Regulation of Home Care Provision: Discussion

First of all, I wish to apologise for the Chairman and Vice Chairman, who are at other meetings at present. They have asked me to step in to open this session. We are dealing with regulation of home care providers.

On behalf of the committee I welcome Mr. Pat Healy and Mr. Michael Fitzgerald of the HSE; Mr. Ed Murphy and Mr. Ed Crotty of Home and Community Care Ireland; and Ms Allison Metcalfe and Mr. Conor McCarthy of Health Care Assistants and Carers Ireland.

I wish to draw your attention to the fact that virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to this committee. However, if you are directed by the committee to cease giving evidence on a particular matter and you continue to so do, you are entitled thereafter only to a qualified privilege in respect of your evidence. You are directed that only evidence connected with the subject matter of these proceedings is to be given and you are asked to respect the parliamentary practice to the effect that, where possible, you should not criticise or make charges against any person, persons or entity by name or in such a way as to make him or her identifiable. Any opening statements you have made to the committee may be published on the committee website after this meeting.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the House or an official either by name or in such a way as to make him or her identifiable.

I will invite Mr. Pat Healy of the HSE to make an opening statement.

Mr. Pat Healy

I thank the committee for the invitation to attend today's meeting to discuss the regulation of and future planning for home care provision. I am joined by my colleague, Mr. Michael Fitzgerald, who is assistant national director in community strategy and planning division with responsibility for services for older people.

I have provided a briefing note with my opening statement that outlines the current position and the actions being taken by the HSE to improve the current service model and to support the work of the Department of Health on the planned legislation and regulation of this service. In this context the focus of my opening statement will be on some of the key issues involved.

The HSE National Service Plan 2018 provides for a little over 17 million home support hours to be delivered to 50,500 people at any one time within a budget of €408 million. This includes the support provided through winter measures for 1,170 people requiring discharge from acute hospital care to a value of €18.2 million. A further initiative saw 324 people being provided with home support services in the context of the recent adverse weather with a value of €5 million in full-year cost.

Home support services for older people funded by the HSE are provided either by directly-employed home help staff or by voluntary and private providers who have formal arrangements with the HSE to deliver the services. The type of support that is provided includes personal care and, where appropriate, essential household duties relating to the people's needs to maintain themselves in their own homes and communities.

With the approval of the Department of Health, from 1 January 2018 the HSE moved to a single funded home support service which combines home help and home care package services into a single service, namely, the home support service for older people. For service users, the public and the health system, the services will be easier to access and easier for the public to understand. Through the streamlining of application processes, there will be a requirement to make only one application and decision for home support services for older people. Service users will also be facilitated to move to changed levels of service as their assessed needs change without the need for an additional application process.

Intensive home care packages are funded separately within a budget of €9 million. The service is being delivered to approximately 235 people at any time. The majority of these people have been diagnosed with dementia and, therefore, have extremely complex needs. They require bespoke combinations of services based on their specific care plans. Without such services, these people are more likely to be admitted to long-stay residential care.

There has been a significant investment of €112 million in home support for older persons over the past three years. However, demand for such services continues to grow as the population of those aged over 65 years increases. As of 31 March 2018, there were 6,458 people assessed and approved for home supports, both new and additional, who were put on a waiting list for services. The vast majority of these people reside at home.

The Department of Health is engaged in a detailed process to determine what type of home support scheme is best suited for Ireland. This process will consider the future design of a scheme as well as the licensing or regulation requirements for these types of services. The HSE welcomes this development and supports the introduction of future legislation in this area. The demand for home support and its importance, as an alternative service to long-stay care, has grown considerably in recent years. Similarly, the type of home support that is now required to meet the needs of the population is a more person-centered personal care model rather than the more traditional home help service of earlier years which was centred around household duties. The development of this new service model, which is grounded in the national standards for safer better healthcare and which is sufficiently flexible to meet the more complex needs of an ageing population, brings with it challenges of ensuring that all providers are in a position to deliver a quality service and one in which the workforce is trained and competent to undertake the required duties. As a result, standards of care supported by appropriate regulation are necessary to ensure that such quality care is provided and maintained and that governance and oversight are at a level to deliver this service safely and to the satisfaction of the recipients. The regulation needs to ensure that providers can quality assure services to demonstrate that they meet the service users' individual needs across a range of headings such as, for example: the training and qualifications of staff undertaking the home support duties; the policies of the providers to deal with person centred care; the safeguarding of recipients of care; and the reliability of provision and suitability of the service.

The absence of a legislative-based scheme in the area of home support has been challenging given that the qualifying criteria for such services can only be based on the needs of the person. There is no legal basis underpinning the scheme or means testing. Also, account is not taken of other circumstances when deciding upon provision. In the development of such legislation it will be important to ensure that there is equitable access and a firm funding basis for a new home support scheme. We must also ensure that the requirements to have a timely and flexible approach to address the recipient's needs is maintained. In legislating for home support, cognisance must be taken of other legislation that has already been enacted, particularly the Nursing Homes Support Scheme Act, so that there are no unintended consequences that could arise and that people are clear as to which scheme applies to their particular needs.

The HSE employs 6,300 home support staff in all areas outside of the great Dublin area and Wicklow, which includes the community healthcare organisations of CHO 6, CHO 9 and parts of CHO 7, and County Clare. In recent years, the HSE, working with staff and their trade union representatives, under the auspices of the Workplace Relations Commission, WRC, has implemented a comprehensive modernisation and improvement programme to better meet the needs of service users and the staff delivering the services. The details of these arrangements are outlined in the briefing note I have provided.

Section 39 grant-aided providers of home support services have traditionally provided supports with household tasks. However, the majority have evolved over the years to deliver personal care as well as essential household duties in line with the changing needs of older people. These providers are independent operators and they employ staff directly. The HSE has worked closely with the voluntary sector to develop and consolidate the sector in order to ensure that appropriate, sustainable and well-governed models of service which meet the needs of service users are implemented.

As service provision has expanded, including via the emergence of private providers, the HSE has developed appropriate specification and standards for the delivery of services with an increased focus on person-centred care and support grounded in the national standards for safer better healthcare. As part of this process, the HSE has engaged in a formal tendering process for home care services that are renewed periodically. As well as ensuring value for money, these arrangements have also assisted in preparing the sector for future regulation of services and for the anticipated implementation of a national statutory scheme for home support in due course.

The HSE recently commenced a tender process for home support services to replace the 2016 tender arrangements. The relevant documents were published on the Government's tender website. As the specific details for the tender process are only available to those who express an interest in participating in the process and given that the process is live, I am not in a position to go into specific details on the matter. However, I have provided an overview of the overall tender process and arrangements in the briefing note submitted.

The tender arrangement for 2018 will provide for the introduction of a consumer-directed approach to the delivery of home support as an additional mechanism of service delivery. This approach will facilitate clients to choose - and to have more of a say in respect of - the days and times of service delivery. Clients will have the opportunity to contact a number of approved providers in order to consider the services on offer. To ensure quality of care, providers must be included on the approved provider tender list set up following the tender process and they must not charge rates in excess of the agreed tender rates. Furthermore, the provider and the client must have regard for specific requirements identified in the HSE assessment of need.

In 2016, the HSE established a forum involving representatives from the - National Community Care Network, NCCN - the for-profit sector - Home and Community Care Ireland, HCCI - and the HSE to discuss home support service issues and to inform the sector of future developments. The forum has been a useful mechanism over the past two years for the sharing of opinions and addressing concerns.

The HSE is also recruiting staff to create audit teams across the nine CHOs. These teams will have the skill set to audit service provision and ensure that the tender service specifications required of successful providers are being implemented. An audit team is being appointed in each CHO, with an initial focus on external providers. Thereafter, the teams will support HSE direct service provision to improve quality standards.

A capacity review was conducted by the Department of Health. It identified that demographic changes during the period up to 2031 will see the population of those over 65 years of age increase by 59% and that of those over 85 years of age increase by over 95%. The scale of these demographic changes, linked to the Sláintecare recommended shift to community-based services, indicates that the scale of service developments required for home support will be in the range of between 70% to 120% by 2031. Meeting these service development targets will require forward planning in order to ensure the availability of the workforce required to deliver the quantum of service and facilitate the training requirements of the workforce to deliver on the service standards, as well as the funding mechanism required to support it in the context of a new scheme. There is a need to ensure that the oversight requirements necessary for such a comprehensive shift of service to the community is achieved safely and with the additional supports in primary care and other services that will be required.

I thank Mr. Healy for his comprehensive statement on the issue of home care. I ask Mr. Ed Murphy from the HCCI to make his presentation.

