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Joint Committee on Health debate -
Wednesday, 9 Feb 2022

Home Care: Discussion

Apologies have been received from Deputy Colm Burke. We have one piece of housekeeping before we hear from the witnesses. Are the draft minutes of our public meeting on Wednesday, 2 February 2022 agreed? Agreed.

Today's meeting will be split into two sessions to discuss issues relating to home care. In the first session, the committee will engage with representatives of Age Action, the Care Alliance and Home and Community Care Ireland, HCCI. I welcome Ms Celine Clarke, head of advocacy and communications and Mr. Nat O'Connor, senior public affairs and policy specialist, Age Action; Ms Bereneice O'Rourke, director, and CEO of Communicare Healthcare; and Mr. Joseph Musgrave, CEO, HCCI; and from the Care Alliance, Ms Adrienne McAvinue, home care co-ordinator with the Alzheimer Society of Ireland, and Ms Catherine Cox, a representative of the Home Care Coalition.

Before we hear the opening statements, I need to point out to our witnesses that there is uncertainty as to whether parliamentary privilege will apply to their evidence if given from a location outside the parliamentary precincts of Leinster House. If, therefore, I direct them to cease giving evidence relating to a particular matter, they must respect that direction.

I call Mr. Musgrave to make his opening remarks.

Mr. Joseph Musgrave

I thank the committee for inviting us to appear today. HCCI is the representative body for the private home care sector in Ireland. Our members, and their 10,000 carers, enable more than 20,000 people of all ages who need support to stay living in the comfort of their own homes. We welcome this opportunity to speak on home care issues with a particular focus on the current recruitment crisis. Our chairman, Jim Daly, a former Deputy and Minister of State, sends his apologies. He cannot attend today’s session due to a prior commitment in the European Parliament. I am delighted to be joined by the director of HCCI, Bereneice O'Rourke, who has 17 years' experience in the industry.

Members of the committee, and the wider public, should be in no doubt that we are in the midst of the most acute recruitment crisis home care has experienced in its history. In autumn 2021, the Government was quoting waiting lists for home care of 800 people. As of the end December 2021, the national waiting list was in excess of 5,000 people. This is an astonishing, and worrying, rate of growth. We currently project that our members alone need to hire 3,000 additional home care workers in 2022 just to reach the goal of providing 24 million hours of home care. This does not include the additional staff needed by the HSE and other home care colleagues.

What this means is that thousands of people with conditions ranging from dementia to post-fall rehabilitation must appeal to the kindness of friends or family to get them out of bed in the morning or suffer the indignity of asking for help to shower or use the bathroom. For others, it means being forced to leave their home and local community and be admitted into a nursing home against their wishes. This is the hard reality of a sector that, for too long, has not received the focus its workforce challenges require. This Government has made clear, in the programme for Government and in public statements, that it supports a home first policy.

We recognise that this Government and its predecessor have substantially increased funding for home care by a total of €150 million since budget 2020. While HCCI argued for this funding increase, we made clear that a workforce strategy would be needed to ensure our members could recruit enough home care workers to meet the projected increase in funded hours. In response to the HSE winter plan for 2021-22, we issued a document with workable solutions to ease the recruitment crisis to members of this committee, the HSE and the Government. That only the HSE and, indeed, some members of this committee engaged with HCCI, while the Government did not, is not good enough. Ireland still lacks a national home care workforce strategy. Most countries have a professional carer strategy and, indeed, the EU is currently developing its own care strategy.

HCCI gives credit to the Minister of State at the Department of Health, Deputy Mary Butler, for announcing, at our annual conference in October last year, the creation of a cross-departmental workforce advisory group. The group’s composition, however, has not been published nor have its terms of reference. In private meetings with officials from the Department of Enterprise, Trade and Employment, we have been told that action on items such as employment permits for home care workers will not be advanced until the advisory group produces at the very least interim recommendations.

Nevertheless, the group is welcome, and we recommend that it develops solutions in at least three key areas. The first of these concerns recognition and career. Front-line home care workers were the first line of defence keeping 50,000 home care clients safe from Covid-19 and preventing them going to hospital. We very much welcome the confirmation that they will receive the €1,000 bonus recently announced by the Government. We would like to see the work of the advisory group supported by a public awareness campaign to boost the profile of the sector and explain how rewarding it can be to enable people to retain their independence to stay in their own homes. We strongly believe that there should be a graded career structure in home care so that care workers can advance their careers and benefit from the rewards of taking on increased responsibilities that follow in other lines of work.

The second area where solutions are needed is in access to the sector. There should be more training options for home care workers, with earn-as-you-learn models such as apprenticeships. Currently, anyone interested in becoming a home care worker must either have two Quality and Qualifications Ireland, QQI, 5 modules or be told to get into a classroom before they can start working. This barrier to recruitment needs to change. During the pandemic, when this same QQI 5 requirement was relaxed by the HSE, recruitment doubled. Other countries, such as England and Australia, maintain high educational and training standards for their home care workers, but it is done on the job: there is no reason Ireland should not follow their example. Indeed, HCCI has developed just such a model in concert with the Royal College of Surgeons in Ireland, RCSI, although this has not yet gained approval from the HSE. We also believe carers from outside the European Economic Area, EEA, should be eligible for employment permits to work in the home care sector in the same way they can in hospitals and nursing homes. We must also correct the absurdity that home care workers lose out on certain social welfare entitlements if they take on extra work.

For this cohort of workers, merely taking on one extra hour on a Wednesday to help someone get out of bed could cost them their medical card.

The third area is pay and conditions. HCCI believes home care workers should be paid a minimum of the living wage and that this should be included as a condition of the next home care tender. The workforce advisory group the Minister of State, Deputy Butler, announced should also consider how we can ensure home care workers are paid both travel expenses and travel time. This will increase the cost of providing home care but it is the right thing to do. As described in previous sessions before this committee, the reality is that the HSE sets the conditions of the market. That carers do not receive payment for travel, except in rare circumstances, results from the current procurement practice.

Exacerbating the crisis is the fact that Ireland is more than two decades behind other countries in developing a professional home care sector. The statutory scheme for home care, which would offer a right to all those living in the State to access home care, was first due to come into force last year. We are now expecting it will not be introduced until 2023. It is HCCI’s view that had the State been obliged, through a statutory scheme, to focus on home care then a clear recruitment strategy would have been developed alongside it.

Members of the committee will be acutely aware of Ireland’s aging demographic. They will also be conscious of how severely the Covid-19 pandemic has affected those receiving care. The pandemic should herald a sea change in how we provide support to these people and lead to the sort of far-reaching reform to our healthcare system as the financial crisis had on banking.

Throughout the pandemic home proved, time and again, to be the safest place to provide care for those who need it. During the last two years we never saw cases exceed 1% of our client base of 20,000. That statistic reflects the hard work, adaptability and tremendous effort of home care workers, their office support staff and colleagues from across the HSE, and Government. I would like to take this opportunity to thank all of them for their dedication and collaboration.

While some delay in developing the scheme in light of Covid is understandable, the pandemic is a reason to accelerate work on the scheme rather than pause it. Until recently, the team at the Department, the reform unit, has been understaffed and rotated through three principal officers in less than 12 months. HCCI has confidence in the current team but it should be given every resource needed to ensure its work is completed by the end of this year. In an unfortunate irony part of the reason for the delay in developing the scheme is the fact that three of the four pilot sites are struggling to recruit the needed home care workers to staff them.

If we are to truly realise a home first vision, one where anyone who wishes can be cared for in the safety, comfort and familiar surroundings of their own home, then the workforce advisory group must move into action swiftly. It should make interim recommendations by May at the latest, with final recommendations by July, which should give sufficient time to inform budget 2023. Alongside this, the statutory scheme for home care cannot be any further delayed; committing to a definitive date for its introduction is critical.

We stand at a major intersection for home care in Ireland. One route leads to further delays, inequities and acrimony. This road will lead to the collapse of a home first vision and condemn thousands of citizens to be forced out of their own homes to receive care. The other road, the one the Government purports to follow, is one where access to home care is made a statutory right early in 2023, where being a home care worker becomes a true profession worthy of the name, and where partners work in collaboration to solve the inevitable challenges that will arise. HCCI and our members are ready and willing to do all we can to make this latter vision a reality.

Once again, I thank the members for this opportunity to appear before the committee and we look forward to answering their questions.

I invite Dr. O'Connor to make his opening remarks.

Dr. Nat O'Connor

I thank the committee for the invitation to present Age Action’s views. Age Action advocates for a society that enables all older people to participate and to live full, independent lives. There is a growing consensus that the direction of policy must be to support people to age in place in their communities and to live in their own home with dignity and independence for as long as possible.

The issue of home supports was raised by many people responding to Age Action’s pre-budget survey of their lived experience. Many people told us they wanted to see more supports to allow them and their loved ones to live at home for longer and many said they did not want to be forced into a nursing home. As one person said, what is needed is "...big movement on the expansion of home care. This is critically important for older people who do not wish to be warehoused for the last years of their lives. Older people need to be valued rather than be seen as a burden.". As another person said: "The thousands of carers in Ireland should be more respected and rewarded, not taken for granted.” We need to place greater value on care in our society. If we appreciate the value of care, we will also properly value care workers, paid and unpaid.

Regarding the long-term system in Ireland, the European Commission’s country report highlights many of the problems the statutory home care system needs to overcome. One major difficulty it identified is the lack of national data on the provision of care and on the need for care, including the volume of unmet care needs. While it is important to develop training for and focus on investment in staff we also need a nationwide analysis of what exactly is needed in order that we can reimagine home care, not just patch up a system that is fundamentally not working for many people.

Another problem the European Commission report identified was the inequity between different HSE regions, where different levels of resources are available and different rules apply, for example, with respect to compensation for travel. It also raised concern about the level of unregulated care activity, including informal employment within people’s homes. It also identified, bluntly, that "the challenges ... are huge in Ireland". Specifically, the challenges it identified are to ensure "a quantitatively and qualitatively adequate ... [long-term care] workforce to meet the rising demand for ... [long-term care] and providing a choice and support for informal carers". It specified the training infrastructure and degree of professional recognition of the value of the sector are low, there are low levels of training in the sector and there is a high level of informal work in the sector. A number of barriers need to be overcome.

In October 2021, the Minister of State, Deputy Butler, reported that waiting lists for home care were greatly reduced due to extra funding during Covid but that the HSE now faced difficulty in recruiting care workers. We heard that in the earlier presentation and on the RTÉ News this morning we heard that in the early years sector four out of every ten staff are actively seeking to leave the sector and nine out of ten cannot make ends meet on low pay and conditions. Clearly, in terms of home care, this will be a problem as we move forward unless care jobs come with decent pay and conditions, commensurate with the significant value of care work, as well as the opportunities people need for training and career progression.

It is also important as we build the home care standards and training, that the provisions of the International Labour Organization's Domestic Workers Convention 2011, which Ireland has ratified, and other labour conventions about migrant workers, be adhered to and built on to ensure decent working conditions and protections. Given that Ireland, historically, has relied heavily on EU and non-EU workers in the social care field, there is a need to protect workers from exploitation, particularly in a situation where a person’s right to remain in Ireland is tied to a single employer. Equally, we should ensure any existing workers who are outside of the formal migration system have a pathway to full documentation.

The World Health Organization’s Global Report on Ageism warns there is evidence of ageism in the provision of long-term care to older people, for example, in terms of controlling language, patronising patterns of communication or making unfounded assumptions about older person’s preferences, sexuality or capabilities. Standards for home care and staff training must ensure address these issues.

Services delivering home supports, whether voluntary, private or public, should all be explicitly brought under the scope of the public sector equality and human rights duty. That, in turn, requires that staff are sufficiently trained to be able to prevent discrimination, including age discrimination, and to protect the human rights of those receiving services. Similarly, staff need training to be able to work with the decision support service under the Assisted Decision Making (Capacity) Act’s provisions. There needs to be training and standards in order that staff can do that.

Most important, the recipients of home care should be included in the co-design of the specific service and type of support they wish to receive. Services being delivered in people’s homes should fit around those people’s lifestyles and preferences and not force people to comply with a one-size-fits-all model imposed from outside. This requires sophistication in how home supports are managed in order that staff are given the necessary permission to be flexible and responsive to people’s needs. At the end of the day, home care services should never lose sight of the fundamental goal of providing people with care so that they can live with dignity and independence as long as possible. I look forward to members’ questions.

