed in 2009. Then the Law Reform Commission produced its report in 2011. It is nine years since that report was produced. It is time to move on with this.

I will quickly go through the sections in the Bill. Section 1 is a standard section setting out necessary definitions.

Section 2(1) amends the definition of designated centres in section 2(1) of the Health Act 2007 to include undertakings, both unincorporated and incorporated, and whether established for gain or not established for gain, which are involved in the provision of professional home care services.

Subsection (2) provides that professional home care should be defined as services which are required to ensure that an adult person can continue to live independently in his or her own home. This may include, but is not limited to, the services of nurses, home care attendants, home helps, various therapies and personal care. It provides that palliative care be included in the definition of professional home care. It also provides that the proposed legislative framework should apply to undertakings which provide professional home care to persons aged 18 years and over.

Section 3(1) provides that section 8(1)(b) of the Health Act 2007 be amended to extend the functions of the Health Information and Quality Authority to include the setting of standards in services provided by professional home care providers. Subsection (2)(a) and (b) provide the Health Service Executive's National Quality Guidelines for Home Care Support Services should form the basis for national standards for professional home care to be prepared by HIQA under the Health Act 2007. Subsection (2)(c) deals with the issue concerning risk assessments. Subsection (2)(d) deals with the matter concerning the care plan, including the companionship plan, the home care plan and advance home care plan. Subsection (2)(e) provides that the standards include requirements concerning the handling of money and property by the professional care provider on behalf of the care recipient.

Subsection (2)(f) provides that the standards include specific guidance on safety and health requirements in the delivery of professional care in the home, including suitable guidance on manual handling, which shall be developed in liaison with the Health and Safety Authority. Subsection (2)(g) provides that the standards include relevant and detailed training requirements for those providing professional home care services. Subsection (2)(h) seeks to ensure that the standards provide that a contract for the provision of home care must include specific provisions setting out, in plain and easily understood language, the fee arrangements between the contracting parties for the agreed services. Subsection (3) provides the guiding principles to be applied in the legislative framework.

Section 4 provides that the social services inspectorate establish a registry of all professional home carers.

Section 5 provides that the ministerial regulation making powers conferred on the Minister under section 101 of the Health Act 2007 be extended to and include the authority to make regulations that apply to an undertaking involved in the provision of professional home care services.

Section 6 includes several subsections. It provides that an assessment of needs of care recipients must be carried out prior to the provision of care and that the assessment considers both the needs of and outcomes desired by the care recipient. Section 6(3) provides for an undertaking providing professional home care services shall make available an easily understood, well publicised and accessible complaints procedure. Section 6(4) provides for an undertaking providing professional home care services shall have policies in place to ensure that professional home care recipients are protected from all forms of abuse. Section 6(5) provides an undertaking providing professional home care services shall agree with the care recipient policies and procedures on the administration of medication in the home, which must be included in the care plan; and maintain a log in the home of all medication administered, which shall be accessible to all. Section 6(6) provides for an undertaking providing professional home care services shall include in the contract for care policies and procedures concerning the handling of money and property by the professional care provider on behalf of the care recipient. Section 6(7) provides that only suitably trained personnel may provide professional home care. Section 6(8) provides an undertaking providing professional home care services shall adequately supervise the individual home care providers to ensure the maintenance of care standards.

Section 7 is a standard section setting out the short title and commencement of arrangements.

Especially now, when we see the challenges posed by Covid, where more people want to continue to reside in their homes but also require necessary support from home care services, this Bill is necessary.

I am delighted to have the opportunity to second this ambitious Bill. For too long there has been an absence of regulations for professional home care. That cannot continue. Great trust is placed on home care workers. They have access to older people's homes and spend large amounts of time unsupervised with them. It is a credit to the professionalism of the home care industry that breeches of trust is not an issue in the sector, but that cannot be left to good fortune. There must be a level of oversight so that people continue to feel safe and be safe in their homes.

Deputy Colm Burke has put great effort into ensuring that this issue gets the attention it deserves. The Minister of State is also working on plans in the area and I am certain she will welcome such a well drafted Bill to complement all the work her Department has been doing over so many years. It is a credit to Deputy Colm Burke that he has put a Bill before the House in the first few months of this Dáil while the Department has worked on this issue for years and still has not published legislation. I am sure there are many complex legal issues to justify such a delay but it is their job to overcome these delays not cling to them as excuses for delaying regulations on such an important area. I hope we do not have to wait for a rogue operator in the industry to take advantage of vulnerable people to spur the Department into action, otherwise we will have failed. I look forward to the Minister of State bringing forward proposals in the next 12 months that largely reflect the good work done by Deputy Colm Burke. I know he will not allow them to kick this important issue to touch, and I will support him in this.