Mr. Ed Murphy

I thank the Chairman and members for inviting HCCI to address the committee. My name is Ed Murphy and I am a director of HCCI. I am joined by my fellow director, Mr. Ed Crotty. Ms Orlaith Carmody is our independent chairperson. She sends her apologies for not being present. She is fulfilling a long-standing engagement abroad.

Home and Community Care Ireland, which was established in 2007, is the representative body for private home care providers, with more than 70 members, employing an estimated 12,000 home carers and providing care to more than 20,000 clients. Some of our members are locally owned and managed home care providers and others are Irish branches of established international home care franchise organisations. As a consequence, some HCCI members have a network and exposure to international best practice.

HCCI is governed by a board of six member directors and an independent chairperson. One of the greatest challenges facing our economy is our ageing population, as Mr. Healy said. Every 15 minutes someone in Ireland turns 65 and every 30 minutes someone turns 80. In light of the health service struggles with long hospital waiting lists and the Government’s stated policy of removing bed blockers by promoting more care in patients' homes, there is an unprecedented demand for home care services. According to the ERSI report, Projections of Demand for Healthcare In Ireland 2015–2030, demand for home care will increase by 50% in the next 11 years. The Department of Health acknowledges that it is unable to keep up with demand. Approximately 4,600 people are on waiting lists for home care, including new applicants and those waiting for additional hours.

While the fair deal scheme obliges the State to provide nursing home places for eligible people, home care is allocated on the basis of resources, which means many people take up a nursing home place because they cannot afford or access home care. This issue was highlighted in the 2017 RTÉ documentary, "We Need to Talk to Dad", by broadcaster Brendan Courtney. A poll carried out by Amárach Research in light of the documentary found that 85% of people wanted to be cared for in their home.

On care workers, we estimate that 40,000 people are employed in home care across the public, voluntary and private sectors. However, the sector is facing enormous problems retaining carers. Owing to working conditions and a lack of professional respect we are faced with the impossible task of finding 25,000 new carers as a matter of urgency. There is a global crisis in home care, with a recent BBC "Panorama" programme suggesting that 1 million new carers will be needed in the UK over the next five years. This is confirmed by our partners in these markets. Home care in Ireland is facing a crisis and urgent steps need to be taken now. Currently, there is no regulation in the home care industry. In the absence of regulation, HCCI is the only body that submits to independent auditors and operates a self-governing framework. The HCCI approach is based on providing a fully managed, relationship and outcome-based home care service to every client who needs it. Every client is professionally assessed and monitored on an ongoing basis. Every carer is Garda vetted, trained, insured, managed and supervised, thereby ensuring the highest standards of care for the client. In addition, HCCI believes it delivers value for money to the taxpayer and is committed to continuing this practice.

The immediate concerns of the industry, as identified by the Oireachtas Library and Research Service, are a lack of regulation and standardisation of home care services throughout the country, which are urgently needed to safeguard the most vulnerable members of our society. In light of this, HCCI is calling for the following measures to be adopted. First, we would like home care be provided on a statutory basis, mirroring the legal entitlement to funding for long-stay care available through the nursing home support scheme. Second, we would like the establishment of an independent authority, such as HIQA, to implement regulation and standards and to drive quality and safe delivery of care to home care clients. Third, we would like a change to the current HSE commissioning procedures to allow care workers operate a workable block weekly schedule, with travel costs included. Many carers also need support from the Department of Social Protection. Currently, if carers work just half an hour or one hour per day, as often occurs under current commissioning practices, they lose their full daily social welfare entitlement. The rules regarding social welfare entitlement need to be seriously examined. Fourth, we would like the introduction of a national register of trained and qualified home care practitioners, which protects both carers and clients. Fifth, we would like the current budgets for nursing home care and home care to be combined. This would enable the HSE to offer expanded home care packages to clients and the opportunity to live independently in the dignity and comfort of their own homes for as long as possible. Sixth, we would like nationwide implementation of client-directed home care, CDC. This has been successfully implemented in many countries and would involve offering a monetary contribution towards an individual’s home care needs, allowing him or her to choose a provider, public, private or voluntary and to also choose their own person-centred health care plan and schedule, which gives much greater satisfaction levels, as evidenced abroad, and is a proven way of getting people out of hospital quicker. All these points are expanded on in HCCI’s position paper, which members will have received, and is additional reading material to this presentation.

HCCI stresses that recruitment and retention of workers is in crisis in the home care sector. We welcome the opportunity to offer insight and to co-operate in bringing urgent change to bear on the legislation, regulation and commission of home care services to significantly expand the workforce. We thank the committee for the invitation, which is particularly timely as the 2018 HSE tender for home care services is live. Should these services be renewed under the existing arrangements, none of the recommendations we have set out to provide governance and significantly raise standards of service to vulnerable clients will be implemented for the next few years, thus deepening the crisis. As public representatives, members need to be aware of this and do all in their power to prevent the situation from worsening. Every citizen who is ageing, or who has a care requirement, should have the right to remain with dignity in his or her own home for as long as possible, which is what we, and every Oireachtas Member, would expect as a minimum standard for our own parents or loved ones.

I thank Mr. Murphy. I invite Ms Metcalfe to make her presentation.

Ms Allison Metcalfe

I thank the committee for inviting us to provide an overview of the home care sector on behalf of HCA and Carers Ireland. I am joined by my colleague, Mr. Conor McCarthy. We represent professional carers working in the industry. We thank the committee for choosing to focus on the regulation of future planning in home care provision. HCA and Carers Ireland was established in 2016. We are a platform for professional carers and health care assistants to provide support, enable dialogue and share the experiences that they face every day in seeking to provide quality service. This has proved to be an essential platform in combatting the isolation that many carers feel when working in this sector. Currently, we have just under 16,000 members.

In 2011, the Law Reform Commission, LRC, recommended regulation of home care, and we are happy to support movement in this regard. We believe a sector providing care needs to be regulated by an external body. Our home care sector is in crisis. Professional carers are leaving the sector every day, with precious few being attracted to replace them. This exodus is reflected in the increasing waiting list for home care packages, which currently stands at more than 5,000 people.

Carers are used inefficiently, as they often work with several providers and cover large geographical areas, resulting in them spending large amounts of their time travelling rather than being with the clients. Considering the demand coming down the tracks, the situation is even more worrying. The recent ESRI report on the future demand for healthcare predicted an increase of more than 50% for home care over the next 12 years. The recruitment and retention problems, which both the for-profit and not-for profit sectors are facing, together with their inability to meet demand, have many serious consequences for people needing care and for our health sector in general. First, the high turnover of carers that providers are experiencing has serious consequences for the quality of care they provide. Continuity of care is one of the principal tenets of quality home care and if the carers for people are changing every few months, the quality of care will be seriously affected no matter how much supervision or governance is in place. Second, if we do not have capacity in home care, this increases the pressure on our hospitals and results in more delayed discharges and a huge drain on the health budget. It also pushes more families towards residential care under the fair deal scheme, which is generally not their first choice. Most people's first preference is to continue living independently at home for as long as possible.

The reasons for the severe shortage of carers in the sector are many, but there are two principal ones. The first is poor employment conditions. On average, professional carers are paid €11 per hour for contact time with clients while many get no travel expenses. This appears to be a pittance given that providers are generally charging €26 per hour for their services. While we understand that there are costs to be covered, these margins are excessive and are putting too much money into the pockets of the providers. They say that the HSE needs to change how it commissions care for them to improve carers' employment conditions. This is just passing the buck. The published accounts of many of these providers show a high return to the owners in comparison with what they are paying their carers. The required change has less to do with HSE commissioning and more to do with profit.

The second reason is that there is little guarantee of work. Most working carers are on if-and-when contracts. This means carers have no guarantee of work and no visibility of earnings to allow them live a normal life where they can plan ahead for holidays and mortgages like the rest of society. These type of contracts enable providers to treat their most important asset, their carers, as a variable cost to be turned on and off at their whim. With increasing waiting lists for home care packages, there is no lack of demand or worry about where the next client will come from. What is the justification for not giving carers guaranteed hour contracts?

To address the capacity crisis and make caring an attractive career, the employment conditions of carers, principally their pay, must radically improve first. This is not so much a need to increase funding but rather to ensure that more existing funding goes to front-line workers and not to the company owners. A happy, well-rewarded carer is the best guarantee of quality home care provision. Providers will not give up their attractive profits easily and, therefore, they must be encouraged to do so. Unfortunately, the recently published HSE home care tender missed an opportunity to insist on a minimum wage for carers who provide HSE-funded care. In the absence of this, why can we not have a joint labour committee for home care that sets and regulates what carers should be paid? Another way of encouraging providers to treat their carers better would be by giving clients the choice of either a commercial provider or directly employing their own carer using the same State funds in a tax compliant manner. Providers talk a great deal about governance and supervision issues when discussing carers working directly with families, but they forget to say that because of their poor record in retaining carers, their supervision is carried out on a different set of carers each time. Continuity of care is perhaps the most important component of delivering quality home care.