Lastly, from the Alzheimer Society of Ireland, we will hear from Ms McAvinue.

Ms Adrienne McAvinue

My name is Adrienne McAvinue and I am a home care co-ordinator with the Alzheimer Society of Ireland, ASI. I would like to begin by reading the opening statement for Care Alliance on behalf of the executive director, Liam O'Sullivan:

I would like to thank the joint committee for the invitation to attend this morning... Care Alliance’s focus is on family carers and on supporting our member organisations and others to better support such families. For many families, home care can be a key support in keeping people well at home.

Over three years on from our attendance at this very committee, progress in the area of home care regulation has been slow. The ESRI’s recent reports on topics are welcome, and we look forward to the imminent publication of its further report on the complex matter of the financing of home care.

Our research from a few years ago highlighted the lengthy waiting times that existed for accessing home care. These lengthy waits continue today. We also know that the demand is estimated to increase by between 70% and 126% by the end of this decade.

Covid-19 has clearly impacted on home care provision, but it has also highlighted the invaluable role played by home care workers and the wider family carer community, in minimising vulnerable people’s exposure to Covid-19. This is to be applauded.

I will now move on to my own statement. As I mentioned, I am a home care co-ordinator and I have been working with The Alzheimer Society of Ireland for the past 21 years. Home care has the power to radically improve people's lives. Our organisation welcomes this opportunity to speak to the committee about staffing issues affecting home care.

As we know, it is the preferred option of most people to continue living in their own homes for as long as possible, in a familiar environment linked to their communities. Home care requires more resourcing in terms of time and investment in professional and personal staff development programmes. Due to a low funding base, some organisations are unable to offer any non-essential learning and development opportunities to home care workers. This impedes on their career progression and results in them leaving for better-funded agencies that can often offer these opportunities. A standardised training package for carers across the board, with various levels of training, should be provided.

Home care is highly skilled, yet it is generally low-paid and undervalued work. The additional skills and expertise required in delivering dementia-specific home care are simply not reflected in the remuneration. There is a critical need to standardise home care rates of pay and benefits. With respect, we have lost countless home care workers to the organisation that funds us, the HSE. We train our teams and nurture them. As a co-ordinator of home care service, it is so disappointing and frustrating when our team members leave for better terms and conditions that our funding simply does not allow us to offer.

Our struggle to retain staff has a real impact on continuity of care. Trust between people living with dementia and their families with their home care workers is essential. High staff turnover does not facilitate that trust. Home care work is most often undertaken by a person working alone. There are risks involved in lone working, and home care workers miss camaraderie and social support from colleagues.

Home care workers are not paid for travel time. This challenge is increased in rural areas where more travel is required between home care recipients. Similarly, many home care workers would like to work additional hours, but this is not possible with travel time.

In the Alzheimer Society of Ireland, we mitigate this by offering blocks of hours. While it is a solution to the fractured nature of home care work, it is also quality care. A block of hours gives the person with dementia a meaningful interaction and allows care to be person-centred and not simply task orientated or delivered in a rushed manner. This also provides the family carer with a significant break, which is so important for their mental and physical health.

To conclude today, I would like to speak about how we recognise and value home care workers. We must consider how committee members, as policymakers, value home care workers. If I were a bank manager or financial consultant looking after members' money, I would be handsomely rewarded. Yet, if I were a carer looking after the most precious people in members' lives, I would be on a wage that is just above the minimum wage.

At the end of the day, we either value this work and its people or we do not. In home care, our most valued commodity is our people. We should stop talking about how we value them and instead show them.

I thank the three groups for their presentations. It certainly is a very important area. I think we would all agree with their comments.

Are some of the company's that Mr. Musgrave represents for-profit private providers as well?

Mr. Joseph Musgrave

Yes, all of the members are private for-profit providers.

That is fine. To comment on Mr. Musgrave's statement, he said that he is disappointed that he did not engage with Government, but he did engage with the HSE and some members of this committee. Can he elaborate a little bit on his disappointment and concerns?

Mr. Joseph Musgrave

One of the key missing planks is that there is no workforce strategy from Government level. It has a policy supporting home first, and has, to its credit, boosted funding. However, it has not explained or set out how we can hire the necessary staff, which includes many of the points raised by other contributors here around travel time and also qualifications, which I mentioned.

Our disappointment is that although the Government has a nexus cross-departmental working group, nothing has happened. It has not met. We have not been invited, other than to give a brief enumeration of issues. We have not been invited to attend a session. We have not been told its timeline. We have been talking about this for 18 months to two years. With the HSE, I get a sense of urgency. I met with Ms Anne O'Connor and Ms Sandra Tuohy on Monday. When the deputy head of the HSE is meeting me to talk about home care recruitment, I get a sense that the HSE understands the depth of the problem.

Where I am confused with this is that I would consider the HSE as the wing of Government that would be responsible for negotiating with Mr. Musgrave.

Mr. Joseph Musgrave

The HSE is like HCCI in that we are waiting for a workforce strategy. We have both asked the Department to engage with us to help us on everything, such as apprenticeships, qualifications and engaging around expanding the tender to include things such as travel time. The HSE cannot unilaterally decide to change the procurement practices. It has to get sign-off from Government because extra money will have to be found in order to fund increased pay and conditions.

That is okay. On engagement of committee members, which members did not engage with you?

Mr. Joseph Musgrave

Members of the committee are busy, but -----

Mr. Musgrave is here giving evidence to the entire committee, so I think that element to his statement should be corrected, to be quite frank with him.

Moving on, in terms of Mr. Musgrave's members, what is the profit margin? For example, on the set of accounts, what would he be declaring in terms of a percentage of his turnover that would be net profit at the end of the day?

Mr. Joseph Musgrave

I am not -----

Just on average.

Mr. Joseph Musgrave

Our members have various profit margins, probably between 5% and 10%, on average.

Do all of Mr. Musgrave's affiliated care companies publish accounts? How many of them are limited and how many are unlimited, bearing in mind that unlimited companies do not publish accounts?

Mr. Joseph Musgrave

If a company is below a certain size, it does not need to publish all of its accounts. Probably around half of our members would be below that official threshold although the money that goes to every company is published as part of the HSE's annual accounts process, so that is transparent.

Sure. Would Mr. Musgrave accept that, given the fact that he is publicly funded, all of his companies should be obliged to publish their accounts?

Mr. Joseph Musgrave

Absolutely not. The Companies Act is very clear that if a company is below a certain revenue threshold it does not need to publish full audited accounts, but the money that goes to them is accounted for as part of the HSE's accounts process.

Our members make sure they engage with the HSE to make sure it is accurate. That is right and proper.

I engage with a lot of older people, as we all do, and some of those whom I speak to find the advertisements run by some HCCI operators on national media quite offensive. They pull at heartstrings, using terms such as "To us, it's personal" and so on. What is Mr. Musgrave's view on a regulator being appointed to oversee the home care industry? Has he seen Deputy Colin Burke's Private Members' Bill? What is the HCCI's attitude and approach to the appointment of a regulator which would regulate the industry, including advertising and so forth?

Mr. Joseph Musgrave

We have engaged extensively with Deputy Colm Burke and we fully support the call for regulation. I have been calling for regulation ever since I came into this job in September 2018. I am part of the HIQA advisory group making sure the standards get done. In my opening statement, I called for regulation and stated the Covid pandemic was a reason to implement rather than delay regulation.

I realise my speaking time is over. I apologise to the other two groups that I did not get to engage with them. I mean no disrespect to them; I have huge admiration for the work they do.

I apologise to the Home Care Coalition. I overlooked the opening statement of Ms Catherine Cox. Perhaps Ms Cox would like to make her statement now, after which we can return to questions. My apologies.

Ms Catherine Cox

Not at all. While I work for Family Carers Ireland, I am representing the Home Care Coalition today. The Home Care Coalition is a group of more than 20 charities, not-for-profit organisations and campaigners that was established with the aim of ensuring the implementation of an adequately resourced, person-centred statutory home care scheme in Ireland, with equality of access and availability across the State regardless of age or condition. Care should be based on need rather than means.

Members of the Home Care Coalition have identified a number of challenges regarding home care, which I will outline. We are looking specifically at recruitment and retention. To begin with, we believe an urgent review is required to provide a balance between State, NGO and private sector providers. This would mean an equality of approach to the pay and terms and conditions of employment for home care workers. The constant transfer of the NGO home care workforce to the HSE is a critical factor for the retention of staff because of this inequality of terms and conditions between the State and the NGO sector, in particular with regard to pay for travel. This is a primary obstacle in recruiting people and also retaining them within the home care sector.

Staff in the NGO sector can only be offered low-hour contracts due to organisations not having certainty over the number of hours they are required to deliver by the HSE. This in turn leads to lack of job and income security and significant challenges for home care workers and individuals applying for loans and mortgages. This uncertainty also impacts on organisations' ability to adhere to the Employment Act 2018, which enables part-time employee to request their employer to place them on a particular band of working hours. Additionally, if a home care worker is issued with a banded hours contract and the client goes into hospital or long-term care, the provider must shoulder the financial burden by paying for these hours to ensure compliance with the banded hours. Home care workers do not receive payment for missed hours if a client goes into hospital. This means they are not guaranteed payment if they are not on these banded hours.

Many home care workers work part time on short-hour contracts, with some in receipt of welfare and other benefits such as the medical card. Government Departments need to take this into account and acknowledge the impact that increased working hours could have on a lower paid sector and employment. An issue that is particularly relevant is that under social protection rules for jobseeker's benefit, casual workers can currently work three days or less in order to receive jobseeker's part payment for the days they have not worked. In plain terms, a person can work three full days, which is 22.5 hours, and still get jobseeker's benefit for the other two days. Where a home carer works only one hour per day for five days or even two hours per day, which would be ten hours per week, he or she cannot get jobseeker's benefit because the payment is based on the three-day rule rather than hours.

The coalition believes that workforce planning measures must be established to ensure the workforce has enough skilled staff to support the demand for home care, with particular consideration needed in the areas of dementia and palliative care. We need to clarify the different skill levels within the home care workforce and identify training and education requirements for each of these levels.

The pandemic has meant there is a much smaller workforce to draw from. People in Ireland have been supported to work from home during the pandemic. This was not an option for home care workers. They served on the front line of the Covid 19 pandemic, supporting people who were receiving care and their family carers through times of immense pressure, frustration and stress. Like many front-line workers, burnout is common and the pandemic had impacted on home care staff in a very personal way. Home care organisations have learned that a personal response is important to support their staff through this, and to reflect incidents so that all in the organisation have an opportunity to input and learn from them and maintain quality care provision. Further time and investment are needed for similar initiatives.

The issues I have outlined, as well as many others, such as the non-payment of travel and mileage by the HSE when outsourcing home care hours and the issue of work permits for non-EEA workers in the home care sector, present significant challenges that are impacting on the lives of people receiving care, their family carers and home care workers in the sector. The Home Care Coalition is calling or a clear plan of action that addresses these key issues, particularly around recruitment and retention of staff and also training and development of our home care workers.

I thank Ms Cox.

I welcome all of our witnesses and thank them for their opening statements and work in this area. The purpose of this meeting is to discuss the recruitment crisis in the home care sector. Many of the issues raised by all of the groups are common and may of the solutions proposed are similar. I cannot ask questions of every group. Unfortunately, each member has a strict time limit of five minutes. I hope we will reach all the witnesses in the questions asked by all the members of the committee.

I will start with Mr. Musgrave and refer to some of the points he made in his opening statement, which I believe we would all agree with. The first point was that home care is in the midst of the most acute recruitment crisis it has experienced in the history of the State. Mr. Musgrave also spoke about the need to hire 3,000 additional home care workers in 2022 just to stand still and provide the current level of 24 million hours of home care. This is before we look at any additionality in the years ahead. That is the additional workforce needed. Mr. Musgrave also spoke of the need for a national home care workforce strategy. Other groups called for something similar and, again, I agree with them.