I move amendment No. 1:

To delete all words after “That” and substitute the following:

“Dáil Éireann resolves that the Health (Amendment) (Professional Home Care) Bill 2020 be deemed to be read a second time this day twelve months, in order to allow the Minister for Health to further consider some of the issues with the Bill, and having regard to the fact that the Minister for Health is already in the process of developing a comprehensive regulatory framework to regulate home support services.”

I am grateful for the opportunity to be here to discuss the important topic of the regulation of home support services. The development of a statutory scheme for the regulation and financing of home support services is a priority for me as Minister of State with responsibility for older people and is in line with successive Governments’ aims to support as many people as possible to live independently for as long as possible in their own homes and communities.

I would also like to say that I very much appreciate Deputies Colm Burke and Higgins’s intention in bringing forward this Bill and their commitment to introducing legislation to guarantee safe, secure home care for all members of society who need it. I am aware that Deputy Colm Burke has been a strong advocate of regulation in the home care sector for a long time and has previously brought forward a similar Private Members' Bill covering this topic. However, while I very much respect the motivation behind the Bill, some extra time is needed to consider further issues relating to it. For this reason I have tabled the amendment to the motion. The additional time sought from the House today will allow for a considered response to the proposals put forward by Deputies Colm Burke and Higgins. I look forward to working with the Deputies to ensure that a comprehensive regulatory framework grounded in an appropriate legal basis is developed. Indeed, this is what my Department is already planning for. I would like to take this opportunity to inform the House of my intentions in this regard.

First let me take a moment to briefly set out how home support services are currently overseen by the HSE. All publicly-funded home support is either delivered through the HSE by directly employed staff or commissioned by the HSE by way of a tender and delivered by the voluntary sector or private providers. While there is currently no statutory regulation of home-support services in Ireland, the HSE has put a number of controls in place to quality-assure the services provided and to safeguard service users. As part of this, the HSE has developed national standards to quality-assure all home care services they fund which align with HIQA’s national standards for safer, better healthcare. All HSE-funded home care providers are expected to comply with these standards.

The HSE has no remit to oversee the services purchased directly by individuals from providers operating independently in the open market. However, I understand that compliance with national standards is a prerequisite for membership of Home and Community Care Ireland which is the national representative body for for-profit providers of home-support services.

I agree that building on the safeguards already in place through the HSE, a comprehensive regulatory framework needs to be put in place on a statutory footing to protect recipients of home care and ensure that a standard, high quality, consistent service is in place across the country. However, while fully supporting the aim of the Bill in this regard, I have concerns with the proposed approach. There are characteristics particular to home care which make its regulation different to residential care and I am of the view that a bespoke regulatory framework for home support services is the appropriate approach.

The main issue I have is that the Bill proposes to include home care providers within the current HIQA regulatory arrangements by amending the definition of "designated centre" in the Health Act 2007. I do not agree that this is the right approach to take, as home care services are not delivered in any one centre but at different locations and in people's homes. Indeed, I believe that this approach would be unworkable.

Instead of extending the register of designated centres, I am strongly of the view that the appropriate approach to adopt to the regulation of home support providers is to develop a bespoke licensing system. HIQA supports this approach. In its March 2017 paper, "Exploring the regulation of health and social care services - Older People's services", HIQA recommended a service provider-based approach and a model of registration based around the service provider with an accompanying suite of regulations tailored for different service types.

In HIQA's view, following a model of registering or certifying the service provider as opposed to the physical location at which the service is provided offers a number of advantages: it provides clarity to service users, providers and regulators; separate regulations can be tailored to the service model; service providers can be more flexible and innovative, for example, they could accommodate service users with different support needs in the same settings; and administration would be reduced for the service provider and the regulator.

Within this context, my Department is engaged in the development of an appropriate regulatory framework for home support services. The central challenge in the development of this regulatory framework is to ensure quality, transparency and accountability while simultaneously supporting the provision of family and unpaid care and encouraging the development of innovative and technology-based solutions to meeting care and support needs.

I will set out for the House at a high level what this proposed approach will encompass. First, it is proposed to draft primary legislation to regulate home support services through the licensing of public and private providers. The objective of such a licensing system is to improve patient safety by ensuring that home support providers do not operate below the standard set by ministerial regulations. The approach being taken in the draft primary legislation will require home support providers to apply to a regulator for licences to undertake home support activities. It would be an offence for a person or provider to carry on a home support activity, either publicly or privately funded, unless he or she was licensed to do so. If a licensed provider is not meeting licensing requirements, the ultimate sanction is the withdrawal of the licence, but other options will be provided to address failings where withdrawal of the licence is not the appropriate action, particularly as a first option of action.