Second, many carers are limited by our rigid social welfare system and are prevented from taking on more hours for fear of facing a sharp drop in benefits. Why can we not make the system more flexible and move from one that only considers the number of days worked to a total hours-based system, and which tapers the drop-off in benefits in order that carers are encouraged to take up more work?

Third, carers must be paid for travel time as well as travel expenses. We must enact in Irish law the European court's ruling in the Tyco case whereby mobile workers with no fixed place of work such as carers are paid from the moment they leave their homes. Carers should also be paid for the wear and tear on their cars. These changes would encourage care to be delivered locally.

Fourth, the number of 30-minute visits to those cases where there is a compelling clinical reason must be limited. Currently, 30-minute visits are used to spread the home care budget.

Finally, the training and upskilling of carers must be funded. Currently, providers do not pay for carers' training. Carers are expected to fund their own training. The State must set up a fund to pay for carers who wish to upskill and progress their careers. The fund should not be channelled through providers but directly to carers themselves. Carers need to be able to see a pathway of career progression through upskilling.

In summary, regulation in home care provision is overdue. External monitoring is required to ensure standards are met. Caring should be made a more attractive career, which will allow the sector to participate fully in the overall health sector. The power of providers must be rebalanced in respect of carers. The best way to do this is by the HSE truly valuing front-line workers by ensuring more funds find their way to the carers and offering choice to families regarding the care they receive.

I welcome any questions from members.

I thank the witnesses for their comprehensive presentations and for making the time and effort to prepare them. Before calling on members for their questions, Ms Metcalfe raised the 2011 LRC report. On foot of that report, I published the Health (Amendment) (Professional Home Care) Bill 2016. It has been debated in the Seanad and has gone to the Department of Health for its consideration. I understand the Department intends to deal with the legislation but I am not sure of the timescale.

A number of members have indicated that they wish to ask questions and I will call three at a time. First, I call Deputy Murphy O'Mahony.

I thank the witnesses for attending this meeting. They are welcome. We are all singing from the same hymn sheet, which is that it is important that people remain in their homes for as long as possible. I acknowledge the work done by carers, both those who are paid to do it and the family members who provide care out of love. It is important to remember all of them today and to acknowledge their work. It is also important that carers are looked after in order that they are in better form and better health to care for the people for whom they provide care.

Ms Metcalfe said that professional carers are rapidly leaving the system. Does she know if they are leaving the country or if they are leaving for other jobs?

Ms Allison Metcalfe

They are still remaining-----

We will take all the questions together and then Ms Metcalfe can respond to them.

Does she think they could be convinced to return to the caring sector?

It is predicted that demand will increase by 50% in the next 12 years. Why are systems not being put in place more quickly to ensure the health service can cope with this? Staff turnover is high. Can this be addressed as a matter of urgency, especially as it has been advised that continuity of care is of the utmost importance?

Mr. Murphy has advised that 25,000 additional carers are needed without delay. Where did he get that figure from? What efforts are being made to regulate this sector? What are the immediate differences between the work ethics and practices of private and public sector workers?

Mr. Healy has cited figures pertaining to the services that are offered. Other speakers have highlighted alarming deficiencies in the system. Is there a big disconnect here? Given that intensive home care packages are treated separately, is it wise to combine home help and home care packages? At a time the demand for home care services is increasing, surely additional investment in this vital sector is needed, particularly as it brings about savings for the taxpayer and takes pressure off the hospital system.

The Acting Chairman has alluded to the 2011 recommendation of the LRC that there should be regulation. In the opinion of the witnesses, what has been done to achieve this?

Are we going to ask loads of questions before we start to get any replies?

No. I will allow three members of the committee to ask questions before getting some replies, if that is okay.

Okay. I thank the witnesses for their time. My questions are for the HSE. It seems there is broad agreement on the need for regulation in this sector.

I remind our guests to note the questions that are being asked. I will ask them to reply after three members of the committee have asked their questions. I hope witnesses will be able to deal with it in that way. We will try to get through it as quickly as possible.

My question is for the HSE. There seems to be broad agreement on the need for regulation, although people might differ on the details of the implementation of regulation. All three bodies have said that regulation is needed. If I understand the HSE correctly, that is under way. However, it needs statutory underpinning. The first of the three issues about which I would like to hear the views of the HSE officials is the question of conditions, pay and retention. Do they agree that the current wage is too low? What does the HSE pay directly employed carers? How does that compare with the private sector wage? Do they agree that there is an issue with retention?

My next question relates to public access. It is obvious that waiting lists are high. Would the witnesses be able to provide some figures with regard to the increases in waiting lists over recent years? I would be particularly interested to hear about the equality or inequality around the country. Is the mismatch between supply and demand growing? How does it fare by geography?

We have heard evidence from the other two bodies with regard to costs and efficiency. It sounds like there are big opportunities to use carers more productively. If we ask a carer to drive a long distance to provide half an hour of care in one house, before asking him or her to drive a further long distance to provide another half an hour of care in another house, that is not a clever use of that person's time. I ask the witnesses to give their views on that statement. Do they agree that we have a big opportunity to get this right? If we use carers more efficiently, as part of that we will make their jobs more rewarding. I imagine it is deeply frustrating for a carer to spend half an hour with someone and then have to drive a long distance to spend another half an hour with someone else. Will the officials give the committee an indication of how much money is required? It has been suggested that €408 million, along with an additional €9 million for the intensive packages, is needed. How much money is required to meet current demand? How much money would be needed in next year's budget to get these waiting lists down to zero, or whatever low amount is a normal amount within the system?

I welcome the witnesses and thank them for their presentations. I would like to ask about the extent to which the HSE can become involved in ensuring there is a supply of trained personnel for caring purposes. The public and private sectors both provide the service in different formats. To what extent have comparisons been made between the efficiency, effectiveness and quality of service from both sectors? To what extent is this monitored?

I ask the witnesses to comment on the merging of the budgets for the nursing home and home care sectors. I assume that will cover the administration of both private and public home care providers.

Is any vetting done to assess the suitability of people who come into the caring sector? A nurse or a former nurse will be trained and will have a vocational commitment. What efforts are being made to assess people who are coming into the public and private sides of the caring sector for the first time? I ask that question because I want to ascertain how much job satisfaction is going with the job. If the person who is providing the service is satisfied with his or her job conditions, he or she will be in a better position to provide a satisfactory service.

I have asked about costs, efficiency, effectiveness and quality. I also want to know about the comparisons that have been made and about any matters that become obvious in the course of service provision. Where do the majority of staff come from now? Where does the HSE get its home care staff? From what walks of life do they come? I am aware that people of different nationalities are available and helpful.

A valid point was made about social welfare. There should be a meeting of minds. Those who hold responsibilities in both of these areas should certainly meet to ascertain the extent to which the provision of this service can be dovetailed with the maximisation of the availability of people who are on part-time social welfare. This can be done effectively, efficiently and without overlapping.

It is important for the regulations that apply to the public and private sectors to be equal. The same standards must apply to the quality of the people providing these services as well. There much be some consistency in remuneration. If we expect the job to be done by one group on the cheap, and in a different way by another group, we will create discontent. If people feel aggrieved in the workplace in the course of their work, they will not provide the service we desire.

My final question relates to the degree to which the provision of public and private services is affecting the demand for places in private and public nursing homes or public hospitals that cater for people in this age group. To what extent has it been noticed that this is happening?

I will go in reverse order. I ask Ms Metcalfe to deal with some of the issues that have been raised. If she wants to come back in later on, I will facilitate that.

Ms Allison Metcalfe

Okay. The first question that was asked related to why carers are leaving the sector.

Carers are staying in Ireland, from what we see from our members. They are leaving the sector and may be moving on within the HSE because they see it as a better role which is better paid. They are leaving to go where they can get full-time contracts with better prospects which allow them to pay their rents. A lot of them are leaving because as the economy is growing a lot more jobs are becoming available. They are seeing jobs advertised which pay €14 or €15 an hour. There are better conditions. There are many reasons they are leaving. The biggest things is if-and-when contracts. People cannot plan their lives if they are working if and when they are wanted for work. The other thing is that carers are expected to use their own transport to drive from one client to the next. They get no expenses for it. Some carers say their entire wages go on their car. They have nothing left to live on after they have paid for their cars.

One thing that has come to light recently with many carers is they are applying for a lot of jobs. They are preparing themselves. They are going for the interview. They have to pay for their Garda vetting when they go for interview. It usually costs around €20. Then they go for induction training and they have to pay for that also. That will be taken out of their wages when they start working. A lot of them are not even getting a job after all of that. Why are employers putting carers through all of that? What is the reason for it?