One paragraph of Mr. Musgrave's opening statement is important. He rightly gave credit to the Minister of State, Deputy Mary Butler, for announcing the establishment of a cross-departmental workforce advisory group. I will ask a number of questions based on Mr. Musgrave's opening statement and the opening statements of the other groups. Will the advisory group that has been established look at graded career structure?

Mr. Joseph Musgrave

I thank the Deputy for the question. The honest answer is that we do not know because the terms of reference for the group have not been published.

Okay. I have a number of questions. The answer is that Mr. Musgrave does not know. Will the advisory group consider the development of a professional home care sector?

Mr. Joseph Musgrave

We do not know.

Will it look at a clear recruitment strategy? This matter has been highlighted by HCCI. We will have representatives of trade unions before us later. They and other groups are seeking changes to the complicated centralised system that they say is failing and does not work. Again, I imagine Mr. Musgrave's answer is that he does not know if the advisory group will look at recruitment.

Mr. Joseph Musgrave

On that question I would say that yes, we have been told the group should look at that.

What about pay and conditions? Will the group look at that issue?

Mr. Joseph Musgrave

It should, yes.

The advisory group was announced in October. Do we know if it has been established yet?

Mr. Joseph Musgrave

We have been told it has met unofficially, though not officially.

It has met unofficially.

Mr. Joseph Musgrave

I do not precisely know what that means.

It was announced in October. We are in the middle of a crisis. The Government provided additional money that we all supported to provide additional home help hours. Budget 2021 provided for 5 million hours. Obviously, Covid had an impact on delivering some of those hours, but so too did the lack of staff. That recruitment crisis is one of the reasons we cannot deliver the level of home care we need.

Through the Chairman, I make the point that the committee needs to write to the HSE and the Minister of State, Deputy Butler, to get answers to these questions. Is the working group formally up and running? What is the composition of the group? Does it have terms of reference? Can those terms of reference be provided to the committee? To what timeframes is the group working? When will we see progress? It strikes me there is an urgency coming from our guests today and from the committee. We have agreed to shine a spotlight on this issue because of the work our guests have done, their lobbying and the correspondence we have received from their groups. We are here to get answers to these questions. Our time is limited. I will leave it at that because we will also have an opportunity to contribute in the second session. The best thing the committee could achieve today is to find out what that group is doing, how urgently it will report back and what are its terms of reference. If the terms of reference are not right, we will not solve many of the problems that have been identified. I apologise for not being able to put questions to the other groups; it is due to the very strict time limit we have.

Those are reasonable requests of the committee. I have no doubt members will not disagree. We can discuss the matter in private session.

I can see the committee is kind of balanced, in terms of some of the views coming out, that it does not like private sector home care. A member of my family was in receipt of private sector family home care and that care was second to none. The employees were an absolute credit to the provider. I wish to put that on record.

I am told the HSE pays, on average, €30 to €32 per hour to the private companies. I ask our guests from HCCI to provide a breakdown of the costs of the private companies. We know they pay considerably less per hour to employees than the HSE does. They pay between €10.50 and €12.50 per hour, whereas the HSE pays, on average, €16 per hour. What is the breakdown of the costs differential? Let us take the lower end of it, that is, €30 per hour, and the higher end of the payment, that is, €12.50 per hour. That is almost €18 of a difference. The costs of HCCI providers are 75% more than what the employee is getting. What are their costs?

Mr. Joseph Musgrave

The actual rate the HSE pays a tier one provider is €27 per hour. It is a 1:1 ratio. By that, I mean the HSE pays between €16 and €17 an hour, let us say, to its employees, but it costs it the same amount to deliver the care, so the total cost to the HSE of delivering care itself is approximately €36 to €40 an hour. It is a similar cost in the private sector. By that, I mean the average wage among HCCI members is approximately €12.80 and it costs approximately the same amount again to deliver the care. There are insurance costs and back office support staff - Ms O'Rourke may be able to address that if we have time. It is insurance, training and recruitment costs, as well as the office staff who help to support the infrastructure to deliver care. I can follow up with precise breakdowns to the Deputy by email if that would be helpful.

That would be helpful. There is so much to get through. The representatives of the Alzheimer Society of Ireland raised the issue of the low levels of training. There is a specific aspect of that I wish to raise. I am wondering what is being done about it because it came up at a meeting of another committee that I attended in respect of gender equality. It is quite a significant issue. Typically, I cannot find the reference in question. It can be grouped under the heading of respect. Is that a big piece of training across the sector? I think it was actually Age Action that raised it. Is it a big piece? The written submission provided by Age Action refers to a warning from the World Health Organization, WHO, that:

there is evidence of ageism in the provision of long-term care to older people, for example in terms of controlling language, patronizing patterns of communication or making unfounded assumptions about older person’s preferences, sexuality or capabilities. Standards for home care, and staff training, must ensure address these issues.

Obviously, that feeds into our guests' observations on the overall need for a national framework in respect of that. What steps do HCCI members, as private organisations, take to address those kinds of issues in training in order to neutralise prejudices and ensure home care workers act respectfully in all cases?

Mr. Joseph Musgrave

I will bring in Ms O'Rourke, who works on the ground and may be able to provide a more detailed answer.

Ms Bereneice O'Rourke

I thank the committee for the opportunity to contribute. I am representative of many of HCCI members across the country. My organisation has been in business for 17 years. In fact, we were one of the founding members of the HCCI and have been calling for regulation since day one. In the area of training and development, we put a large emphasis on respect and dignity in the workplace and for our clients. Obviously, our clients are at the centre of everything we do. We have regular training on the issues the Deputy mentioned. That includes how one speaks to people, such as how one addresses a person of a certain age, for example. We have many carers across the country from all over the world who come and work with us. We have rural and urban offices, so are representative of that divide as well. We have our own in-house academy, as do many HCCI members, and there is a significant emphasis on mental well-being for staff and clients. We have regular reviews on that. Supervision and mentoring are significant in the community. We carry out regular visits to the home while staff are present to watch what the staff are saying to their elderly clients and to be respectful in that regard.

Is there awareness of the gender issue, which is an emerging one? It only came up last year in the context of another issue. It took me by surprise but it is actually quite obvious. Particularly with older people, it can be a very private and personal thing because of the generation from which they come.

Ms Bereneice O'Rourke

It is a really good question. We try to match carers to suit the client. The majority of our staff across the sector are female and aged over 40. On the recruitment issues we have, I have never seen anything like it and I have been in the business a long time. Even before the pandemic, trying to recruit male carers, for example, was a real struggle. For the past two years in particular, most of my day is spent dealing with the issue of recruitment and how we are going to recruit staff. We place a strong emphasis on that gender piece to ensure we recognise the personal nature of home care and the importance of respecting the client, whether male or female, and his or her preferences. As all present are aware, the world has changed, and we have to move with that. We have done so. In fact, we brought in our own expert on gender equality to train up our supervisors who, in turn, do a lot of training on the ground with staff.

I invite our guests from Age Action to contribute on that issue.

Dr. Nat O'Connor

The Deputy referred to the global report on ageism published last year by the WHO. It surveyed 55,000 people around the world, including across Europe, and found age prejudice or age discrimination is very common and occurs in many different ways. That is the root issue the training has to address. As a society, there can be obvious age discrimination, but there is also an internalisation of age discrimination, where people are ageist towards themselves, if one likes, and reduce their own expectations of what they are allowed to do, particularly in a care environment. As such, it is very important the care is designed to empower the person to live as independently as possible. Quite a sophisticated level of training is needed. Of course, the fast turnover of staff, as described by other witnesses, means it can be difficult to build up staff training. One can inculcate those values among staff only to see the staff leave again. It is a challenge as part of the training piece.

I have a final question, if I may.

The Deputy is over time. I am stuck for time this morning, given the number of groups that are represented. My apologies.

I thank all the groups in attendance. All their presentations have described very well the scale of the issues and the challenges in ensuring we have a fit-for-purpose care service to meet the needs of our ageing population in a dignified way and that we afford workers in the sector a viable, fulfilling and properly rewarded career. We are very far from that at the moment. Much important time has been lost on this. There was an undertaking to introduce the statutory home care scheme but time is just ticking by on that. It seems incredible that we have not got to the point of setting up the group to consider all of the many issues involved in this — the cross-departmental strategic workforce advisory group. In response to a parliamentary question I submitted in December, the Minister of State said she hoped to set it up in early 2022 and that, in the meantime, she would be consulting for a month or so. Have all the groups made submissions to the consultation?

Mr. Joseph Musgrave

HCCI has.

They are all nodding their heads. That is a "Yes".

That is good. I agree that we now need to have the Minister of State in to see about establishing that group and determine its terms of reference, because time is of the essence.

The critical point is the waiting list that exists. All of us, as Deputies, know that the bar is set pretty high in respect of qualifying for home care. There are currently 5,320 people who have been approved for home care but who are being denied it because of staff difficulties. That is just intolerable.

I raised with the Minister for Enterprise, Trade and Employment the question of work permits for people in this sector. Effectively, he said there was not a skills shortage and that the problem was that the contracts of employment being offered are not sufficient to attract people into the sector. It strikes me that there is a bit of passing the parcel here. The contracts of employment are not attractive enough, yet the terms offered by the HSE do not allow for attractive contracts. There seems to be no meeting of minds regarding the HSE and the needs of the sector. Of course, the Government determines all that.

There is much talk about an apprenticeship model. It is up to the commissioning Department to request places for an apprenticeship model. There is now a lot of money available for apprenticeships but the HSE has not put in the requests yet. Do the delegates all agree that we should operate on the basis of an apprenticeship model?

Mr. Joseph Musgrave

Yes, although we have been told by SOLAS that a level-5 apprenticeship is not suitable for the sector. We have been involved in a level-6 apprenticeship and have been told by the HSE public health nurses that they have hesitations regarding employing that in the home care service. We were part of the consortium. Again, it is a bit like the point on passing the parcel regarding work permits in that we are getting the same thing regarding apprenticeships. Everyone says it is a good idea but when we engage with people we are told this and that are not suitable. It is quite frustrating.

Ms Catherine Cox

A number of years ago, we had an apprenticeship programme for the training and development of family carers and others working in the industry. It did work very well and was quite successful. We would welcome the opportunity to engage with something like that. However, there are some other issues that could be addressed. One that I highlighted was the three-day rule. That is a crucial one to address and change. Somebody can work in a shop for 22.5 hours per week and get two days' jobseeker's benefit whereas-----

I take that point. Has Ms Cox engaged with the Department of Social Protection on that issue?

Ms Catherine Cox

We have raised it and continue to do so. If there were a change to hours rather than days, it would improve the quality and continuity of care. A home care worker could get somebody up every morning and support him or her in getting to bed every evening. It is about better quality and continuity of home care as well as allowing the worker to get more hours. It would be a win for everybody. It could and should be changed.

The other aspect concerns non-EEA workers. They can work in nursing homes but cannot work in the care sector. They are being encouraged into nursing homes, sometimes for less pay, but they are doing it because they cannot work or get work in the home care sector.

That is something practical that the committee can follow through on. Maybe we will forward the point to the social protection committee and raise it with the Minister also. Therefore, there will be some action from today's meeting.

I thank all the witnesses for attending. There is a huge challenge concerning home care at the moment, and there always has been. I was a home care worker for a long time before I was elected to the Dáil, so I have an insight into the home care setting. It is a very rewarding job but it can be very challenging in some cases.

I have some quickfire questions. Regarding travel time and travel expenses, what is the additional cost to the provider? Obviously, this would have a bearing on the worker. What is the hourly rate the HSE gives to a private provider?

Ms Catherine Cox

Since Home Care Alliance is a provider as well as a lobbying organisation, I am aware that its hourly rate is around €13.50. On the point on travel, it would be either half an hour's travel or one hour's travel. Therefore, one could be talking about that same rate again for that hour. It could be a considerable cost but, at the same time, the HSE is providing it for its workers, as we mentioned. I would imagine it would work it out based on mileage rather than on the basis of an hourly cost. It would depend on how far the person is travelling and how long it would take to travel. Mr. Musgrave might answer from the perspective of the private sector.

Mr. Joseph Musgrave

I think it would be similar, but it would depend on whether the travel was in an urban area, where journey times are typically 15 or 20 minutes, or a rural area, where journey times can be from one hour to an hour and a half or two hours, depending on where the care is to be delivered.