Second, in tandem with the development of primary legislation, my Department is progressing work on the development of minimum standards that will form the criteria against which the regulator will determine whether a home support provider's service is of the requisite standard for the provider to be licensed to operate. Pending the enactment of the requisite primary legislation, providers would be encouraged to meet these minimum standards on a voluntary basis. In this regard, my Department plans to undertake a targeted stakeholder consultation on these draft minimum standards before the end of the year. I would be more than happy to involve Deputies Colm Burke and Higgins in this process. I will be in touch with home support providers in due course to advise them of my intention and I look forward to engaging with the sector further on the development of appropriate minimum standards, which will serve to safeguard home support users.

Third, the development of primary legislation and minimum standards is expected to be complemented by the development of national standards for home support services by HIQA. My Department has already submitted a proposal for the development of national standards. That proposal is due to be considered by the board of HIQA at its meeting scheduled for next week. I am of the view that the power for HIQA to develop standards for home support services already exists in the Health Act 2007. As such, I do not agree that it needs to be provided for separately as proposed in the Bill before us.

If my Department's proposal is accepted, HIQA will follow its established procedure to support the development of new national standards. This will involve a national and international evidence review as well as stakeholder engagement. Therefore, I am of the view that it is not appropriate, as proposed by Deputies Colm Burke and Higgins, to include specific requirements in primary legislation about what should be included in such standards. HIQA already has considerable experience in the development of standards and we should leave it to develop the standards through its tried and tested procedures. If the board of HIQA agrees to undertake the development of national standards for home support services, I expect that there will be ample opportunity for stakeholders to contribute to their development and to ensure that they include appropriate matters, such as those proposed in this Private Members' Bill. If Deputies Colm Burke and Higgins would like to become involved in that process, I would be more than happy to facilitate their engagement with HIQA.

It is important that all stakeholders be involved in the development of an appropriate regulatory framework for home support services. Along with my officials, I will be more than happy to ensure that the regulatory framework is developed in as collaborative a fashion as possible. We all want the same outcome, namely, a high quality and safe home support service. It is important that we all work together to achieve this outcome.

I strongly welcome the focus in the winter plan that was published today on providing a substantial increase in the number of home care hours available. I welcome the new Home First approach, which emphasises reablement and providing extensive home support packages to those with more complex needs. This expansion of home care is an integral part of the ongoing development of the much-needed statutory home care scheme, which is a programme for Government commitment.

I am pleased that this Home First approach will bring with it the roll-out of the single assessment tool, which many Deputies will know I have been championing for some time. It is essential that there be consistency in the context of how needs are assessed. Regardless of where someone is in the country or what type of service he or she is entering, be it home care or residential care, it is imperative that his or her postal address not matter. There should be the same assessment of need tool for every person in every country.

I once again extend my appreciation to Deputies Colm Burke and Higgins for raising this important matter and facilitating this important discussion in the House. Along with my officials, I look forward to engaging further on this critical issue with Deputies, especially Deputies Colm Burke and Higgins, as our work progresses in order to ensure that the most appropriate regulatory framework for home support providers is in place to safeguard all home support users.

Could we stop the clock for a minute, please? For the information of Members, Thursday evening's Private Members' business, by way of the order of the House, is to be taken for 75 minutes. The opening 30 minutes are available in the format of 15 minutes for the proposer of the motion and 15 minutes for the Minister or Minister of State to respond. At the end, the Government has five minutes to respond and the proposer has ten minutes to make an overall response. In the middle, the rest of the time must be consumed by other Members, who must indicate on a first come, first served basis.

After all of that, we have more people offering than we would be able to give ten minutes to each. They will need to work out between themselves-----

I propose that we take five minutes each. I would be happy with that.

The Deputies can suit themselves. It is up to them to work it out. There are 36 minutes remaining, with five Deputies offering. They could have seven minutes each if they wanted. Deputy Cullinane is up first.

To be helpful, I will take five minutes.

I commend Deputy Colm Burke on introducing this Bill. Speaking as the author of three Bills that were subjected to the dreadful amendment that they would "be deemed to be read a second time this day twelve months", that was not some form of legislative purgatory as most if not all of those Bills withered on the vine. I hope this Bill will not be one of those, but I would not hold my breath. We will see what happens.

I welcome this timely Bill. Regulation of professional home care is needed, particularly as our population ages and we look to a new model of care for older people.

The Covid pandemic has shown us the need for a new statutory national framework and strategy for the care of older people. It is a statement of the obvious that we should seek to care for as many people as possible in their own homes. There are cases where that is not possible and people have to go into residential care facilities, including community nursing homes. Some people will also need a period of hospitalisation. However, there are many people in residential care homes who could be in their own homes if better supports were available to them.