One of the other big things is communication. There is very bad communication between the carer and the employer. That comes up with us time and again. It is one of the biggest things.

Ms Allison Metcalfe

It is because carers are seen as the lowest rank in society. I am repeating what I have been told by our members. They feel undervalued and invisible and as if they are the lowest rank. The way they are treated tells them they are the lowest rank and they are undervalued.

That has to be worked on.

Ms Allison Metcalfe

It drastically needs to be worked on because, as the economy grows, we will see more and more carers leaving the sector. Who will care for us?

It will not be long before that.

Ms Allison Metcalfe

The reality is none of us knows when we will need a carer. One does not have to be old.

I will come back to Ms Metcalfe if there are other issues she wants to come in on. I will go to Mr. Ed Murphy now.

Mr. Ed Murphy

The question was about where we will get 25,000 carers. Ms Metcalfe has covered a number of elements of it. In terms of where we will get them, changes in social welfare rules would mean somewhere between 10,000 and 15,000 people could be brought back into the sector. In the agricultural sector, there was a possibility of being able to get more people into the country. About 30% of carers are foreign nationals. We need to open up the possibility of getting more into the country and we need to make it easier. There is no question about it. That will certainly increase the supply of carers. Ms Metcalfe made the point about how commissioning done at the moment with half-hour shifts or one-hour shifts and no pay for travel is an issue. It is a job that should be attractive and wonderful. The people doing the caring are wonderful people. I agree they are not being valued in a number of cases. They are not being trained properly in a number of cases. They are not being supported in a number of cases. Regulation is very necessary to make sure all carers are properly respected. More training and support is required.

Home care has a vital part to play in the overall healthcare continuum. In other countries, home carers are moving up the ranks in terms of providing healthcare, but that needs training. If, with the aid of technology in the home, not only home care but home healthcare is provided, that can greatly influence and contribute to the overall healthcare system, but that needs investment by providers, companies and the HSE. It will give better jobs to carers. To go back to Ms Metcalfe's point, with current commissioning of half-hour and one-hour shifts and travel, there are huge inefficiencies and it does not allow block contracts which would keep more people in the industry for longer. That is very important. Regulation in all its forms is very much required.

Mr. Ed Crotty

I am with the HCCI but my day job is running a home care business. I am based in Dun Laoghaire and we have about 100 carers working for us. I will make a number of observations. There has been talk about the contracts for carers and the way carers are employed using flexible contracts. Many providers offer guaranteed hours, including us. Not everyone is treating it the same way and most probably do not. We certainly offer that where it is appropriate. It is important to remember that many carers want to work in a flexible way. Caring suits people who have 20 or 30 hours a week to give. They may not want to work in a nine-to-five type job and that is why they are carers in the first place. It is important not to lose sight of that flexibility.

In our company we pay for training and the QQI qualifications. We also pay for carers to come to induction. They are a number of clarifications.

Mr. Pat Healy

There are a number of components that I will address and I will ask Mr. Fitzgerald to deal with one or two of them. Deputy Murphy O'Mahony mentioned a number of things. It can be gleaned that there is a challenge for us in maintaining and developing the workforce into the future. That is the biggest challenge. One of the underlying issues over recent years is that we have invested €112 million on the public side over the past three years. We have increased the workforce. There is €408 million. About €200 million is the HSE. There are 6,300 people working for us as an employer and we are running home care services. The private sector runs about €120 million of that, which is about 30%. The voluntary sector is about €80 million of that. We have been growing the sector in recent times but we have come close to full employment in Ireland and therefore we are now in competition with many other businesses like McDonald's, community hospitals, the health sector generally and private providers. There is competition for care staff. That is a significant issue.

A lot has been done by the HSE itself and I have set that out in my briefing note. Working with the trade unions and under the auspices of the Workplace Relations Commission a lot has been done to develop the contract, to make the job more fulfilling for the staff and at the same time to bring the standard up to FETAC level 5 so that the care for the individual is good. That is important. There is a challenge facing us. We have to work collectively to try to address that challenge into the future. Looking to 2031, we could require between 70% and 120% growth in home support when we take account not only of the needs of home support itself, but the shift to primary and community care called for in Sláintecare.

That will require significant resources. It will also require proper training and investment. This also plays into the regulation. We are all agreed that there should be regulation, as Deputy Donnelly has said.

Deputy Murphy O'Mahony specifically asked about the regulation. The Department has indicated that it is preparing the ground for regulation. It is receiving consultation on the statutory scheme, regulation and licensing. The Department has responsibility for driving that. We are supporting the Department, and it is actively engaged in that. We expect that over the coming months it will have the output of that ongoing consultation. That will be valuable in addressing how we move forward on regulation.

Mr. Pat Healy

Exactly. One other important piece is the forum we established, which I referenced, consisting of representative organisations such as the voluntary sector organisations, the private sector and the HSE. Mr. Fitzgerald chairs that process. We have been working with those groups collectively to address many of these issues and to see how we can work collaboratively, each within our own remit, to progress this over time. That is an important thing to say.

In answer to Deputy Donnelly on the conditions of employment, obviously there are different conditions in the three components of the sector to which I have referred. As an employer, the HSE pays rates of around €18 to €20 per hour. There are contracts. Deputy O'Reilly will remember from a previous role that we spent several years working with SIPTU to improve the conditions for HSE workers in the sector. Significant progress was made on that over a period of years, with the benefit of the Workplace Relations Commission, WRC, as it is called now. There is still more to be done on that, but in my briefing note I have referenced the progress that has been made, which is significant.

Part of what Deputy Donnelly was saying was that there must be a balance. On the one hand, we need a flexible service that is responsive to the needs of service users - the people we are serving. If we do not have a contract that works for the staff as well, however, we will obviously run into difficulties around continuity of service and so on. It is important strike that balance.

On the private side, we tender for services. While there is not regulation, we have set out a standard of care that has to be achieved. I have referenced that and the themes that we use. Those themes are drawn from the national standards for safer and better healthcare outlined by the Health Information and Quality Authority, HIQA. We are drawing on what we hope will be the regulated system in the future, and we reflect that in our contracts with private providers. We set a standard that has to be delivered.

The State is paying €18 to €20 an hour. Roughly how much per hour are the private providers contracted by the State paying their carers?

Mr. Pat Healy

It varies. We have a contract, and we provide them with an all-in cost. Included in the contract is a requirement that they comply with employment legislation and so on. We have that in the contract. They are individual providers and contractors in their own right, and they obviously engage and contract employees.

What is a typical wage?

Mr. Pat Healy

It varies.

I know. Mr. Healy is spending vast amounts of money. I presume he has a good sense of how much carers are getting paid.

Mr. Pat Healy

On average, we pay the providers between €20 and €25 euro. They run the full business from that, and there is variation in what they charge. Again-----

Talk to us about the variation.

Mr. Pat Healy

I do not have it. We do not monitor that. What we monitor is-----

Mr Healy does not know?

Mr. Pat Healy

We monitor their provision of the service we are paying them for, and ensure that they are doing that in accordance with their contract. They have to manage their employees in the same way as the HSE manages its employees and the voluntary sector manages its employees.

The figure we were given earlier was about €11 per hour. Does that sound about right to Mr. Healy?

Mr. Pat Healy

I do not know. It varies. I would not want to give a general figure. Evidence has been given today by people who are involved on the carers' side. Maybe Mr. Murphy and the team here could give a better idea, because they are providing the private service. They could-----

It would be good to get it. It is just-----

In fairness, there are a few other members who want to ask questions. I am going to allow them at this stage.

There is at least one question I asked that has not been answered yet. I refer to the comparison between the public and the private sector on effectiveness, efficiency, the standards of care provided and the associated costs.

Mr. Pat Healy

I will ask Mr. Fitzgerald to answer that. He may also answer the question Deputy Donnelly asked about geographic variation across the country. Mr. Fitzgerald has the detail on the lists across the country. I will ask him to cover that as well.

Mr. Michael Fitzgerald

There are two different questions to address. We have been formally maintaining a waiting list for between a year and a half and two years, collected throughout the country. It is ever-increasing and currently has just under 6,500 people on it nationally. A question was asked about whether it varies from one area to another. It does, somewhat. The north side of Dublin city, community healthcare organisation, CHO, 9 has one of the largest waiting lists at approximately 1,400 people. The Galway, Mayo and Roscommon area is at a similar level. There are also waiting lists in the urban areas. West Dublin, CHO 7, has significant waiting lists, as does CHO 8, which covers an area from the midlands up to north-east Dublin. They are the largest. However, they are all carrying significant waiting numbers.

What is driving the difference in waiting lists around the country?