Mr. Musgrave may be able to answer my next question. What percentage of home care overall in the State is being provided by the private sector?

Mr. Joseph Musgrave

Of the HSE-commissioned care, around 30% to 40% is delivered by private agencies and 50% is delivered by the HSE itself. Some 10% to 20% is delivered by the non-profit sector. I am not sure of the exact figures right now.

Mr. Musgrave mentioned unregulated practices in home care. Is this prevalent?

Mr. Joseph Musgrave

I believe Age Action raised that point. Its representatives might want to respond.

Dr. Nat O'Connor

With regard to the broader care picture, the issue is that there is much informal care whereby people are simply employed directly to work in somebody's home. They are not necessarily working for an agency at all, or even for a non-profit, meaning there is no regulation or supervision at that end of the spectrum regarding the employment relationship.

It is simply that a person has directly employed someone to work as a carer in the home. If we are going to have a statutory home care system, which perhaps provides funding, how will it interact with the informal care that goes on to make sure it is regularised and regulated?

My next question is on the retention of staff. When there is a haemorrhaging of staff it is for a number of reasons, mainly to do with pay. There are also other factors but pay can be a major factor. According to the HCCI statement, it aspires to provide workers with the living wage. At present the living wage is €12.90. What is the hourly rate for the majority of HCCI members?

Mr. Joseph Musgrave

The average wage among our members is approximately €12.70 an hour.

It is just below the living wage.

Mr. Joseph Musgrave

Yes, it is at or just below it.

The aspiration is to increase this.

Mr. Joseph Musgrave

I would like to see the living wage included as the minimum rated pay in the sector.

Is it possible that someone's hourly rate could be below €12.70?

Mr. Joseph Musgrave

The minimum we have recorded among our members is €11.93.

The private providers get multiples of this. There are overhead costs and I understand this. There is a plethora of private providers and they are doing quite well. The question is why staff, who are very motivated by the work they do and in a very responsible position, are leaving the sector. It is usually down to pay and conditions. The private sector has to look at this. Otherwise staff will not be retained and we will have a perpetual situation with regard to keeping staff.

Mr. Joseph Musgrave

I am not sure whether that is for me to answer.

It is more of a statement. Some of the opening statements this morning also mentioned that the HSE, which is the main funding agency, was recruiting staff and how unfair the system is.

I welcome the witnesses. It would appear that co-ordination is urgently required on the provision of services. In other words there is a multiplicity of organisations all providing services, whether they be public, private or not-for-profit. There is a necessity for a co-ordinated approach. Otherwise it becomes very unwieldy and I think it is unwieldy at present. How do the witnesses respond to this suggestion?

Mr. Joseph Musgrave

As part of a statutory scheme for home care, a national home support office was meant to be set up within the HSE and Sandra Tuohy's team. At present she is managing nursing homes and home care. As the Deputy has said, it is a huge infrastructure to manage. She needs to be given the staff to have the co-ordination oversight in a national home support office.

Ms Catherine Cox

As I am here representing the Home Care Coalition I want to add that there is a co-ordinated approach among the voluntary sector and NGOs. A total of 22 organisations have come together on supporting the implementation of a statutory home care scheme for care in Ireland. It is very much a co-ordinated approach.

Does it operate at present? Is it working?

Ms Catherine Cox

Yes it is.

My question originates from the idea of somebody requiring nursing home quality care at home. How quickly can this be administered? How quickly can the application be processed? Who does the processing?

Ms Catherine Cox

It depends. Home care packages come through the HSE. In some cases the HSE may provide the care. In other cases the care is contracted out to approved home care providers who have tendered for it. Is it quick and swift? Sometimes it is not. It depends on whether the agencies or organisations can meet the demands. For example, they will need to have staff in the area. Given that we are speaking today about the lack of staff and recruitment it can be difficult to fill a care package very quickly. If the first organisation the HSE goes to cannot do this, it moves on to another. It is not as quick as it could or should be. What is very important is that quality care is provided and that the organisation has staff who are properly trained and equipped to provide that level of care. It is not perfect. Perhaps Mr. Musgrave would like to respond on the private sector.

I would like to interpose another question because we are running out of time. There needs to be a model to which everybody can operate. That way the consumer is likely to be best served. Travel time has been mentioned. We politicians have our own way of assessing travel time because we do what we call clinics and the public call various other things. Travel time is hugely important. Reference was made to travel time of an hour between situations. That is totally unacceptable. We have to find a way to get around this. That is an hour when patients' needs cannot be addressed. Whatever happens, some means has to be found to address this down time and travel time. Anything between 20 minutes and half an hour is the maximum that is tolerable to give a proper service. Do any of the witnesses want to comment on this?

Mr. Joseph Musgrave

In Australia the modified Monash model rates areas from urban to rural, with urban being one and the most rural being seven. A top-up payment is given depending on how rural an area is. I do not think we would always be able to eliminate an hour's travel in a rural location but we should be able to limit the amount of travel in urban locations by offering a small supplement to incentivise providers to keep the travel time low and to pay for it properly.

The point has been made on the minimum wage and recruitment. It is a matter for the various services to try to ensure that recruitment and retention are possible. Is there a way to deal with the competition between the HSE and the care sector for employees? I have mentioned co-ordination. A co-ordinated effort should mean people do not bump each other in the course of seeking employment. Some people could be forced out or put at a disadvantage. To my mind a huge degree of co-ordination is necessary in this area if we are to provide a service.

The purpose of the exercise is to provide a quality service to the patients. This is my issue with travel time. It is down time and a way has to be found to narrow it down as much as possible and provide services where they are needed.

Everyone is in the same place.

Every constituency office has dealt with multiple cases in which families have had difficulties in accessing these services and ensuring their loved ones can be looked after in their homes. It is vital. Weekend care has been a major issue. The Chair has already dealt with a significant amount of the work. The work advisory task force has to recognise that pay, conditions and expenses are not cutting the mustard. I have had interactions with the Minister of State on this matter. There have been a number of informal meetings but this group has to lay out what needs to be done. In fairness, the Minister of State has spoken about the many alternatives, including offering tax breaks and allowing people who work in healthcare and who would be able to do this work to do it as a nixer. We have to look at all the issues across the board in respect of visas and so on.

Something has come up to which I would like an answer. It is the issue of weekend care and the expenses, including travel expenses. There seem to be differences in payments between different community healthcare organisations, CHOs. Mr. Musgrave is probably the most likely to have a significant amount of detail on this matter. Could we get a layout of that issue and the associated difficulties?

Mr. Joseph Musgrave

I thank the Deputy. We have records of four CHOs that commonly pay travel expenses, that is, mileage. These are: CHO 2, Galway; CHO 4, Cork; CHO 5, Wexford-Waterford; and CHO 8, Laois-Offaly-Louth. Of the nine CHOs in the country, only four have a record of consistently paying mileage. In other CHOs, it is discretionary. Our members tend to pay an additional supplement to workers to work on weekends and to work unsocial hours to incentivise them and to get as much care to people as possible. The main impediment to continuing that level of service is a simple inability to recruit enough staff. Every group has enumerated the issues we have had with that.

On the issue of contracts more widely, are there variations across the CHOs with regard to how much providers get paid and what they can pay their employees?

Mr. Joseph Musgrave

Yes. CHOs 2, 4 and 5 pay between €3 and €5 as a mileage supplement per home visit. CHO 8 sometimes pays a flat rate of €30 per day to healthcare workers. Again, that is only in parts of the CHO 8 area. It varies quite widely between the four CHOs that have a history of paying it.

This is like an awful lot of other sectors, such as the childcare sector, which was mentioned earlier, in which we are not giving people the respect and pay they need. That is why we are not able to retain people. It is as simple as that. Obviously, the contracts are not fit to do the business we need to have done. We all welcome the fact this work advisory task force is now in place, but it has work to do. I will ask each of the witnesses to tell us, as quickly as possible, what is the minimum we need to deliver for people, to create a sustainable system and, beyond that, to provide people with training and other things they need with regard to their work. If I can be greedy, I will ask everyone to give their view.

Ms Celine Clarke

Age Action would say we need a national care strategy because home supports are part of a continuum of care we need to have in place throughout the life course.

Ms Adrienne McAvinue

To attract the appropriate people, we certainly need to look at pay and progression for staff. We have carers who come to us for interview and who ask whether there is room for progression. Without the training they need, there really is not and, because we are a charitable organisation, we do not have the funding base to offer non-essential training. Pay and conditions need to be looked at.

There is also the issue that was spoken about earlier, which is that you do not necessarily have guaranteed hours if someone is hospitalised, which happens from time to time, sometimes as a result of an insufficient amount of care.

Ms Catherine Cox

To add to that, it is a matter of pay, conditions, the terms and conditions of employment and being able to offer guaranteed hours. Mileage is a very significant issue. There is no doubt about that. To go back to the issue of non-EEA workers, if they could get work permits, it would certainly help. There is no one solution. Combined efforts are necessary. Again, with regard to the three-day rule, if workers could do their five or ten hours over five days, that would help. Given that I come from Family Carers Ireland, it is important for me to state that, as we said a few moments ago, this is about caring for people in their homes, maintaining their independence and dignity for as long as possible, working with their family carers, which they most often will have, and supporting them to continue caring safely for their loved ones. Home help and those services provide a crucial support to allow that to happen.

I believe that is accepted. We have had a number of reports on the difficulties we have and on how we are not addressing elder care as we need to. We need to facilitate people who want to stay in their own homes. If it is possible, I will ask Mr. Musgrave to come in on the wider issue of the contracts required. I accept he is representing private care operators, which obviously intend to make a profit. That is on the record. There is no question about that. However, it is still part of the system and is very much required at this time.

Mr. Joseph Musgrave

I will ask Ms O'Rourke to speak on our behalf on this matter.

Ms Bereneice O'Rourke

I thank the Deputy. As an organisation within the sector, we call on the joint committee, Government and the HSE to work together on this. We do not have all the answers. We have come with recommendations we think are workable. We need to work through them collaboratively. As I have said, we have been in business for 17 years and have seen great change. I have never seen a crisis in recruitment like we have now. However, we do have solutions. We want to make caring a protected profession like nursing and social care work. We need to move on that fast. There is a real opportunity here. I am very hopeful we can make progress if we strip it back, look at what needs to be done, be practical about it and put value on the carer. The client is at the centre of everything we do, but without the staff we have nothing. We would welcome exploration of the recommendations we have made. That echoes through all of the witness statements we have heard today. There is opportunity here and it is good to see we are talking about these matters.

I will finish up. It is vital there is follow-up, particularly with regard to the work advisory task force. We need to put in place a system that is fit for purpose.

To follow up on the issue of staff retention, people clearly feel a lack of self-worth with regard to the work they are doing. On the Covid payments, what is the attitude of members of the various organisations here to the fact they were not included in the Covid recognition payment? Does that play into the lack of self-worth many of those members may feel? We are all aware people were going into homes and did not know whether Covid was present. Let us be honest about it; they were on the front line. Is that lack of recognition another factor?

Ms Catherine Cox

It certainly is. We employ up to 500 home care workers and, when the news hit, first there was joy, then there was disappointment and then there was sheer frustration. Again, they felt home care workers were not being recognised for the work they do. We fought for that payment to be paid to family carers as well. They were not recognised or included either. As front-line workers, home care workers were going into multiple homes. They were up to their ears in personal protective equipment and doing very similar work to that being done in nursing homes and hospitals.

At first, they felt they were not included. Now, we have been told they are included, but it has not been confirmed in full so some organisations are still querying it.

Ms Adrienne McAvinue

We are still waiting for confirmation.

The committee could possibly follow that up with the relevant Minister. One significant issue for many families is the assessment of home care support needs. We have not really touched on it this morning. It is a big issue. Families often come to us and ask how it works out. Perhaps their loved one only needs an hour or half an hour of home care. One complaint in previous years was there was a system-wide roll-out of a single assessment tool in the HSE. There were concerns about various practitioners within the HSE being quite liberal with it in some areas. Is the assessment tool working properly? Is it State-wide? Is it one of the outstanding issues?