The Minister of State noted in her speech that the winter plan announced today includes provision for more home help hours. That provision is quite substantial but it needs to be considered in the context of the substantial cuts that were made in this area over the past five years and more. Those cuts did not make sense when we all agree that we should, as best we can, be treating people in the home. We need to look at the whole area of care for the elderly, including what is happening in nursing homes. I will address that aspect of the matter presently. As a member of the new Oireachtas health committee, which is due to meet for the first time next week, I will do all I can to ensure we deliver a new model of care for older people, and all that needs to flow from that, as part of a broad, in-depth examination of all of these issues by the committee. I look forward to working with the Minister of State, Deputy Butler, and the Minister, Deputy Stephen Donnelly, in that regard.

We need to look at the structural relationship between the Department of Health, the HSE, nursing homes and care providers, the framework for clinical governance and the need for a deep examination of the current provision and the introduction of better legislation and regulations relating to this sector. Changes in the provision of home care must be brought forward urgently in the spirit of this Bill. The Bill is important for a number of reasons, primarily to ensure quality of care but also in respect of the safeguarding of vulnerable adults. While I support the Bill, I would make the point that we cannot look at this issue in isolation from the need to reform legislation in regard to adult safeguarding. I met representatives of HIQA some weeks ago to discuss this issue. We all know what happened in nursing homes as a consequence of the Covid crisis. However, it is true that over time, the vast majority of people get the very best of care in nursing homes. Having said that, there are instances where abuse and neglect occur. Those issues need to be dealt with and there must be investigations and examinations into all such instances.

In private nursing homes, social care teams do not have the power to go in of their own volition; they must be invited to do so. It is a cause for concern that adult safeguarding legislation is quite weak and it needs to be amended. HIQA sets the standards in this area, as it does in other areas and it is very eager to play a role in this regard. Indeed, it has said that there is a need for change in this area. Adult safeguarding concerns also apply in the case of home care, where caregivers are going into people's homes to look after them. We must protect the recipients of that care by ensuring there are proper regulations and enforcement in place. Standards of care are one part of the issue and what this Bill seeks to address. Work in that area is needed but it must be done in tandem with work on adult safeguarding standards, which also requires robust enforcement of legislation. There is an absence of legislation in both areas.

I commend Deputy Colm Burke on the Bill. As I said, I look forward to working with the Minister of State and the Minister, at the health committee, in looking at all of these areas. I genuinely hope we can all work in a spirit of co-operation with a view to ensuring we get the very best national strategy for the care of older people, including in their own homes but also in residential care settings and elsewhere. We need a strategy that is robust and effective and underpinned by strong regulation and enforcement. Where there are breaches, as we have seen in the past, the powers of enforcement must be sufficient to deal with them. Our objective should be to have the very highest standards of care for older people set out in legislation and in a national statutory framework.

I welcome the Bill brought forward by Deputy Colm Burke and the regulation it proposes to introduce for this sector. I would fully support any policy or legislation which seeks to put in place the necessary supports to allow older people or people with disabilities to remain living in their own homes. Demand for care services is due to rise in the coming years as the population of older people grows. A capacity review that was carried out by the Department of Health estimated that a 120% increase in home care provision would be needed between 2017 and 2031. That growing demand is not being met at the moment, with some 6,000 people on HSE waiting lists. As we know, not everybody is in a position to pay for home care.

The Bill sets out provisions in section 6, which amends section 106(1)(b) of the Health Act 2007, regarding assessment of needs. I note that the needs listed under this subsection differ greatly from the needs considered when a person is applying for the carer's allowance, for example. I agree that the needs listed in this Bill should indeed be taken into account when somebody is looking for home care hours in order to stay at home. My concern is that in the case of carer's allowance, unfortunately, only those at the highest level of need are considered and it is quite difficult to secure a successful outcome.

There is also a reference in the Bill to "suitably trained personnel". Home care assistants working for the HSE are required to have a FETAC level 5 qualification as a minimum. In the private sector, some of these workers are paid less than €10 per hour, which is less than the minimum wage. Many have to travel up to 40 minutes for what might be a half-hour slot and they are not paid for the time they spend travelling. In the current circumstances, they are not reimbursed for the personal protective equipment, PPE, they are required to use. As a result of the poor pay and conditions for these workers, staff turnover is high, which is detrimental to both carers and home care recipients. On the other hand, there are some people without qualifications who are calling themselves home care assistants. This happens because there is no legal requirement for assistants and carers outside the public sector to have full formal training. That leads to gaps in knowledge and practice. I have also heard of carers being thrown in at the deep end without proper training, which is not fair to them or the care recipient. There is very little continuing or in-service education and a lack of governance within the private sector.

Another concern is that there is no register of home care assistants, which means the title, as SIPTU has highlighted, is not protected. As I said, anybody can call himself or herself a home care assistant. This means that if a carer is guilty of abusing a care recipient, there is nothing to stop him or her getting a caring job elsewhere because there is no register from which he or she can be struck. Many of the private companies are driven by profit and I suggest that strong consideration be given to supporting not-for-profit providers. The lack of regulation means the professional home care companies are not held to account by anybody. People in receipt of home care services are vulnerable and need to be supported and protected. We are behind many of our European counterparts in this regard.