Mr. Michael Fitzgerald

I think there are two pieces. We are collecting information on people who are waiting for new service, that is, they have no service at the moment. We are also collecting information on people who are seeking additional service. We are combining those figures for this purpose. Different levels of resources are available from one location to another. The other piece of it is that provision takes a different format from one location to the other where assessment processes are concerned. They are factors that might be considered in a scheme that would bring some kind of co-ordinated approach.

I am going to allow other members ask questions and then deal with the replies.

My question has not been answered yet. Is there an answer?

Mr. Michael Fitzgerald

I can answer the Deputy's question.

I would like to have it, then.

Mr. Michael Fitzgerald

The Deputy raises the question of whether there is a difference in the standard-----

I asked about the comparison between the public and private sectors regarding standards of care and qualified carers available, and the associated costs.

Mr. Michael Fitzgerald

Whether care is provided by the voluntary sector, the HSE or the private providers, we are all trying to ensure that the same standard of care is provided to the very best capability of the people who can provide it, and to maintain people at home. On a positive note, we are quite successful in doing that. We are talking about providing this type of service to individuals in their homes, sometimes twice or three times a day, at a very high level of personal care in many cases. At any given time we are supporting 50,500 people. That is a fair representation of it.

The second piece is important. Over recent years, as we have assessed of the number of people who, due to demographics, may require additional places in long-stay care, we have not seen that reflected in the number that end up going into long-stay care. One of the factors supporting that has been the increase in the funding provided for home support in recent years, particularly during those key months in winter when we target people who are coming out of hospital after an acute spell and require home support. They are two important things for all of us to bear in mind as we consider-----

Does Mr. Fitzgerald have a view on the merging of the budgets of home carers and the private nursing home sector?

Mr. Michael Fitzgerald

Does Deputy Durkan mean the merger of the home help and the home care package?

Yes. I refer to all the elements.

Mr. Michael Fitzgerald

I think that the HSE would like to see a stand-alone scheme for home support.

The reason we would like to see that is that it should dovetail and should be symbiotic with the nursing home support scheme. The nursing home support scheme is a stand-alone scheme and has been so for a number of years and has worked its way in as a model of service of support of people needing long-stay care. It supports 23,500 people with high-level requirements at any given time. The point we would make is that we would like to see a scheme that would be an alternative to that, an attractive scheme, that would maintain people in their own homes. They would be two quite distinct schemes but they would have to work closely together.

Would there be a merging of the budgets?

Mr. Michael Fitzgerald

No. At the moment, the nursing home support scheme is, on a legislative basis, a Voted scheme in its own right.

In fairness, there are other members who want to ask questions. I want to allow Deputies O'Reilly and O'Connell and Senator Rose Conway-Walsh in. I call Deputy O'Reilly.

I welcome the witnesses and apologise for missing the first portion of the meeting but I was unavoidably elsewhere. The waiting list of 1,400 in CHO 9, which is my area, was mentioned. I would be interested in the witness's view as to whether the unacceptably long waiting list in CHO 9 has any relationship to the drop in the number of nurses in the community because since 2007, we have seen a significant drop in the number of nurses in my area. It is a parochial question but it is a broader issue. Is there any relationship between the cut in the number of nursing staff and other staff in the community and the length of the waiting lists for home support?

I would like to make a broader point. There is a registered recognised trade union that represents home helps and home carers but it is not here. An opportunity should be afforded to it, as the registered body, to speak on behalf of those workers. I understand it has written to the committee.

I have a particular view on this matter and, as Mr. Healy alluded to, I had some involvement in representing home helps before I was elected. My view, which is formed from talking to people in my family and in my community, is that the people who are availing of this home care want to be cared for by people who are being treated decently. These people need care and they want to stay in their homes but they want to know that the people who are caring for them are treated with some dignity and respect. When we have representatives of the private sector coming in and saying they want changes to the social welfare rules, that, to me, speaks to a race to the bottom as regards terms and conditions that I do not think is helpful for the development of a service that we all agree needs to be developed.

In respect of the terms and conditions of employment, and Deputy Donnelly asked a question on this, I have a view as to what is enforceable. Maybe Mr. Healy might be able to elaborate a little more as to what is enforceable as regards the contract. There is no joint labour committee, JLC, for home carers, but there is an accepted rate for the job. I would argue that it should be the rate struck by the HSE. My understanding is that is a million miles from the rate that is paid in the private sector. Maybe we could get some information on the difference. In terms of the contract the HSE has for outsourcing work - the two witnesses will be very familiar with my views on this - there is nothing specific in the terms and conditions on it other than that which is set down in legislation. The only obligation on private sector employers who are clearly in this business to make money - that is their responsibility - is to pay the minimum wage. As long as they are doing that, they are fulfilling the terms of that contract. Are there any plans to put some terms and conditions in it that would be helpful to the workers? I have never heard any value-for-money argument advanced that convinced me in terms of directly employed versus privately provided home help services being better value for money. If I am wrong on that and if the value for money argument can be made, I would ask that the witnesses might elaborate on that.

I am interested to know if anyone has undertaken any kind of a survey of the workers, about whom we are talking, and what the results of it are. Ms Metcalfe, as a representative, might outline in what capacity she represents workers. What are the rules of the association? How do people feed into the organisation and how does that representation work? It would be helpful to me, as a former trade union official, to understand that.

On the variation in the provision of service, there is clear variation geographically. Maybe Mr. Fitzgerald is the right man to answer this question but is there any correlation between where carers are directly employed, or are predominantly directly employed, or where the service is predominantly outsourced? Is there any link in terms of this geographic variation? This is a small country, and an even smaller State, so there should be some sort of uniformity of provision. However, there does not appear to any uniformity of provision. We are interested in understanding what the rationale for that is and where that comes from. The witness might be able to provide us with some insight on this.

My final question relates to the time I spent representing these workers. One of the things we were resisting at the time was a reduction in the call-out. It used to be an hour, which was seen as the minimum. Then it went to 30 minutes. As I was exiting that area, there was talk of a 15 minute call-out being introduced. Can all the witnesses advise what is the shortest call-out service that is offered by them and give an explanation? Quite frankly, if it is anything less than an hour, I would like to hear an explanation as to how they think that is actually going to provide a service to an elderly person.

I thank the witnesses for coming in this morning. Following on from Deputy Durkan's questions about the difference between that which is provided by the private sector and the public sector and the budgets, it makes no sense to me that the budgets would be separate because then it would almost be like a target to be reached rather than basket to take from. Has anybody any figures on the proportion of women in carer jobs? I used to be a carer when I was a student in Tullamore hospital and my memory of it was that it was nearly all women in the job. I refer to the €11 an hour wage and the correlation, which seems very apparent to me, with people working within the childcare sector, that is, that this is a vocational job and people should, out of goodwill, work with somebody and be his or her person of contact on a daily basis. This seems disrespectful to the career of caring and to those people providing the service.

Perhaps the private providers will outline where that margin from €11 to €26 arises. While I understand there are operational costs with a business, it seems excessive that the gross would be €26 and it would net down to €11 for the employee. Can we have some figures on what that margin goes towards? If it is not providing cars or expenses, I would like to know where it is going.

Has any proper qualitative analysis been done on the outcomes for people in their homes in terms of consistency of care? If a person receives home care for 15 minutes or a half an hour every day of the week and it is provided by a different person each day, has there been any sort of analysis done on? It seems logical that it would have a negative impact, especially on older people living alone, where a new person comes into their home every time. It would appear to be very disruptive.

It would also lead to a reduced standard in care because while many carers are not authorised to administer medication, they do check if it has been taken. There is a huge responsibility on the carer in building a relationship with the client. Have the organisations undertaken studies on the negative outcomes for the patient of a lack of consistency in service provision?

On the issue of a separate budget, I am concerned as to why private companies would want it. Deputy Durkan asked about the difference in pay between the private and public sectors, which I do not believe Mr. Fitzgerald answered. When I was doing the job 15 years ago as a student, for me it was a well-paid job. I am sure those who are doing the job now are doing so to fund mortgages and their families and so it is probably not a particularly well-paid job in comparison with other professions. Deputy O'Reilly spoke about the minimum time for a visit, such that carers only have time to stick their heads in the door and check a person's pulse. To my mind, this is the opposite of the word "carer".

I thank the witnesses for their presentations. I commend all of our carers and those who provide home help on the work they do throughout the country, including in my community. This is a battle we have been fighting since 2010 when drastic cuts were made to home help hours. Previous to these cuts, we had a very good system in which people were employed by the HSE, paid a proper wage, and service users knew what they could expect. Why did the HSE break a system that was working?