Ms Adrienne McAvinue

We do not deliver home care packages. We receive core funding. I manage home care for south Dublin and we receive core funding. I am inundated with phone calls from families about the tool that is used to determine whether someone with dementia and living at home can have a home care package. The tool is used to determine people's ability to shower themselves or go to the bathroom themselves. One could visit somebody in the morning who has dementia and that person could really need somebody in to help with all of those things, but by the afternoon, he or she is really looking for company. It is determined based on whether people can go to the bathroom themselves or need assistance. There is no room for allowing the primary carer time and much-needed respite. I hear that home care packages of a maximum of 21 hours will be delivered, with an hour in the morning, an hour in the afternoon and an hour in the evening.

Much of the time, people would benefit much more from somebody coming in for a block of three hours to give primary carers respite. For example, a couple of years ago, I went to visit the home of a 92-year-old man who was looking after his 86-year-old wife. They had a home care package of 21 hours. That man cried and said he had a home care package of 21 hours. He asked for more to allow him time to go to do shopping on a Friday, collect their pensions and so on. Those 21 hours did not allow that man to leave his home. We need to look at how we deliver and how we assess people for hours of care.

Mr. Joseph Musgrave

The single assessment tool was part of the four pilot sites the Government announced as part of the statutory home care scheme. Only one of those sites is currently in operation. The single assessment tool is being trialled as part of those. One of the two single assessment tool parts is not up and running because staff cannot be recruited to do it. That should in theory solve the problem that is being talked about. There would be a national tool for the first time, but it is still pending, in the pilot stage.

That is a recommendation that goes back to 2018. To elaborate on what Ms McAvinue said, 48% of spousal care involves people caring for their loved ones during every waking moment. Some 54% struggle with mental health and 40% have physical health issues. That has a significant impact on individuals.

Does anyone want to elaborate on the matter of hours?

Ms Celine Clarke

The Chair mentioned the situation with home carers being undervalued. How does somebody who needs care, who is in the middle of that discussion about what we deliver, feel about it? It is desperately important those older people participate in the conversation about what they need. It should not be done through digital means, since they cannot participate. Some 65% of people over the age of 65 experience digital exclusion. Most of what we do is done online. They should be in charge of the determination of what they need. At no point in our lives do we diminish ourselves such that we cannot determine what we need or participate in the conversation about our needs except when we are over the age of 65 and need care. We fundamentally need to root out the ageism in our society, our processes and our institutional approaches to how we manage our ageing population in general. Until we do that, we will not value care or the carer and we will not resolve the problem.

A cross-departmental workforce strategy group was established. Are any of the groups represented here today on that strategy group? Have they been asked to participate in that strategy group?

Ms Catherine Cox

We wrote to the Minister and asked if we could participate in that group. As it has not been set up yet, we are not sure if we will be represented. We hope to be. I refer to Family Carers Ireland rather than the Home Care Coalition.

Family Carers Ireland has sought representation but has not received clarity about the structure or composition of the group or what its terms of reference are. We can add that to the list of questions for the HSE.

We agreed on a number of actions today. The most important thing is for the committee to thank the witnesses and their organisations for the fantastic work they and their members do. We appreciate it. This morning's meeting was informative. It is hoped that some of the actions that come out of it will help members of the witnesses' organisations and, more importantly, those who are badly in need of care. I appreciate the witnesses' attendance this morning. I am sorry it was somewhat disjointed. Five minutes is not really adequate for questions and answers. I thank the witnesses for their time and effort.

Sitting suspended at 10.58 a.m. and resumed at 11.06 a.m.

In this session of the meeting, the committee will engage with union representatives. I formally welcome the second group of witnesses to the meeting. I welcome from SIPTU, Mr. Damian Ginley, sector organiser of SIPTU health division, and Ms Aideen Carberry, assistant industrial organiser of SIPTU health division; and from Fórsa, Mr. Éamonn Donnelly, head of health and welfare division, and Ms Catherine Keogh, assistant general secretary. I invite Mr. Donnelly to make his opening remarks.

Mr. Éamonn Donnelly

Fórsa Trade Union welcomes the opportunity to address the committee on issues relating to homecare, including recruitment issues. Fórsa represents more than 30,000 health workers working in hospitals, the community health system and residential and social care settings, as well as at the corporate centre of health service planning and delivery. We represent workers in direct public service employment, such as the HSE and section 38 voluntary hospitals, as well as workers in section 39 agencies and the private sector. Our members include health and social care professionals as well as clerical, administrative, management and technical staff. We consider it one of the many strengths of this union that our members are central to the delivery of the full array of health and welfare services in Ireland. Fórsa is unequivocally on record as being a strong supporter of the community health intervention and servicing model proposed by the Sláintecare report. Indeed, Fórsa and our members played a pivotal role in the process that established community health networks.

I refer to the current landscape of home support services. Home support services are currently delivered in a fragmented manner by the HSE directly, the not-for-profit sector and the for-profit sector. A recent Economic and Social Research Institute, ESRI, report entitled Demand for the Statutory Home Support Scheme, authored by Dr. Brendan Walsh and Dr. Seán Lyons and published in March 2021, showed that in 2019, 65,346 people accessed home support services amounting to almost 24.7 million hours.

I am having some difficulty with my vision, so I will ask my colleague, Ms Keogh, to complete our opening statement.

Ms Catherine Keogh

We will see how good my eyesight is. I did not realise I would be delivering our opening statement. Of the home support hours referred to by my colleague, more than 18 million hours were funded by the public purse, with the HSE providing access either through the direct provision of 8.2 million hours by HSE staff or by funding the purchase of hours from private for-profit providers. It is noteworthy that HSE standards for the home support service only apply to services received either by or through the HSE. Where home support hours are privately purchased, there are no similar standards.

This presents a real risk to both home support service workers and service users. In a position paper entitled, Regulation of Homecare published, in December 2021, HIQA called for immediate reform, including the introduction of regulation, of Ireland’s homecare services. It is very clear that all commentators, including Fórsa, agree that there needs to be reform of the home support services in advance of the legislation to put home support services on a statutory footing, as envisaged in the Sláintecare report and as set out in the current programme for Government, to ensure a modern, dynamic, fit-for-purpose, adequately funded and standardised service.

Fórsa members carry out a number of key roles and functions in home support services. Our home support resource managers, formerly home help co-ordinators, are responsible for the day-to-day delivery of home support services within primary care and social care. Just over 100 home support resource managers manage the work of more than 5,000 directly employed healthcare support workers, which currently equates to approximately 10 million hours, as well as administering the complex home care package scheme. Fórsa members working as health and social care professionals, including occupational therapists, physiotherapists, speech and language therapists, dietitians, social workers, orthoptists and podiatrists, also form the majority of the multidisciplinary teams that are central to ensuring the evolving needs of home support service users are met.

When the HSE’s national service plan for 2021 provided for 5 million additional home support hours introducing additional capacity for long-term care avoidance and waiting list reduction, it fell on the shoulders of home support resource managers to incorporate these hours into an already overburdened system. The lack of a standardised approach was highlighted by widely differing approaches taken by the nine different community health organisations, CHOs. Some CHOs adopted the view that the increased budget was solely for the additional hours without any additional resources to support the administration of these hours. Other CHOs could see that to ask a home support resource manager to appropriately and effectively maximise the benefit of these hours to the benefit of people on waiting lists meant ensuring ancillary supports were put in place.

Our members working on the front line in delivering this essential service have expressed to us their absolute frustration at the lack of investment in the service over the past 20 years and the effect this has had on recruitment and retention of staff as well as on waiting lists. Fórsa has been highlighting to the HSE since 2018 the necessity for the introduction of a national IT system that will allow for the prompt payment of wages and travel time to the thousands of healthcare support workers who day in, day out are ensuring that people can stay in their homes for as long as possible. It is not acceptable that five years later, the HSE is only in the planning stages of this system and that laborious time-consuming manual systems are still the norm. When I counted five years, I was going "2018, 2019, 2020, 2021 and 2022" so I was not adding an extra year. I was counting them as calendar years.

The HSE has also established with unions and the Labour Court an ongoing commitment to the direct employment of home helps to maximum effect for those with the appropriate skill set. This commitment can only be honoured if those tasked with managing, and those working in, the service are resourced properly. Our members have also reported that they are often working with no clerical administrative support while they are carrying out a complex role with multiple demands. Furthermore, they inform us that the ad hoc approach to recruitment and the inordinate time delay from job offer to start date is a key inhibitor to recruitment of healthcare support workers, particularly in such a competitive job market. While direct employment with the HSE is seen as the gold standard in home care work compared to the terms and conditions offered by the private for-profit service providers, the delays in recruitment processes are a significant factor in the HSE’s ability or otherwise to increase its capacity to meet the growing needs of the population and to upsize to be ready to meet increased demands that will follow the introduction of the statutory scheme.

The solutions to the problems I have set out are clear. There needs to be a standardised approach across all CHOs to the provision of home support services. There needs to be appropriate support structures in place both in terms of a dedicated clerical-administrative resource and a national IT system and there needs to be a streamlined recruitment system. It is important to remember that a great debt of gratitude is owed to the workers in the home support services for their outstanding performance throughout the ongoing Covid-19 pandemic. Through their work, they were able to ensure that as many people as possible received care safely in their own homes at the height of the pandemic. This made a crucial difference to the lives of the people to whom they provide the service and to the communities in which they live. Once again, I thank the committee for its attention and time. We will endeavour to answer any questions members may have.

I invite Mr. Ginley to make his opening statement.

Mr. Damian Ginley

I thank the committee for the opportunity to highlight some observations on this important matter on behalf of SIPTU's health division. I am here with my colleague, Ms Aideen Carberry. SIPTU's health division represents 40,000 workers across private and public health organisations. SIPTU has significant membership across the community home care health sector. When looking at the strategic workforce challenges in front-line home care roles in home support, we must accept at the outset that each is delivered in very different environments with different levels of autonomy and responsibility. Services are delivered through one-off direct HSE public services, voluntary not-for-profit services, which are also known as section 39 organisations, and private home care providers. Organisations compete for home care hours via a tender process.

Our population demographic is getting older. Over the next two decades the proportion of those aged over 65 will increase from 14% of the population to 22.4% and the ESRI predicts that the demand for home support services will rise by 48% in the years ahead. The HSE national service plan for 2021 set a target of 24 million hours for home support services, an additional 5 million hours on the 2020 allocation.

The predominant role within the home care sector is that of health care support assistant, HCSA, formerly known as home help. The HCSA reports to the home support co-ordinator or organiser. He or she provides direct patient care to members of our community in the client’s home environment. With the continued roll-out of community-based services, the demand for this type of role will only increase. The HCSA plays an integral role in the delivery of health services as without same, a larger percentage of our community would require inpatient hospital or nursing home care. Our members were not found wanting during the Covid pandemic.

When we discuss recruitment, we must first look at the different pay arrangements across the sector. Within the direct HSE-run services,significant progress has been achieved for our members in recent years through a number of agreements involving the Workplace Relations Commission, WRC, the Labour Court and HSE circulars. The agreements provide for full access to contracts of employment, recognised travel time, superannuation and sick pay for our members. The hourly rate now established for HSE HCSAs ranges from €14.52 to €18.72 per hour, which is the same as our healthcare assistants in hospital settings.

Staff terms and conditions of employment vary in section 39 organisations. In many cases, pay was linked to the public services until 2008. The HSE cut funding to these services arising from the economic crisis, which resulted in pay cuts being applied. A WRC agreement in 2019 for section 39 organisations approved restoration of pay cuts over three phases. A new ICTU-led campaign for further pay movement within the sector has launched as there remain differences in the terms versus those in the HSE. There is limited, if any, access to paid sick leave, travel time, etc. Section 39 providers have anecdotally cited difficulties with the HSE’s tendering process. They have cited being in competition with for-profit providers, which offer lesser terms and conditions of employment, and, therefore, lose out on tendered work as they cannot afford to offer the work for less than private providers. They also have cited losing out on HSE tenders as being a rationale for not being able to afford to increase the terms and conditions of our members.

Staff working in private organisations are facing significant challenges with regard to their terms and conditions. There are concerns around precarious contracts of employment. Hourly rates start from just above minimum wages rates. Staff have limited, if any, access to sick pay, maternity pay and pensions. The private sector operates on a for-profit model. Workers are not covered by any collective negotiating agreements. In most cases, there is aggressive resistance to trade unions and workers trying to organise. There is evidence to suggest that due to the lack of regulation of the sector, there is large-scale turnover of staff and lack of continuity of care to clients.