While I welcome better regulation as a means of protecting home care recipients and improving pay and conditions for employees, that regulation should not be overburdensome, which might have the effect of pushing small providers out of the market. The top three home care companies, which between them received €110 million from the HSE last year, are all large, non-Irish companies. I am concerned that the potentially high cost involved in regulation could drive out the smaller companies and thereby reduce competition.

I welcome the Bill introduced by Deputy Colm Burke. It is unfortunate that it is coming nine years after legislative provision in this area was recommended by the Law Reform Commission. Strong regulation in respect of professional home care services is long overdue. The number of people aged over 65 in this country is expected to increase to more than 1 million by 2040. Moreover, the number of people aged over 80 is set to increase dramatically. As Sinn Féin spokesperson for older people, I am aware that the majority of older people live active lives. Indeed, many of them are the backbone of our charities through the voluntary work they do. I had the pleasure of working with the Society of St. Vincent de Paul in both Athy and Kilcullen in south Kildare, where many of my fellow workers were older volunteers. Those men and women were very good at their job and I commend them on the work they do.

A minority of older people require assistance to live independently and the increase in the older population will likely result in a greater need for community-based healthcare and social care services. If possible, this should be provided in people's own homes, as the Minister of State acknowledges. The need for home care is not confined to older people. It is also required by those who develop a chronic illness, those with a different physical or mental ability and those who are recovering at home after illness or an accident. I welcome the extension of the function of HIQA to include the setting of standards in regard to services provided by professional home care companies. I hope the Minister will, on the back of this Bill, introduce regulations dealing with all aspects of home care, including the requirement to prepare a home care plan.

We also need to set standards around detailed training requirements for those who provide these services. I particularly welcome the requirement to include the contract for care policies and procedures for the handling of money and property by the professional care provider on behalf of the care recipient. We have all heard horror stories of elder financial abuse. The Bill contains an undertaking to provide professional home care services. It must have policies in place to ensure the professional home care recipients are protected from all forms of abuse.

Our older citizens have been disproportionately affected by the Covid-19 pandemic. Telling them to cocoon and to stay out of sight until they are told to rejoin society is really not acceptable. We now need to see respite and care services reopened and we need to see a balance between physical health and mental health.

I commend the work of nurses, palliative care and home care attendants, home helps, various therapists and the personal care assistants who provide the home care. The work done by Older Voices Kildare and Denise Croke and her team of volunteers is invaluable. I invite the Minister of State, Deputy Butler, to Kildare, and Deputy Colm Burke at his convenience, to meet groups such as Older Voices Kildare. Hopefully we could then loosen up the Department's purse strings and maybe get something in their favour. I thank Deputy Colm Burke again for bringing the Bill forward.

After the most recent election, an exit poll conducted by The Irish Times highlighted that 40% of voters said health was the most important issue influencing their vote. The subsequent pandemic has further highlighted the need for systematic change within our health service. Therefore, I welcome the introduction of the Bill this evening.

The programme for Government includes a commitment to "Expand community-based care bringing it closer to home, in line with the Sláintecare Implementation plan" and "Introduce a statutory scheme to support people to live in their own homes which will provide equitable access to high quality, regulated home care." Covid-19 and its devastating impacts and consequences for residents in nursing homes must make this even more of a priority for the Minister of State, Deputy Butler, and her colleagues in government. I would also like to think that when the Minister of State and her colleagues say "statutory", they mean statutory and not the channelling of more public funds into agencies and commercial providers in the private sector as the first port of call over the public sector.

There can be no doubt that there needs to be a radical shift in how we care for our elderly, our more vulnerable and those who provide that care. The policies of successive Governments over recent decades have resulted in an expansion of home care in the private sector, coupled with a devaluing of public and not-for-profit providers. The main issue that has contributed to this growth of private sector providers is the lack of capacity in the public sector. Instead of the State investing in the public provision of care to address capacity, funds have been channelled towards private providers. As my colleague, Deputy Tully, has outlined, this has been to the tune of more than €100 million. The implementation of competitive tendering in 2012, which was a startling development whereby private companies compete with one another to win contracts to provide care, was based on criteria that included price. This cultivated the conditions necessary for the growth and profits of the private sector of home care provision. This has had repercussions for the home care workers and for the quality of care provided. I hope it is obvious to the Minister of State, as it always has been to me and my Sinn Féin colleagues, that when the provision of care is based on a business of profit, care can also be sacrificed to that profit.