Allowing people to be cared for in their home is vital. It should be a priority for the HSE. The resources being allocated to this service and the manner in which it is being operated and privatised, however, does not speak to that. There is an imbalance between the words that are being spoken and the manner in which carers and home help providers are being treated. I live in a rural area, where I regularly see carers running from one client to another for half an hour. It is ridiculous. One could not make this up. A junior certificate student would fail if he or she wrote that type of prescription to deliver home care, especially in rural areas. It is bizarre. Has any analysis been done on the cost to the HSE of providing one hour of home help via a private company? What is the saving to the HSE per hour in not employing carers directly?

There are 6,450 people waiting for services, which is crazy. The cost to the HSE of providing each of them with, say, four hours of home care per week, even if provided through the private system at €26 per call, would be €670,000. Has the HSE requested this funding? This is not all about numbers. I know of a 79 year old man who is soon to be discharged from hospital. His wife has dementia, chronic pancreatic cirrhosis of the liver, diabetes and chronic arthritis. They have been told they are not a priority case. This couple is among the 6,450 people on the waiting list. This is so wrong. The funding necessary to provide all of them with services must be made available.

Does the HSE propose to return to the one-hour service? Staff recruitment and retention is a problem because of the if-and-when manner in which services are being provided. The one-hour service is not satisfactory to the person delivering it and it is certainly not satisfactory to the vulnerable person that a carer would not have even have time to speak to him or her. Reference was made to an audit and it being a priority issue. I agree that there need to be standards and proper training, but the HSE is not running an army. My concern is that we will have more layers of management, governance, audits and so on and no carers to provide home help services because people will not be willing to do it. It is not the case that we have full employment because unemployment across Mayo is at 30%. What formal communications has the HSE had with the Department of Employment Affairs and Social Protection around working patterns in this area. Currently, when a person does even one hour per day, his or her social protection entitlements are messed up such that he or she cannot pay the bills and so on. Who in their right mind would be home carer? It does not add up.

There are many other questions I would like to ask but it is difficult to answer questions in batches because one cannot develop the answers.

Mr. Ed Murphy

In response to a question from Deputy O'Connell, approximately 94% of carers are females. The HCCI is one of the private providers working with the HSE. We work for people who come to us privately, as many providers do, and we also do work on behalf of the HSE. In our case, approximately 40% of our work is done privately. Like Mr. Fitzgerald and Mr. Healy, I would not know what other providers pay, be they not-for-profit, voluntary or HSE providers. The HCCI recently carried out a survey of its providers nationwide. The rate of pay within our company is €13.80 per hour.

As a carer might be providing only a 15 minute service, he or she would be earning only a tiny fraction of that €13.80 per hour.

Mr. Ed Murphy

I think the average paid by the HSE under current tender is approximately €23.50 per hour, but I cannot confirm that. As I said, the HCCI rate is €13.80. On top of this, we pay PRSI, bank holidays and annual leave. In all cases, a nurse will assess a client before we go in and on a quarterly basis thereafter. We also have costs around insurance, quality control and office administration. The average cost of efficient administration of an office for any organisation would be in the region of 30% to 32%.

In our case, in terms of a contribution to profit and further investment, we are running at a figure in the area of 6% to 8%. In the past year, to be efficient in our scheduling, customer relationship management and telemonitoring systems, our organisation has spent over €1 million on technology to be more professional and efficient, as well as to provide for better transparency and accountability. The HSE, rightly, requires us to be accountable for every hour we use to ensure there is good value for money for the taxpayer, etc. We have the technologies in place, but they do not come cheap.

We are in a position to pay more and offer better conditions of employment. It could be the same carer doing work for the HSE, but we may use him or her for a private client. If it is a private client, we can offer better conditions of employment such as group hours, not if-and-when contracts, and pay for transport because we are in charge. With respect, in the HSE's case, it has to get the best value for money. If it is not paying transport or whatever else, it is difficult for us to do so. In the case of a private client, we are totally in control, particularly of the travel part of contracts of employment. The average shift with a private client is three hours. In many countries the shifts can be two, three and four hours. It is a different ball game when we are in control in dealing with private clients. Accordingly, one of our genuine recommendations, having seen it in other countries, is the provision of client directed home care. That is where we give the client the choice, but it is not only the client. Up to 70% to 80% of the people making decisions on home care for, say, an 83 year old client are usually the sons or daughters. We give them a choice of provider, whether they want to use the HSE, a voluntary, not for profit or private care service. I do not mind which provider it is. They should have a choice of provider and care plan. One must ensure it is a care plan which suits them. It should not involve a half-hour or one-hour shift or the carer being at the home at 9 a.m. or 11 p.m. They should be given a choice not only of care plan in terms of what, when and how it will happen but also of schedule. If they do not like a provider, they should have the chance to move to another one when and if they want. Consumer-directed care is implemented in many countries. It gives group carers a chance to reduce transport and cluster carers and clients on the same street or in the same area. It gives us flexibility and adaptability we can use with private clients. That is difficult to do in the case of the HSE.

Ms Allison Metcalfe

Health Care Assistants and Carers Ireland is a not-for-profit network. We support carers in all sectors. We saw that there was a gap where carers did not have support. It is a place which provides for open dialogue and support for people who would otherwise be isolated. Many of our members are already members of unions, meaning that it is outside our remit. Many of them tell us that they frequently make 30-minute calls. They have to assist an elderly person to get out of bed in the morning and bring him or her downstairs to have breakfast. Naturally, the person needs care - he or she may have mobility issues - and his or her needs need to be met. Carers are extremely stressed because they know that they will only be paid for 30 minutes, but they will be with the person for longer.

We carried out a survey among our group. Some 44% of carers said they were unhappy with their current employment conditions, while 46% felt unsupported by their employer. We believe, from direct feedback, that there are far too many issues with in-home care services. Regulation and everybody singing from the same hymn sheet are definitely needed. The minimum rate is a big issue. We said €11 an hour, but there are many who are only earning €10.

That means that €11 is the average payment.

Mr. Conor McCarthy

Yes. That is what came out of the survey. We asked what carers saw as a fair wage. The average was €14.50.

Mr. Pat Healy

In CHO area nine, when one makes a comparison, I do not believe it is related to the nursing issue. There are 1,400 in CHO area nine and Galway which principally delivers its own services. It is more about how we have expanded the service significantly in the past three years, which is a good development.

However, there are waiting lists.

Mr. Pat Healy

Yes, there are more people. We flag this issue frequently. The population is ageing and the number of those aged over 85 years is increasing at a significant rate. The dependency levels of those whom we are maintaining in the community are far higher than they were. That is a good point and what we need to develop. The Sláintecare report stated we needed more of it. In the nursing home sector there are private, voluntary and public providers. In this sector it will be the same. The HSE accounts for over half of service provision, while the private sector accounts for 30%. We will require the three components of the sector to work collectively to maximise results for service users.

We do not specifically survey care staff, but we carry out a survey of all HSE staff periodically. Home helps and home care assistants would be involved.

Deputy Kate O’Connell asked about the separation of the budget. There might have been some confusion when I was replying to Deputy Bernard J. Durkan. We are not talking about separating the home care budget. Instead, we see the home care budget being separate from the budget for the nursing home support scheme. Nursing home residential care is different and has its own requirements. There is also a large private sector involvement in it. It is a Vote in its own right, on which we have done a significant amount of work. There is confidence in the Departments of Health and Public Expenditure and Reform that it is a well managed service with good controls, as well as good identification of costs and so on. On the home care side, we have a single resource and budget for all home care services, whether they be private, public or voluntary. It all comes from the same budget.

Deputy O'Connell may have thought we were saying we would separate the home care budget, but I do not think that is the case. I will ask Mr. Fitzgerald to deal with the question on outcomes and how it is linked to our audit and so on.

Senator Conway-Walsh expressed a concern that we were in some way breaking a service that was working well. That certainly is not our view. What the public looks for in the service has changed. Private sector offerings emerged and the private sector is very much part of the system now and the public want to use it. The public wants to have choice. In many locations there are home care offerings from the HSE, the private sector and the voluntary sector. Members of the public want the capacity to have the choice. It is not that the HSE went out looking for the private sector to become involved. It was more the case that the private sector become involved and developed offerings the public was interested in using.

I am sorry, but I do not think that it is the case. People want to be cared for in their home. I have not yet met a person who expressed an opinion on whether or not the care is private or voluntary. Half of the people do not know if it is a voluntary sector, private or HSE service. The witnesses know my view on this, which is that the HSE cut back on the services and allowed the private sector to come in to take what it has now become. Mr. Healy and Mr. Fitzgerald are two people who are directly employed and I would fight just as hard for their jobs as I would for directly employed home helps. A vacuum was created deliberately. Mr. Healy said people want choice but I have never heard anybody say that. They want to be cared for in their own home, but they do not say they want the choice of home care provided by-----

In fairness, I have come across people who have looked for choices so it depends on the area and on the quality of service being offered.