It is evident that pay and conditions are mutually inclusive. The development of quality jobs across the sector will result in better service, less attrition, user confidence and, ultimately, quality care. The Sláintecare principle of providing the right care at the right time in the right place will only be achieved when the front-line home care roles are recognised, developed, and paid appropriately.

Recruitment and retention of staff are paramount to the delivery of services. Quality jobs provide quality care. Despite significant progress, we continue to see challenges with recruitment of new HCSAs within the HSE. This results in significant vacancies within the service. The rosters are then filled by agency or private providers. The staff working for the private providers are on reduced terms and hourly rates. It is also evident that there are vacancies in the private and not-for-profit sectors due to high turnover and staff morale within the sector. In recent years, the percentage of homecare provided by HSE is reducing with an increased dependence on private providers.

In some HSE CHO regions, the private provider will potentially be the dominant provider if current trends continue. There is no logic to this from an employee perspective when one considers the terms and conditions outlined above. Why would somebody apply for a role in the private sector first when a similar role is available in the public service with better terms? It does not make sense that a private provider is able to recruit staff on lesser terms while the HSE has numerous vacancies across the regions. Our members have identified vacancies in several regions throughout the country, as outlined in our written submission.

Information suggests that difficulties with the current recruitment model are resulting in vacancies across the HSE. Recruitment is centralised and removed from the home support office. Sometimes it is outsourced. Issues highlighted include a lack of information on upcoming campaigns, delays in progressing campaigns, and unrealistic offers of employment, for example, roles not offered within local catchment areas or contracts offered on significantly reduced hours, such as ten hours. A return of recruitment to local home support offices is required. More home care management resources would assist and ensure localised recruitment campaigns can be progressed in a timely manner. An increase in resources would also address issues raised regarding delays in implementing Workplace Relations Commission agreements, rosters and pay awards within HSE home support.

In conclusion, we would like consideration to be given to the following areas going forward. The improved conditions of employment vis-à-vis public versus private facilities should ensure the HSE is in a better position to attract staff to provide home care services. A renewed emphasis on HSE recruitment campaigns is required with local-county focus - wider national panels have not worked. Continued investment in the roll-out of home care packages is needed in line with Sláintecare and HSE service delivery plans with a focus on delivery of hours via direct HSE employees. We are seeking the implementation of the roster element of the HCSA agreement. This would provide stability to workers while also assisting in addressing some of the other issues raised. Offers of permanent contracts of employment with guaranteed hours, including flexible family-friendly rosters are required, as the workforce is predominately female. Progression of the HSE steering groups established under the WRC agreement is also requested. Career progression options need to be considered to encourage retention through a career pathway for home care workers with ongoing supported training. Increased funding for training is also required to ensure the availability of a Quality and Qualifications Ireland, QQI, level 5 workforce to meet growing demands. There needs to be more engagement with stakeholders on securing directly provided home care jobs for workers in tandem with the increased service plan funding provided to meet the growing demands.

Failure to deliver the key element of increased community services, as proposed under Sláintecare, will have knock-on implications for the rest of the rest of the health system. A clear commitment from Government to directly provide home care support is required. A more focused emphasis on HSE recruitment of HCSA doctors should go some way to removing the race to the bottom in the tender process. There should be a review of the current tendering process to determine actual costs. It is estimated that the cost of providing private home care is equal to, if not greater than, the cost of HSE care despite the low wages applicable in the private sector. We need to remove profit from the provision of home care.

We would welcome the establishment of a collective bargaining forum for staff in the private home care provider sector. SIPTU remains available to engage with parties to ensure the full implementation of the above recommendations and conclusions.

I will move straight to questions. Senator Kyne is first.

I thank Mr. Donnelly, Ms Keogh and Mr. Ginley for their presentations, and I acknowledge the important contribution that healthcare support aids and other staff within the network have provided during Covid and, indeed, provide at all times. We all have experience within our families of the important and valuable work home helps provide. My first question is directed to Mr. Donnelly or Ms Keogh. The need for a standardised approach across all CHO areas was mentioned. Which CHO has the best model or approach? Is that information available to them?

Mr. Éamonn Donnelly

I would not say there is any great CHO that has a great model. Let us look at the way recruitment is done for an organisation the size of the HSE. There is a recruitment hub in Manorhamilton that was part of decentralisation, which does great and fantastic work, but it only has the capacity to handle what needs to be done. One cannot decide to strip Manorhamilton of that function because a different societal problem would be created, therefore, the hub needs to be there. Our view is that CHO recruitment should migrate into the CHO regions. That would leave the Manorhamilton facility to be a real recruitment hub for the non-CHO elements and each CHO would have an agile recruitment system that is capable of recruiting people more quickly and they would be more fit for purpose in each area.

On developing a career pathway, which Mr. Donnelly mentioned, is there a role for better options at higher and further education level or is the pay and conditions issue the main stumbling block and barrier in employing home helps? As is the case in other jobs, such as teachers or crèche workers, it is predominantly female staff who are working as home helps, although not exclusively female. What needs to be done to attract more men into the profession? We are dealing with trying to recruit a sufficient number of home helps from half the population effectively, although recruitment is obviously open to both sexes. What can we do to encourage more men into the profession?

Mr. Damian Ginley

On the career pathway, it is difficult to talk about it in isolation when the private sector is versus the public sector. From the public sector perspective, the foundations have been laid with the establishment of terms and conditions of employment that finally recognise the role of the healthcare support assistant in the community. For years, they were underpaid and undervalued. Therefore, we welcome the developments within the HSE. To build on that, where staff are established and loyal to the service, a career pathway that includes supervisory and additional manager positions would assist our colleagues in Fórsa in the delivery of the rosters they have been asked to manage. It is the staff on the ground who know the service, know the geographical area and know the clients' needs. With the incentive of a career pathway, they would be more inclined to stay within the service.

Would Mr. Donnelly or Ms Keogh like to comment on that?

Ms Catherine Keogh

I echo what Mr. Donnelly said in terms of the career pathway. Fórsa has been working with the HSE to establish a deputy home help grade. It is a new title. The role was called home help co-ordinator. Now it is called home support resource manager. We have been looking to establish a deputy grade. It would make sense that a career pathway is developed for people who know and work in the system and who will stay in the system. At the mention of career pathways, people think that we are just talking about promotions, but it is not about that. It is about capturing the knowledge in a service and making sure it is used to the betterment of the service. We support SIPTU in seeking that career pathway.

On family-friendly working, Mr. Ginley's point is well made. One of the key barriers for our managers who are involved in the recruitment process, in terms of the interviewing piece rather than the Manorhamilton piece, is not having sufficient hours to give appropriate contracts to people who would take the contracts up if they could balance them against their family commitments. We ask the HSE to be agile. Agility is what we need in this regard. Many home support services are needed early in the morning and late in the evening, but people do not want split contracts. The managers of the service and the workers need to have a system that reacts to the needs of service, the needs of the clients and the needs of the workforce.

Is there flexibility at present for those who do not want full hours and want to work fewer hours, as part-time job, be it due to age or burnout? Can they make the decision to work part-time hours? I assume the system accommodates that because it would make perfect sense.

Mr. Damian Ginley

I will focus on the public service. There is flexibility within the rosters at present to allow people to reduce their hours. If adequate resources are not available, the ability of the HSE to provide the full range of service needed becomes challenging. Therefore, we would arrive in a situation where hours are contracted out and that brings its own challenges.

What we are seeking is a fully resourced, direct labour home support service, and those flexibilities would be provided within that in greater arrangements. The same arrangements apply in the private sector where people in some cases start on quite low hours and try to build their hours. There is flexibility there, but the employees say it is less or more limited in the private environment.

I welcome the witnesses. We had many of the advocacy and representative groups before the committee earlier. I am not sure if the witnesses heard their presentations and the issues they raised, but they were very similar to the issues both trade unions have raised. Obviously, there is a consistency across what trade unions and the advocacy groups are seeking. The representative of Home and Community Care Ireland said, "we are in the midst of the most acute recruitment crisis home care has experienced in its history". Would the witnesses agree with that assessment?

Ms Catherine Keogh

It is that stark, and especially at a time, as we mentioned in our submission, when the HSE should be upsizing and getting ready to meet an increased demand when it is put on a statutory footing. There is a lot of common ground between the two unions here. We have to value the work that home support workers do. That is a key issue. These roles were originally known as the home help co-ordinators and the home helps. The key to part of this issue is the names we use to describe the work that was carried out. It was seen as just a job in the parish where somebody went in and did a couple of hours, not as the major function of social care that it actually is. That is part of the reason we are in this recruitment crisis.

Mr. Ginley made a number of points in his opening statement with which I agree. He said that vacancies in the private and not-for-profit sectors are due to high turnover and staff morale within the sector. Is it fair to say that there are problems in recruitment in both the public and private sectors and that the HSE is also struggling to recruit, and that this in turn, as well as the issues Mr. Ginley raised, is putting major pressures on both private providers and the sections 38 and 39 organisation providers in recruitment? Is it a problem across the sector?

Mr. Damian Ginley

Yes, there is a challenge across the entire service. The genesis of our submission is to ask the Government to clarify exactly how it wishes home care to be provided. We have finally established terms and conditions of employment for healthcare support assistants that give them an annual salary ranging from just under €30,000 to just under €40,000 per annum for full-time work. They are finally being recognised. Despite that, we are still hitting barriers from a recruitment point of view in the HSE. In fairness to the HSE managers we are engaging with - for example, there was a recent meeting with CHO area 8 - there is acceptance that there has to be a localised approach to try to speed up recruitment because delays in the HSE magnify the situation.

Is there a problem with a difference in pay or no parity between the public and private sectors? Is that one of the key issues?

Mr. Damian Ginley

Yes, I assume there is a huge challenge for the for-profit providers with regard to retention of staff because having established terms and conditions in the HSE means that people are opting with their feet and leaving. The Government has to decide how home care is going to be provided in Ireland because it is the clients on the ground who are ultimately losing out.

Is it fair to say that both unions have concerns about the recruitment process? SIPTU highlighted as a particular issue the national centralisation of this.

Mr. Damian Ginley

Yes. In the CHO meetings that have been set up to deal with this issue we have called for a localised campaign. To give a quick example, in the midlands-east region people are being offered opportunities, but they are being asked to travel into a different county to avail of those opportunities. It is not practical based on the hours that home care workers are being offered.

Is that because of a national panel?

Mr. Damian Ginley

It is because of challenges with the panel.

I have a question for both of the unions. We had some discussion earlier about the cross-departmental workforce advisory group that was established. Obviously, we hope that advisory group will look at all the issues relating to recruitment, retention, pay, parity between both public and private sector providers in terms of terms and conditions of employment, training and other crucial issues. Has either of the unions been invited to participate in that advisory group?

Mr. Damian Ginley

It is my understanding that requests for submissions were made prior to Christmas and submissions have been made.

The unions have made submissions.

Mr. Damian Ginley

That is my understanding.

Mr. Éamonn Donnelly

I wish to make one remark about the recruitment process that the Deputy referenced. The answer to the recruitment crisis is not to outsource recruitment, but to look at the way the health sector is modelled and match the recruitment process to that within the organisation.

The next speaker is Deputy Shortall.

I welcome the representatives of the two unions. I have a couple of questions for both unions. The first relates to the level of representation they have in the home care sector. How does the representation of public sector workers compare with that of the private sector? The other relates to the cross-departmental strategic workforce advisory group being set up by the Minister. Have the unions received an invitation to participate in that group apart from making a submission? Our understanding is that the group is being put together at present. Has either union been invited to attend? Those are my opening questions.

Mr. Damian Ginley

From the point of view of representation, we have significant levels of density in the public service and we have been able to use that and the ability and strength of workers uniting together to improve immensely the terms and conditions of employment there, as outlined in the submission. In the section 39 organisations we have a limited, but fairly okay, level of density but we are challenged in respect of what we can do. Ultimately, those organisations can only pass on what they get from a funding point of view. That is the race to the bottom and the challenge associated with that. In the private sector, it is much more challenging for the trade unions and our workers who would like to have a voice in that sector. In our submission we have called for a collective bargaining negotiation forum to be established in that regard.