Another unsettling fact that has become more widely known is that there is a vast disparity of working conditions among carers in the public and private sectors. Those employed directly by the HSE have guaranteed hours of work, sick pay and pensions. On the other hand, those employed by private care are often on low pay and have precarious if-and-when contracts. The Home Care Coalition estimates that while there has been a 20% reduction in the provision of home care demands since the arrival of Covid-19, the end result has been the reduction of hours and income for home carers in the private sector. Crucially, these workers have not been laid off and are not entitled to the pandemic unemployment payment.

A further discrepancy that needs to be tackled is the issue of unpaid travel time. HSE-funded packages are often subcontracted out to private providers, yet they do not include pay for travel time. HSE staff are entitled to travel allowance. If a private home care provider has to travel between six or seven clients per day, over the course of the week this leads to hours of unpaid work.

When I recently met representatives of the Irish Farmers Association, IFA, and business representatives in Longford-Westmeath about their pre-budget priorities, both sectors raised the fair deal scheme as an issue. A key concern of the IFA is the urgent need to reintroduce the nursing homes support scheme (amendment) Bill 2019. This is a key ask because since the introduction of the scheme, it has been a potentially uncapped liability for farm businesses and for small family-owned businesses. These are productive assets required to generate income. They are not a measure of additional capacity to pay. The current fair deal scheme has seen anxiety and significant uncertainty for family farmers and for small family-owned businesses. There is a genuine fear that the viability of farms and businesses will be undermined while families attempt to meet the cost of care. I put it to the Minister of State that this is very unfair. Traditionally, farms and small businesses in my constituency have been passed down through generations. One barrier to the next generation taking over the farm can be the death of a person associated with it, whereby the fair deal scheme includes assets transferred within the last five years. One vital factor for constituencies like mine with very rural communities is the importance of these farms and businesses because they continue to operate when other employers do not. They play a vital role in supporting rural employment and the social fabric of many small rural towns and villages.

When the Minister of State, Deputy Butler, spoke at length on licensing, a question jumped to my mind. I am sure it occurred to others in the Chamber tonight. Will this equate to another financial burden intended to be borne by already low-paid workers in the private home care sector?

I commend Deputy Colm Burke on the Bill. I welcome the opportunity to speak as it will allow me to talk about the care of our older people. In this regard we are really talking about ourselves because, if we are lucky, old age will come to us all. I am sure that most of us here would like to live independently at home for as long as possible and then, if necessary, with some form of independent but sheltered arrangement in the community. The word "independent" matters. It is one of the great injustices of old age that just as we gain the wisdom of years we can so easily lose our say, our choices and our autonomy, going from managing homes, families and businesses to "Does she take sugar in her tea?". This is why for older people, independence, home care and home supports must be high on the agenda of a modern republic.

Tonight I specifically want to address the deaths of men and women in nursing homes. For some, the nursing home was their home. We paid a heavy price in my constituency of Kildare North. In April of this year, there was sixfold increase in deaths in nursing homes in Kildare. Sixfold is critical. It is huge. Husbands, wives, grandparents, aunties and uncles died unnecessarily. Some of them may only have had five or six years left, but five or six years is a long time in the life of a grandparent or a grandchild. Five years can see a newly born grandchild, a grandchild having a first day at school, or a young adult granddaughter getting married and starting a family of her own. As a result of Covid-19, these years and experiences were stolen. In north Kildare, their stealing haunts us and it is right that it should. Last month Professor Denis Cusack, the county coroner for Kildare, published his report into nursing home deaths in Kildare. Professor Cusack's interviews on "Drivetime" and KFM stopped me in my tracks. His concern, shock and compassion were palpable. Suddenly there was an official warmth and openness to replace the certain coldness and closedness that seemed to have taken hold.

There was a sense that we should not be looking because mistakes were made and blame might follow but nobody wanted blame then and nobody wants it now. I said that to Deputy Harris when he was the Minister for Health. What we want is to learn because if we do not learn, we risk a repeat and we simply cannot allow that to happen in the coming winter.

Out of 139 cited Covid-19 deaths in Kildare over this period, 113 were in nursing homes. In a reply to a parliamentary question the HSE told me that neither the executive nor the Health Protection Surveillance Centre, HPSC, collected testing data prior to the transfer of patients from hospital to nursing homes. There were over 60 such transfers in north Kildare and when I highlighted this, there was not much interest. It is a hard fact of politics now that for some Mean Girls has more resonance than dead girls, especially when those dead girls are old. However, the coroner in confirming their deaths, brought these people's voices back to life. He spoke of the atypical presentation of Covid, the lethargy, the loss of appetite that was not recognised, the quietness and the tests that were left undone. In this, Professor Cusack has done the dead in Kildare and the State some service and I thank him for that. He says that we need to know why Kildare was so disproportionately affected and he is right. I thought at the time that perhaps there were more nursing homes in Kildare than in other counties but that simply was not the case. Kildare suffered very badly. We cannot and must not wash our hands of this because for the dead, the unique and the loved, we must hold firm.