That is to make up a deficit. I imagine that the vast majority of people want to be cared for by the HSE, or else they have no preferences.

Mr. Pat Healy

Certainly, more than half of the people are being cared for through services provided directly by the HSE. For example, 80% of the residential care system is provided by the private sector and 20% is provided publicly. In this sector we currently provide half of the service. It is significant for us and Members of the Oireachtas, in considering what will take place in the period until 2031, that the population is ageing and the demographic is increasing. We will have to work collectively. The HSE set up the forum with the voluntary and private sectors to work collectively to develop the service in the way that will be necessary. This is an important part of the response.

I believe some people use HSE and privately delivered services. At certain times, for example, when the HSE service is not available people can receive the private service and vice versa.

Mr. Pat Healy

That is correct. As Mr. Murphy stated, apart from our funding of the public system for which we use private sector providers to deliver on behalf of the public system, the private sector is also providing private services directly to families. That is separate from our provision. In those cases we try to dovetail services as best we can. We have gone to tender on three occasions and on each occasion we have improved and developed the service as part of the tender. On this occasion we are moving towards the consumer-directed approach, which is similar to the systems in place in other jurisdictions, to which Mr. Murphy referred, under which service users are given a greater say on how the service is delivered. This includes giving choices on times. At times our service offering can be very fixed. We are trying to increase the level of choice through the tender so that individual service users can choose times that suit them, their families and the wider circle of support available to them. This will be a feature of how we must work and we are trying to move into this type of model as we go forward.

Mr. Healy's response is extremely unsatisfactory-----

Sorry Senator Conway-Walsh-----

Mr. Pat Healy

I just want to finish my point.

We will let Mr. Healy finish, after which Mr. Fitzgerald will contribute and the Senator can then speak again.

Mr. Pat Healy

Part of what the HSE is doing in all of this is preparing the sector for the emergence of regulation. That the sector will be regulated in due course is very much on our minds. The Department is holding consultations on the issue and there will be a statutory scheme. We need to make sure the sector is ready and able to meet the challenges of that change when it arises. I invite Mr. Fitzgerald to cover the other points.

Mr. Michael Fitzgerald

There are just a couple of key points, one of which, the prevalence of the 30 minute service, was referred to by a number of members. While much criticism is made of the service, when we asked our professional staff who call up the requirements for service from a care plan perspective, they were anxious to retain the 30 minute service. There are circumstances when a 30 minute call is absolutely appropriate. We certainly would not condone a 30 minute call for a service that would take one and a half hours to complete, or trying to shoehorn a one hour call into 30 minutes. With calls that require toileting people, ensuring they are eating their meals or meal supervision, or that they are up and about their business, a 30 minute call is very much appropriate. It is also very hard to do. Private and voluntary providers and directly provided service providers do not always want to engage in a 30 minute call because it can mean it is a call to be done within their patch or their area. We try to use it this approach as judiciously as possible, but it is an absolute requirement as per our own professional staff.

What about 15 minute calls?

Mr. Michael Fitzgerald

I do not think we do that any more. The recent contract does not have 15 minute calls. The 30 minute visit is the minimum time in contracts.

Fifteen minute calls are no longer used.

Mr. Michael Fitzgerald

No.

Were they deliberately removed from the contract?

Mr. Michael Fitzgerald

In the discussions for the 2016 tender and through the consultation in the forum, all parties felt that 15 minutes was being used to do work that required far greater time and that a 15 minute visit was not enough. Even though people wanted us to increase the minimum call to one hour, our staff was anxious to retain the half hour call, specifically for the reasons I described.

The issue of multiple people visiting a house to provide the service was raised. This occurs when the carers available change and new staff have to be introduced, which is not good from an outcome perspective. It is true that this is not a good approach and we expect our care staff and providers to minimise the need to do that. We are anxious, however, from a best practice perspective to ensure the person receiving care knows a number of carers because there will inevitably be times when carers are on leave or sick leave. For maintaining the relationship between the person and the carer it is sometimes better to have a number of people involved rather than having people becoming dependent on one carer. This is another aspect.

On the main question on what differences regulation might bring compared with the current regime. One of the main issues is to be able to say, through our own tendering arrangements with providers and our own provision of services, that it is all quality assured and to a standard. We will need regulation to do that appropriately and we will all have to comply with it. The Senator raised the concern about audit teams and further levels of management. Our audit teams are not for the purpose of increasing management but to ensure that, as a forerunner to regulation, we can say what type and quality of service are being delivered by all providers. This is done through surveys and oversight of the services currently being delivered by providers. We cannot get away from the whole issue of having proper oversight of personal care. This is a significant issue and the more personal care we provide in people's homes the more we have to be satisfied that there is good governance and good clinical oversight of providers, and that if issues arise, they will be identified and addressed.

We cannot give that assurance today in the absence of regulation. I do not believe any of the providers, voluntary or private, can say that to that degree either. The history of bringing in regulations - as Mr. Healy alluded to - shows that we have to be clear that it is not just to shrink the service to a size we are comfortable with. We have to maintain the flexibility and the good parts of the service, which are really important. We are going into the homes of people and delivering services. We are guests. It is not the same as residential care, and we have to have a regulation that reflects that type of service.

Several of my questions were not answered. The witness spoke about the tendering process and the fact that-----

Which questions were not answered? The Senator might repeat them.

Has an analysis been done on the cost of the provision of the service of an hour of home help from the HSE as opposed to a private provider? What formal communications does the HSE have with the Department of Employment Affairs and Social Protection? Is the witness going to seriously look at applying a one hour minimum?

Mr. Pat Healy

Mr. Fitzgerald has spoken about the one hour minimum. He spoke about the half hour, and why we would keep the half hour time limit.

Is the HSE going to look at bringing back a one hour service? A yes or no answer will suffice.

Mr. Pat Healy

Staff are saying that they want to maintain the half an hour service because there are particular circumstances where only a half an hour is required. A full personal care review would take an hour, but they might want to visit a person for a short period of time to check on particular things.

If that changed would it then be brought up to an hour? The witness has said that the staff are driving this, but I do not accept that.

Mr. Ed Murphy

Is the Deputy talking about the care staff or-----

If the staff themselves wanted it to be changed to an hour would it be changed?

Mr. Michael Fitzgerald

The requirement is connected to the person's care plan. If the requirements of that person changed and there were further additional duties required, an increase from half an hour to one hour, or whatever length of time was required, would certainly be put in place. There are certain aspects of the care plans that only require half an hour. There were many discussions around having a minimum of one hour service, but people felt that half an hour was quite adequate in many circumstances to meet the specific requirements of certain people. The visit might just be a drop in to help a person go to the toilet, to make sure he or she has eaten or has taken his or her medication. It also serves as an oversight or supervision of the person, to make sure the person is getting on with his or her business for the day. A half an hour is adequate for that. My own mother gets the half hour visit every once in a while, and it absolutely fits the bill for her needs.

Mr. Pat Healy

On the question of pay and how we deal with it, from a public sector point of view, the HSE does not set pay rates. The Department of Public Expenditure and Reform sets them, and we fall in with that. We have no choice in that. We pay the rates that the Department of Public Expenditure and Reform sets for public pay. It controls public pay policy and we implement what it decides.

Competition law dictates the private side of things. All of our tenders are fully compliant with competition law, which is quite strict. We comply with that, and specify in that, as Deputy O'Reilly has said, the requirement on the providers to comply with legislation. That covers the minimum wage and so on.

I am talking about the decision-making process in terms of the analysis of whether it is better to have people directly employed by the HSE or whether it is better to provide them through a third party. The witness has said that people wanted a choice, and that is why the service was privatised and thousands and thousands of hours were cut.

Mr. Pat Healy

We have not privatised the service. We currently deliver 50% of the service. Furthermore, the tendering process we engaged in did not cut services but actually increased them. We engaged with private contracting during the tendering because, in the greater Dublin area, we were introducing a far higher level of homecare packages. We were trying to implement homecare packages. The HSE does not deliver homecare in the greater Dublin area; it is done through the voluntary sector. We went to tender, and both the voluntary sector and the private sector compete through a tendering process. It was not done in the context of cutting services but rather in the context of extending services. Homecare packages have been funded, and over the last three years there has been an increase of 112 million hours. The service is now expanding. At the beginning of 2008, when the economic downturn came, there was definitely a contraction of service, but it was not related to the introduction of tendering.

People were left in a situation in March where all of the workers from one of the private providers were gathered together and told that they would no longer be providing care after 15 April. All of those workers were left in a hugely precarious situation and caused huge concern in the community that there would be no home help provided. The witness is-----

Mr. Pat Healy

The Senator might provide-----

-----painting a picture and saying that the tender has been issued and that everything is under control.