On the Deputy's second question, I can double check but it is my understanding that we have not received a formal invitation to engage in any forum in respect of the advisory group.

Ms Aideen Carberry

To add to my colleague's comments on the representation issue, it is important that the committee note that in the voluntary sector, in particular, which receives a great deal of public funding, we have received some resistance to collectively bargaining on behalf of workers in that area. We have examples of particular employers that have not necessarily been willing to engage with the trade union on that part.

Could the representatives of Fórsa respond to those two questions?

Ms Catherine Keogh

I will take the second one first, which is the easier question. No, we have not been invited, similar to what Mr. Ginley said, unless something has come in during very recent days. We were asked for the submission, but that was it. It is important to Fórsa that it would be invited to such a forum. We have established good working set-ups now within the HSE where the people who are involved in the service are now finally getting to have an input into how current service delivery is planned. However, and we have said this repeatedly to the HSE, it makes no sense to come back to the workers after one has designed the system. It is necessary to talk to the workers when one is designing the system to make sure it is future-proofed and it starts off working well, rather than us pointing out the flaws after the event because nobody asked us.

With regard to representation, from a Fórsa perspective we represent the managers of the system, 99% of which are based in the public sector. We would not have the issues that our colleagues, Mr. Ginley and Ms Carberry, reference. It is key to remember as well that while much of the hours are provided by the for-profit sector, and we referred to this in our submission, that is still funded by the public purse.

Our home support resource managers co-ordinate both the 8 million direct hours and the 10 million purchased hours. We referred to direct employment. From Fórsa's perspective, direct employment is the way to go to ensure that this service is standardised and fit for purpose.

I have just two further brief questions. First, Mr. Ginley spoke about the distinction between the terms and conditions in the public sector and those in the private sector. How is that determined? Who determines the split between public and private? Is it done on a county basis or across CHOs? I sense that much more of the services, certainly in the greater Dublin area, are provided by the private sector. What is the basis on which those decisions are taken? Why does the HSE not provide more services in, say, the Dublin area?

My second point relates to the comments Mr. Ginley made on the WRC and Labour Court success SIPTU has had for public sector workers. What would it take to extend those terms and conditions to the private sector? Would it require a sectoral employment order, and is any progress being made in that regard?

Mr. Damian Ginley

In response to the Deputy's first question, my understanding is that a lot of how home care packages are currently allocated and provided is based on the historical arrangement. As she rightly said, many of these services are provided via the section 39 not-for-profit organisations. We have experienced a significant challenge with that in the greater Dublin region. My colleague, Ms Carberry, has vast experience there. Section 39 organisations tender for work and the problem is that their experience is that they are tendering against organisations in the for-profit sector, which offer lesser terms and conditions again. It has proven very hard for our members in the sector to make any inroads. Ultimately, organisations say the level of funding will determine the rate of pay. We have highlighted in our submission our concern that the public service agreement signed in 2010 commits clearly to the direct provision of labour to the greatest extent possible. In that context we will ask the HSE to ensure that, now we have established HCSA terms and conditions that are respectable, based on the role and the level of responsibility, etc., we build on that. If we do not, and if the private sector is not managed, staff will leave home support services, and that will have a knock-on implication for the wider health arrangements. The whole principle of Sláintecare, as the Deputy will be acutely aware, is about care in the community and at home. If we do not deliver on that, it will end up hitting the hospitals, nursing homes, etc.

Mr. Éamonn Donnelly

If I may add to that, we have discussed the section 39 providers previously in this room, probably in a different forum. The answer there is to have a systemic funding model for section 39 providers. We cannot keep going to the well when we have a few bob and then, when we are economically regressing, taking back those services. All that does is create a bed of straw for what is an essential service. As Mr. Ginley said, and as envisaged by Sláintecare, this care should be a right of people and must be provided on a systemic basis.

On that question, what would it take to extend the WRC agreement to private sector workers?

Mr. Damian Ginley

As Mr. Donnelly alluded to, we have sought under the Congress umbrella engagement with the private providers' representatives to see whether they are willing to engage in a forum that can ultimately work in tandem so we can try to achieve this. That process is ongoing. Ultimately, however, it will take a funding commitment from the Government for this to happen because there are significant differences in the rates of pay.

I need to move on. Deputy Gino Kenny is next.

I thank all our witnesses. This is a very important matter. It is a fact that 50% of home care hours now are publicly provided and probably more than 40% are from the private sector. SIPTU's opening statement states that this trend is moving towards a model of private home care. There is a huge downside to that in respect of pay and conditions. I have just worked out that the mean hourly pay under the HCSA terms is probably €16.50 while in the private sector it is €12.50. That is a considerable difference per hour. A worker is paid probably €4 extra, if not more, in the public sector. Home care providers in the private sector get enormous amounts from the HSE to provide home care. Obviously, they are for-profit organisations and make their profit from that difference while also putting pressure on the pay and conditions of their workers. There is a reason workers are leaving the sector, particularly the private sector, and it is those pay and conditions. There is also a retention issue in that regard. There is no getting away from that, and it spills over into the public sector as well.

My main question is whether that is the case. There is a worry about what we have seen in the nursing home sector. Fifteen or 20 years ago, 80% of home care was provided by the State; now that share is 20% and the roles of the public sector and the private sector have reversed. In the same way as has happened to the nursing home sector, could the private sector essentially take over the home care sector? This should be a service for public good rather than profit. The latter brings with it a downward pressure on workers' wages, which is a really bad thing.

Mr. Damian Ginley

I agree 100% with the Deputy's comments and observations. Not alone is the hourly rate significantly less for our members in the private, for-profit provides, they do not have access to guaranteed hours, sick pay, a superannuation scheme, maternity pay in a lot of cases, etc. It is, in our view, a race to the bottom in respect of terms and conditions of employment. We would therefore be anxious that, given we now have established terms and conditions, the role and responsibility and the efforts of our workers in providing home care be recognised. That is important. We all have family members involved and have seen the benefits of this care. There should not be a race to the bottom and it should not be a matter of securing hours based on how little the worker is paid. The HSE, the Department of Health and the Government have now established these rates with us through the third-party machinery. Our aim is to maximise those hours available to avoid the scenario to which the Deputy has alluded.

Mr. Éamonn Donnelly

The Deputy asked whether what happened in the nursing home sector could happen in this sector. It could, but it would not if we all were to get on board the Sláintecare bus; it is as simple as that. It would be treated as a different type of citizen's right and would be delivered in that way. In the nursing home sector it happened almost by degree and death by a thousand cuts because the for-profit organisations were lurking around looking for this type of business. I do not mean to be disrespectful, but this is a profit-making industry, and we should not allow that to happen.

Ms Catherine Keogh

I see a very real threat to the service at the moment, that is, the fact that the HSE is already unable to fulfil people's needs and giving 10 million hours a year to the private, for-profit sector. As everyone has said, the difference between wages is the profit the private sector has to make. If the HSE does not resource the sector properly with the willingness of the Government, Sláintecare, the Department of Health and so on, we will see that happening. One thing that worries me about nursing homes is that there were some obvious tax incentives that made the area a very lucrative one in which to invest for a long time.

This is why it is so important that this conversation is happening now. We need to resource the sector properly through direct labour to ensure there is no opportunity for the private sector to tell an organisation that it is on a statutory footing, that it will provide statutory home care to every person in the country over 18 years of age now that such a right exists, and that people should not worry about getting it. That is why we are so delighted to be here today to raise these issues. It is vital that we move on this now. I will again echo what Mr. Donnelly said. Sláintecare is the way forward. That is our view.

My final supplementary question relates to the private sector. How profitable is the home care industry? I ask SIPTU and Fórsa to answer that question.

Mr. Damian Ginley

It is hard to give an accurate answer. The number of providers is growing and competition is increasing. There is obviously something of benefit to providers. From our understanding, the cost of providing home care via the private sector to the State works out at a similar cost to providing it directly. We then have to ask where is the difference going from the point of view of hourly rates, etc.

Mr. Éamonn Donnelly

We would add that if we allow what happened in the nursing home sector to happen here, the profit margin will increase. These services are not provided by profit-making organisations out of pure benevolence; it is a combination of providing a service out of benevolence and the fact they are ultimately in existence in order to make a profit. The results would be inevitable.

I thank Deputy Kenny.

I have received a couple of queries about why people cannot choose their own home care provider when they know someone locally, in cases where the HSE cannot allocate one to them.

In my constituency, I have become aware of the issue of childcare. I happen to be the director of a social enterprise. We are not big on social enterprise in Ireland. In Ireland we tend to associate enterprise with profit, but there are many people who are enterprising and would be interested in establishing businesses that are not for profit. I have come across a very interesting organisation in my constituency in Tallaght which provides after-school care for children with special needs. It is a social enterprise. It is a halfway house between private care, which everybody thinks is for profit.

According to the evidence we have heard in this committee, it costs around the same amount for private providers to provide home care as it does for the HSE to do so, if not less. Have we ever considered the social enterprise model? It would mean a service could be provided on a not-for-profit basis but people would be paid reasonable salaries and remunerated accordingly.

Ms Aideen Carberry

I thank Deputy Lahart. As per our submission, there is already quite a substantial voluntary sector providing home support. However, that sector is not providing similar terms and conditions as our colleagues in the HSE have. We addressed that somewhat in our submission. Providers have cited the tendering process, whereby they are in competition with private providers, as creating a difficulty for them in terms of maintaining the terms and conditions of employment and the recruitment and retention of staff.

I would like to mention another issue which may not appear to be connected but is. A PhD student in my constituency came to me recently with a very detailed and interesting questionnaire about our housing stock. I thought it was about social housing stock, but it was about housing stock in a particular part of the constituency from the point of view of people being able to remain in their homes in the long term. As we know, new home builds have completely different building regulations. The survey included things like stair lifts, getting wheelchairs indoors and the fact the required width of houses built in the 1950s, 1960s, 1970s and 1980s is nothing like it is now. The Government retrofit plan has been launched today. There is a retro aspect to making houses livable, in particular older houses, and making it easier for carers to care for people, as opposed to houses having large steps which require ramps to be installed and so on. It is something that the witnesses could make a very rich contribution to. Housing is associated with the caring issue. Do the witnesses have any views on that?

Ms Catherine Keogh

I thank the Deputy for the question. From our perspective, Fórsa has health and local government divisions. We represent workers in local government. We are aware that housing departments in local government provide grants to adapt houses for people as they get older or those with special needs. The Deputy is correct in that a holistic approach to this has to happen. One of the key factors to remaining in one's home is the ability to live, move around and be cared for in it. We see the link between health and local government in terms of providing that service.

Very often local government intervenes when a person becomes less able or incapacitated and it is almost at the point of crisis. All of the witnesses who came before the committee today could offer something really valuable in terms of how the State could anticipate that in order to ensure it is possible for people to stay in their homes for as long as possible. What is the experience of the witnesses of unregulated care activity, such as the informal care of people in their home? Is it widespread? What does the committee need to know about that?

Mr. Damian Ginley

I do not have much knowledge of that. I understand it is reducing in the context of the increasing number of regulations. Carers are now being formally recognised from a terms and conditions point of view, which means the sector has become more formalised and structured.

The Deputy asked about choice. If people were coming to my home environment, I would like them to be paid appropriately, not to have to worry about things like sick pay and to have access to a pension scheme, maternity care, if needed, and guaranteed hours of employment in their contracts. I know when such people come into my home they are committed to me and the organisation and are well settled and structured. That is the choice I would like, from the point of view of a provider of home care.

I have had direct experience of the issue of travel. Carers are predominantly female. Depending on when shifts end, in a 24-hour shift divided between people, a young woman could leave a house in a particular area at 10 p.m. or midnight. Given the focus on events arising in the past month, what kind of concerns do care workers express about that? I am sure there is some kind of preference for walking or cycling rather than using public transport or a taxi in order to save money. What anecdotal evidence do the witnesses have in that regard?

Mr. Damian Ginley

Public service travel is recognised in the new contracts as part of the hours of a contract. It is well established there. Compensation is paid to people who use their cars in the form of mileage. There are also lone working policies established in the HSE which provide mechanisms to support our staff. Advances in technology are also being considered in the HSE to assist people, such as access to phones, etc.