We had very substantial contributions by all of the Deputies who spoke. Would the Minister of State care to respond?

I wish to thank all the Deputies who contributed to this important debate in the House. Once again I would like to thank Deputies Burke and Higgins for bringing forward this Private Members' Bill. The debate this evening has been very useful and the early discussion of the issues concerned will be of great benefit as my Department continues to progress proposals to regulate the home support sector.

I thank all of the Deputies for their contributions in what is known as the graveyard shift, late on a Thursday evening. It is great to see so many Deputies present and I thank them for being here to discuss the Bill proposed by Deputies Burke and Higgins. I welcome the fact that Deputy Patricia Ryan is the spokesperson for older people for Sinn Féin and I would be happy to meet her some day. I have already met Deputy Ward who is the Sinn Féin spokesperson on mental health. I would have no problem meeting Deputy Ryan some day to discuss the various issues about which she is concerned. She was quite right when she said that home care is not confined to older people - far from it. We have many children with intellectual disabilities, adults with disabilities and many others who need home care and it is so important that we get it right.

I accept Deputy Clarke's point that statutory should mean statutory. She spoke at length about a fair deal for farmers, which is something I have been working on since taking up my role about ten weeks ago. The situation last year was that legislation was before the Oireachtas Joint Committee on Health for pre-legislative scrutiny. Then we had the Christmas break, followed by the election. The committee has been reconvened and I have written to the clerk to find out the status of the legislation because I would like to move it before Christmas if possible. It will have an enormous effect on farmers and small business owners. As we all know, under the fair deal scheme, there is a charge on an individual's property of 7.5% for three years but there is no cap for farmers or small business owners. I am very conscious of that fact and fully aware of it. I met representatives of Macra na Feirme last week who raised it with me. I will also be meeting representatives of the IFA this week. I assure the Deputy that I am very conscious of the issue and thank her for highlighting it again tonight.

Having heard Deputy Cronin's contribution, I will listen to a podcast of Professor Cusack's interview. The Deputy is quite right to say that the pandemic has borne down hardest on our older population. It certainly bore down very hard on elderly people living in nursing homes. Approximately 54% of all deaths to date occurred in the nursing home sector and I am acutely aware of that. The HSE and the Department of Health are working very hard with the nursing home sector to make sure that what occurred earlier this year does not happen again. We are working to ensure that they have the necessary PPE, the staff they need and that adequate infection prevention and control measures are in place. As the Deputy knows, the expert panel's review of nursing homes was published recently. Three meetings have been held already to meet the sector's short-term requirements in advance of the winter because we could be facing into a winter of the vomiting bug, influenza and Covid-19. I assure Deputies that I am on top of all of that and I am happy to work with them on these issues. It is great to hear so many Deputies interested in our older people. It was clear from everyone's contributions that they care and it is great to see that.

There seems to be consensus across the House on this issue. We may have different views on how this can best be achieved but we ultimately all want the same result, that is, a comprehensive regulatory framework placed on a statutory footing to protect recipients of home care and ensure that a standard, high quality, consistent service is in place across the country. A high quality, consistent home support service focused on keeping people well in their homes and communities for as long as possible is a key enabler to ensuring that people across a continuum of care get the right care in the right place at the right time. A comprehensive regulatory framework is a crucial component of this.

As the Minister of State with responsibility for mental health and older people, I was delighted to be part of the launch this morning of the HSE's winter plan. It is very important to me that this plan has a strong focus on supporting older people. Our aim must be to provide as much care as possible in the community but where people do require hospital care, we must enable them to be discharged back to their own home, with support in the community, as soon as possible. The last thing we want to see is older people in acute beds in hospitals during the winter when the only place they want to be is at home. I was delighted to see the focus in the plan on providing a very substantial increase in the number of home care hours available. We know that Irish people are living longer than ever before which is very welcome news but we need to ensure they live well. In that context, we need to do more. I sat on the other side of the House for the last four years and on every opportunity I got, I raised the issue of home care supports, wraparound supports, home care packages and so on. At one stage there were between 6,000 and 7,000 people waiting for supports. Hopefully the 5 million additional home care hours announced today will enable us to really tackle those waiting lists.

I appreciate that Deputy Burke must be somewhat frustrated at the perceived lack of progress but I assure the House that my Department is committed to advancing this work as a priority. While there is no doubt that the Private Members' Bill we are discussing in the House this evening is very well intentioned, for the reasons I have already set out, I do not believe the approach proposed is the appropriate way to progress this issue. As I have already outlined to the House, my Department is progressing a bespoke regulatory framework for home support services along three strands. The amendment I have tabled this evening will provide the time for my Department to consider the issues raised during the debate this evening and determine how best to address these issues in the context of the development of the appropriate regulatory framework. As I said earlier, I look forward to working with Deputies Burke and Higgins and any other interested Deputies to progress this work as a matter of urgency over the next 12 months.