Mr. Pat Healy

The Senator might provide details of that incident to me. I am not familiar with it.

To clarify, the witnesses have said that there are now 50,500 people in receipt of homecare packages. What has that increased from? What was the previous figure?

Mr. Pat Healy

I believe it was 47,500.

Mr. Michael Fitzgerald

We have seen it increase over the last number of years from 44,500 to over 50,000 now. More people are being visited by the service.

That corresponds to the demographic change in age etc.

Mr. Michael Fitzgerald

It also corresponds with the additional funding that has been made available over the last number of years.

For 2019, if one was planning a budget, how will people be provided with homecare? There are currently 50,500.

Mr. Pat Healy

We obviously want to prioritise a reduction in waiting lists, if possible, and we would also be looking for an increase to take account of demographics. To stand still, demographics means that we will have to provide more just to keep things steady. We would like to gain sufficient resources to eat into the 6,500 strong waiting list of people who are awaiting service. Some of those already have some service but they are looking for more. Some people have no service.

Mr. Ed Murphy

The issue of the 30 minute shifts has been spoken about at length. I understand where Mr. Fitzgerald is coming from. Home and Community Care Ireland carried out a survey of both our clients and our carers and found that 96% of clients said they would rather not have 30 minute shifts, and 98% of carers said they do not want 30 minute shifts. We have to think of the clients, of course, but we have to think of the carers as well. It is extremely difficult to achieve. There are travel costs, and within the HSE tender there is no automatic right to get travel costs to cover 30 minute shifts. It is not catered for in the tender. Carers and clients do not want it. I would contend that if the 30 minutes was extended to 60 minutes the carers will always find something to do. It might be personal care, housekeeping, meal preparation or medication reminders. There is always something to do in a 60 minute visit, and I am very concerned that we will not be able to retain and recruit carers. The 30 minute shift makes it too difficult. We are not respecting the carer, which is really important here. Sending them around on 30 minute shifts is killing the industry.

Choice is also very important, as Deputy O'Reilly mentioned earlier. Even in the current system there is no choice. The client does not have a full choice of the provider he or she uses.

I am very happy if someone is given a full choice as to whether to use a private provider, a charity provider, a not-for-profit provider or the HSE. Currently people are not given the choice. They are told that the HSE will do it and if it cannot do the weekends, it will do the weekdays and give the weekends to someone else. The client does not have full choice over the provider being used. I do not care who is the right person to do it as it may be internal to the HSE, the local charity or a private entity; let the client and family decide. It should be the local provider and somebody who may have looked after a neighbour or friend. If the clients are happy, that is what matters. Let somebody working two doors down finish with Mrs. Murphy and go to Mrs. O'Connell. It is the right way to do it, whoever that person is and wherever the organisation is. It can be private, public or whatever.

Travel allowance is needed. There are many problems with carers and clients. The HSE has tried to bring in many incremental improvements for all the right reasons. Home care can become a far more vital part of the health care continuum. We might forget about all the issues we have to say we can bring the hospital to the home and train our carers to almost become medical in nature. We can pay them more and provide a more vital service to older people, GPs and the health care continuum. We have the technology to include in the home care package that will not only allow us to look after a person when we are in the home but also enable us to monitor and manage the person's health and well-being when we are not in the home. It could become part of a consumer-directed care package today. We could monitor people 24 hours per day rather than for an hour or half hour as we are currently doing. It is a limited service that we are giving and I am worried that home care is the poorer relation in the health care system. We can do so much better and there is such an opportunity for home care to provide a far more reasonable, cost-effective and vital part of the health care continuum, with the possibility of upskilling carers and introducing technology. We could make a significant difference to health care overall in Ireland.

Ms Allison Metcalfe

I will speak about the 30-minute calls. It is impossible to go to somebody's house and assist him or her with going to and from the bathroom or sitting down in a chair within 30 minutes. I know with elderly people that when I knock on the door, say hello and have a conversation, time is always ticking. They like to chat and the carer might be the only social contact for the whole day. I represent carers today and they want rid of 30-minute calls. We had somebody discussing this only the other day in Westmeath. The person was driving six miles to go to a client to provide 30 minutes of care and then six miles home again. The person did it in the morning, at lunch and at dinner time. Some people are doing those types of half-hour calls and getting €11.50 per hour. I know not all companies are paying that rate but many are. They are paid €5.75 for the 30 minutes, which is quite bad.

The carer is the front-line worker and the person representing the HSE or whatever company in the community. People do not go into caring just for the sake of it and they are naturally very caring before starting that work. They invest in themselves and do their training. All carers must have the required training stipulated by the HSE before they are allowed to go near clients. It is always carried out, to my knowledge and from what members are telling us. There is no point in trying to implement new training for carers if we are not going to deal with drastically improving the conditions for existing carers.

I am concerned about the more than 6,000 people waiting for care. I mentioned earlier the people waiting to get jobs so is there something we can do? We know many carers looking for work so why are so many clients waiting for care when carers are looking for jobs?

It is a fair point. Does Mr. McCarthy have anything to add?

Mr. Conor McCarthy

No, I was about to say exactly what Ms Metcalfe said about 30-minute visits. I agree fully with what Mr. Murphy said about it as well.

Mr. Michael Fitzgerald

I hear very clearly the discussion around the 30 minutes. I can only say that our professional nursing, home care and home support managing staff are very clear about this requirement, although it might be difficult to provide it in a day's routine. If the half hour makes the difference in maintaining somebody at home, it is what we must do.

I will not go over the ground again but it is incumbent on all providers, both voluntary and private, to attract people into this service provision, as we will need them in future.. The HSE will certainly work with them in this regard. From the HSE perspective, where there is a directly provided HSE service, we retain the right to provide those services. If people are refusing to provide services, the only provision might come through the HSE. The direct provision is there and our intention is to maintain direct provision. That said, we want providers for choice, and that has worked quite well in other spheres, such as in nursing homes and residential care services, etc. It is important.

Is there a standardised way of dealing with complaints? Is there a particular complaints procedure for the public, private and voluntary sectors? How does it operate?

Mr. Michael Fitzgerald

There is a complaints procedure. The HSE has its own complaints procedure known as Your Service, Your Say and each of the providers has a requirement for a complaints procedure. In the event of people not being happy with a response from a provider, they can come to the HSE to seek further follow-up with issues. Complaints are made to all providers-----

What is the most common complaint?

Mr. Michael Fitzgerald

One of the most common complaints would be where a person did not turn up.

Yes, that is what I am looking at.

Mr. Michael Fitzgerald

It happens. Given that we have a large workforce and we make many calls on a daily basis, one might expect it. I do not condone such things but it would be expected to be at a higher level. A second type of complaint comes where people might not get on with one another, for want of a better phrase.

How often does the problem with people not turning up occur?

Mr. Michael Fitzgerald

I could not tell the Deputy about frequency but it is certainly the highest level of complaints we have.

Are they all investigated?

Mr. Michael Fitzgerald

They are. In the majority of cases-----

I ask the question because I dealt with such an issue not so long ago and it was a laborious process to get to the bottom of it. I do not know how good or effective is the system but from the patient's perspective, the facts were well established.

Mr. Pat Healy

The quality assurance piece is important from an audit perspective. It needs to be external to the direct provision of the people running the service. There should be regulation in due course.

A really significant aspect for the committee is that when the Department completes its consultations, the development of the legislation and regulation in this sector and the establishment of a scheme will be very significant undertakings. Part of what we are trying to emphasise is that we will have to maintain the flexibility of the system in this one, as well as developing a statutory scheme. If it is to be made statutory and if regulation is to be implemented, the flexibility of the home care service is significant. I agree with what Mr. Murphy and other colleagues said. We are all agreed that it will be a cornerstone of the continuum of care. It is going to be really important and it is very timely. We support the work of the Department in developing this but it will require a lot of close attention to get it right.

I thank Mr. Healy, Mr. Fitzgerald, Mr. Murphy, Mr. Crotty, Ms Metcalfe and Mr. McCarthy for their contributions. I certainly think it was a learning experience for all of us. The Law Reform Commission report on the regulation of home care providers has already been published. There is a draft Bill in place. I know the Department is working on this. However, I hope that, in the context of the work relating to that draft legislation, there will be consultation with our witnesses. They are the people who operate at the coalface. I am also talking about the home care workers. One of the other issues raised was about people who are in receipt of social welfare and their difficulties. They want to make a contribution but they are restricted in what they can do. That needs to be looked at fairly promptly in order to get people into the workplace.

The joint committee adjourned at 11.50 a.m. until 9 a.m. on Wednesday, 13 June 2018.