Deputies Burke and Higgins have stimulated a very important debate. I invite Deputy Burke to respond to that debate now.

I thank the Minister of State for being here this evening to deal with this matter. I fully appreciate that there are lots of pressures on the Department of Health as it is an area on which I have focused since coming into the Oireachtas back in 2011. I also thank all of the Deputies who contributed to this debate. I very much appreciate that and I also thank my colleague, Deputy Higgins, for her support in working with me on the drafting of this Bill.

I wish to advise the Minister of State that I do not go away. This is the third Bill that I have instigated. I initiated a medical practitioner's (amendment) Bill relating to professional indemnity insurance for all doctors. When I came into the Oireachtas, that was not the law so I introduced a Private Members' Bill. That is now law, as a result of a Government subsequently bringing forward a Bill. The second one was missing persons legislation, the Civil Law (Presumption of Death) Bill which I was told could not be done. In fairness, I got the then Minister for Justice and Equality, Deputy Flanagan, on board and that is now law.

I hope I will also be able to contribute to the implementation of legislation in this area.

My involvement with elderly care goes back to well before I came into this House in that I was involved in a legal challenge to the Department of Health in regard to the provision of nursing home care, which subsequently, as a result of that legal challenge, changed the whole process of how we provide nursing home care. Even though we sometimes think that when we are outside this House, we cannot bring about change, in fact, when we can use the courts system, we can force the change that is required and force proper structures to be set in place. I am delighted that, as a result of those legal challenges, proper structures were put in place.

I believe it is time to deal with this issue. As I said earlier, this is my third time bringing forward a Bill. While I fully accept there are other pressures on the Department, I believe that as a result of Covid, more than anything else, there is now an urgent need to deal with this whole area. The figures I produced earlier demonstrate there will be 338,000 people aged over 80 by 2036, which is only 16 years away, and 1 million people aged over 65 by 2030. Therefore, we need an increased level of home care available because an increasing number will be looking for that kind of support.

A lot of research has been done already. The Health Research Board did work in 2017 which looked at programmes in Scotland, Sweden, Germany and the Netherlands. Quite a lot of research has been done in regard to what is in place in other countries, and we should use that without having to go down the road of doing further research, given the information is already set out quite clearly. Likewise, the Law Reform Commission report in 2011 was based on a huge amount of research which was set out quite clearly on the publication of that report. The groundwork is done. I have no problem working with the Minister of State to amend anything needed to deal with this area, but I believe it is important that we have the regulation in place.

We do not give enough recognition to informal carers, although I know we do not need legislation for them. The last CSO figures showed there were 195,000 people providing informal care in their own home. We need to acknowledge the work they are doing and how they are caring for someone in their home. They are doing this not for two or three hours a day, not for two or three days a week, not for two or three weeks a year, but 24-7, 365 days of the year. We need to acknowledge their contribution and the work they are doing.

It is also important that we acknowledge the work provided by carers employed either by the HSE or the private companies. While we might be critical of some of the private companies, they are providing a service where the statutory agencies are not able to provide it. In drafting legislation, we need to make sure we cover all the angles, whether the service is provided by the HSE or other State agencies, or by private companies.

I am determined that we will have legislation in this area before this Dáil is dissolved. This is crucial for the people who want care but we must also make sure that the appropriate level of care is provided. Coming from a legal background, one of the things that concerns me, and one of my colleagues referred to this during the debate, is the abuse of elderly people. I have seen it. We need to make sure we have all of the processes and procedures in place so this can be easily brought under control without someone suffering any loss. It is extremely important that we provide that. There were a number of reports recently in the newspapers, and the Irish Mail on Sunday recently had a very disturbing story in regard to a person with a disability who was provided with care but that care fell totally short of what the person wanted, and it was clear there was also abuse. It is important, where members of the general public are concerned in any way about the care being provided, that they bring that information to the relevant authorities and make them aware of it. We all have a part to play. There is no point saying, “That is someone else's problem, not mine.” It is our problem. It is important that we make sure our elderly are protected at all stages in regard to financial matters and in regard to their care, upkeep and healthcare.

We need to move forward with this legislation. I fully accept the Minister of State requires time and I look forward to working with her. I want to make a contribution to this in the same way I have made a contribution to the other legislation I have been involved in. I hope that, by this time next year, we will have a clear programme in place for the legislation to go through and be enacted, and to have it fully operational.

Amendment agreed to.
Motion, as amended, put and agreed to.
The Dáil adjourned at 7.38 p.m. until 1.30 p.m. on Tuesday, 29 September 2020.