The travel issue has been a major factor in the contributions from NGOs at this meeting.

The compensation piece does not seem to be equitably distributed across HSE regions.

Mr. Damian Ginley

In private and not-for-profit sectors, travel is not included. For example, I could see eight clients today and each client may take 30 minutes but the time taken to travel between client A and client B is not included in many organisations. However, the Labour Court assisted in determining travel being included as part of the working week. In the public service that is now established, so staff get recognition for the amount of time they are spending working. Going back to the race to the bottom concerns we have, our carers were offered contracts with clients that may have been only 30 minutes or 15 minutes in duration but the time spent travelling between those appointments was not included in the working day, creating major challenges for our members in those sectors. I am thankful that in the public service we have progressed.

I thank the witnesses for coming. This is a follow-up from the previous meeting this morning. We are in the middle of a recruitment crisis and there are families who cannot get the carers they want. On some level I also accept these people probably do not care where the service comes from, whether it is the private or public sector, once their loved one can stay at home.

I agree with the witnesses that what we do not want happening here is what happened in nursing homes. The investors were ready to invest and tax breaks were given so - shock and horror - the obvious happened. I suppose at this point there is a recruitment difficulty even with the HSE. There is another element to the crisis in the sense that we are also reliant at this point on private providers, which cannot recruit. We all welcome the workforce advisory group and it has had informal meetings but I am not entirely sure who attended those. None of this will matter until we see some action. There was talk about bespoke solutions that may suit certain people with the likes of tax breaks, for example. That is not necessarily the overall solution but it is a stop-gap answer because we are under pressure.

What is the view of the witnesses of those proposals or what the Minister has alluded to? We could be looking at tax breaks and ensuring people do not lose out on SUSI grants. We might be facilitating people to work in the health service and, for want of a better term, to do "nixer" jobs at the weekend. We also have to deal with the fact that travel expenses are a complete disaster. It seems that with private operators there is an inconsistency across all CHO areas with respect to terms. Will the witnesses speak to that, although we accept that the ultimate solution is for the State to put clear pathways for workers to deal with pay, conditions and expenses so the required service can be directly offered?

Mr. Éamonn Donnelly

Regardless of whether it is private or public, people want to keep their loved ones at home as best they can. There would be a tipping point if that became too expensive. The State has a duty of care to provide home care. It is a different world than what it was 30 years ago. The population is getting older; people are getting more able but there is more sickness.

People are surviving with sickness.

Mr. Éamonn Donnelly

Exactly. We have all of that to consider. The solution is not to say it should all be provided by the State and nothing else but rather that this industry should be regulated that is able to attract people. The terms and conditions should be resourceful enough to be able to provide care in a structured way to meet people's expectations. If people have choices, that is okay. The one point I want to make is that having a choice is grand until it becomes too expensive and then a person no longer has that choice.

Mr. Damian Ginley

Similar to what Mr. Donnelly has said, the biggest challenge we see in the provision of home care in the home is pay. In fairness to the Government, it has increased the funding allocation and the number of hours in this year's budget. If we do not attract people to carry out those duties, we go nowhere. Tax breaks and all these other measures may be considered but we seek an overhaul. Why put arrangements in place that throw good money after bad when we just need to consider the root problem? Similar evidence is growing in the childcare sector, despite the inroads being made there. We face a similar crisis in that sector. In our submission we have called for the opportunity for a collective bargaining mechanism for the private home care providers. That would allow us to establish terms and conditions of employment that could be deemed suitable.

I suppose there are multiple issues. We are reliant on these private sector operators that have built in their profit. HCCI indicated earlier this was between 5% and 10% for companies, on average. They would state there would be a difficulty with the tendering process. If they build in their profit, the State is probably trying to get this on the cheap. Workers will make a determination and go somewhere else where they will get better pay and conditions. I get this.

I can accept short-term fixes for what they are but if we are serious about this, the only action that will keep people in this particular type of work is ensuring the right pay, conditions and ensuring expenses. We could not survive without them and the amazing work they do. The witnesses have spoken about finally valuing the work and this is a type of work that has lost out on the basis that it has largely been a female workforce over many years. We are starting from a bad place and we need to improve the position. If we do not do it, we will be under serious pressure.

What are the big requests from the witnesses? They have said the State must step up on some level. What do individual workers need? I know what has been said about the recruitment system and we need something that is agile, fit for purpose and which can deliver. Beyond that Mr. Ginley said, there are still difficulties with the tendering process.

Mr. Damian Ginley

I am paraphrasing from the full submission but the commitment to direct labour is a key requirement. Terms and conditions of employment have been established in the public service so we do not see why somebody should be doing the same job but be paid significantly less. There is no explanation for that other than it is for profit. The role of home care support is key to the roll-out of Sláintecare because the principle of Sláintecare is care in the community and at home. It is about caring for people who do not need to be in facilities such as hospitals or nursing homes. It is what people want. They want the care delivered in their home where it can be provided.

We ask the HSE to ensure any recruitment issues are addressed and to continue the engagements with us on that. We are asking for the provision of localised campaigns to speed up that process. Separately, we are seeking a process with the Government to establish a collective bargaining mechanism to allow us to engage on behalf of the private and the not-for-profit sector on their terms and conditions. That is to try to get a foundation we can work from.

There is probably an opportunity in that respect at this point. If the workforce advisory group is serious, it should get down to dealing with those specific matters, although there is a need for short-term fixes.

Ms Catherine Keogh

I have a very brief point. We echo everything that our SIPTU colleagues are seeking and we do not need to repeat them. Everything unions seek has a cost but I remind everyone of the astronomical difference between the cost of keeping someone at home compared with the cost of long-term care.

The difference between the two is absolutely astronomical. There is value in investing more in home support services. It makes good fiscal sense, apart from the points that we have made today.

Chairman: The point is that families come to home support service providers. Politicians, in particular, make that point all tha. We heard earlier on that in the submission in relation to people being burnt out, spousal care - they are looking after their loved one day and night. The difficulty of - it was mentioned about people going to the post office, going out to the shops - that head space if your hours are not together. In the SIPTU submission, it mentioned the different CHO 7, CHO 1 and so on and the different vacancies in each CHO. What is the reality of those vacancies not being filled? What is the impact on the ground in relation to those families who are - those vacancies that are there. I ask the witnesses to elaborate on that.

The point is that families come to home support service providers. Politicians make that point all the time. We heard earlier in the witnesses' submission how people are suffering from burnout. In the case of spousal care, people are looking after their loved ones day and night. It was mentioned that people go out to the post office or to the shops to get some headspace if the hours are not together. In its submission SIPTU notes that there are vacancies in different CHO areas. What is the reality of those vacancies not being filled? How does that impact the families on the ground? I ask the witnesses to elaborate on that point.

The other point I wish to raise relates to the announcement of the provision of 5 million extra hours. The witnesses have made the point about there being no administrative supports for management. What does that mean in reality for those hours or for the smooth running of that service if the providers do not have that clerical support? The witnesses have stated that the role of managers is complex and has multiple demands. It is not just about the provision of the hours; it is about the backup package in relation to that. I ask the witnesses to give members a sense of what is involved in that.

Mr. Damian Ginley

I will try to answer as best I can. On the question of the hours, in our submission we just gave examples of a snapshot of information we receive from colleagues on the current level of vacancies. My understanding is that there are efforts afoot to try to address those vacancies around the country. The impact of the vacancies, from the point of view of the organisation, is twofold. Obviously, there is also a knock-on implication for the client availing of the service or trying to avail of the service. What our members are saying to us is that in the offices where they do not have fully resourced staff, they are trying to juggle people around, cross cover and they are making decisions as to who is most in urgent need of care or prioritisation. They are making calls on whether somebody can be - I do not like using the word "skipped" - left today and prioritised tomorrow, and taking measures like that. We understand that where urgent care needs exist, the hours are then going to the private providers, who are backfilling where they can. To assist the smooth operation of the service, which is key for the person who is availing of the service, we need these posts to be filled, because then, our colleagues in Fórsa and their team there could populate rosters to ensure that there are no gaps or fewer gaps in them. They would have the resources available to ensure that if, for example, a worker is unavailable because he or she is on sick leave or annual leave, there is cover in the numbers employed. That way, we can get away from that response reaction, as opposed to a planned approach. As I said, the impact on the ground is that decisions are being taken on whether a full hour or a half hour can be provided to a particular client on a particular day, based on resources. That is the real impact of not having full recruitment.

Ms Catherine Keogh

I wish to comment on the Fórsa members' perspective and that of our home support resource managers. I am just getting to the new title; it was only agreed on Friday. A typical day in the life of those managers could be that on a Sunday evening, he or she receives a a call reporting that one of the home support care assistants is a close Covid contact and he or she cannot go into the home or somebody has symptoms. That worker is there trying to juggle hours. As Mr. Ginley alluded to, it can be so much that they are ringing up a family, with whom they have personal relationships, and asking them, for example, whether they can cover the morning hours for their mam because someone who lives three doors down is in dire need, so the home healthcare assistants are being moved there to do the work. The knock-on effect is that the same resource manager is trying to contact the multidisciplinary team that is dealing with a discharge from a hospital and perhaps contacting a social worker to tell them that the home support package cannot be provided on a particular day, as planned, because they do not have the resources. That frenetic pace of work and the ad hoc, fragmented approach show where the real deficits are. As the Chairman rightly pointed out, at the back of all that are families who are desperate for these resources to be put in place for their loved ones to keep them at home.

I know we keep talking about resourcing the service properly, but it has to be done and it has to be done properly. It has to be done at a national level and it has to be standardised. The members of SIPTU within the public sector now get paid for their travel. It was agreed and it was the right thing to do. However, what the HSE did not do behind it was to bring in an IT system that would create a streamlined function, in this day and age. Instead, there are home support managers who, without any clerical administrative support, are trying to manually update hours on a day-to-day basis as people hand them in a sheet while they travel to a number of homes. It is not right for a worker in this day and age to be waiting on payment. It is also not a good use of HSE resources. Sometimes, because Fórsa proudly represents clerical administrative workers, people say that there are too many managers in the system and there are too many clerical administrative staff. I am often the one who says that there needs to be more. The reason I say that is that the appropriate people should be doing the appropriate work. It makes sense to me to resource home support with a proper clerical administrative function so that the resource manager who is juggling the needs of the clients, the workers and the multidisciplinary teams has somebody there inputting timesheets. A senior manager, with all his or her skills, should not be having to spend three hours of his or her evening updating timesheets because the resources are not there. That is a bad use of money. The actual impact of all of this, because we are all citizens and family members and we all have personal experience of this, is people at home not getting the service they need. It is stark. That is why I made the point that investment in home support services is actually a really good use of taxpayers' money.

Mr. Éamonn Donnelly

I wish to add one point about the home support resource managers. We are very proud of the fact that the much-maligned managerial cohort that we represent are generic and agile, and can move across the health system. However, as with the civil registration service, there needs to be consideration that when we get a bank of expertise in organising home care, we should probably try to hold on to it and not let it migrate out into the generic system. There may be a case for some specialisation of the management function there, given the wealth and bank of knowledge. Many of these people come and develop that knowledge in an industry that is moving at a frenetic pace, as Ms Keogh has described. All of a sudden, they are off somewhere else, they are lost and we must start from scratch. There is a case for looking at that.

In different CHOs or HSE areas, there seem to be different approaches to the issue. That must create a lot of tension. Staff talk to each other and discuss what is happening in one area that is not happening in another. That creates all sorts of problems within the system itself. It seems to be a crazy system. One can understand that the Minister was under pressure to announce the provision of extra hours, but we also need that backup. We all accept that we need more hours in the system. Is this one of the boxes that we need to tick if we are seeking to deliver these far-reaching solutions to the challenges that are out there to ensure that we have the basic supports in place?

Mr. Damian Ginley

Yes, 100%. It is good that there is increased investment from the point of view of more hours, but that needs to be supported properly and funded. Hours need to be structured and fit for purpose. There are good practices out there. I am not going to sit here today and say that it is all bad. However, we must learn from the lessons we have. We must accept now that there are accepted terms and conditions of employment for the sector and afford people access to permanent contracts with guaranteed hours. All that falls into place then and improves the delivery of care that is being provided. Ultimately, we are strong in our call for the removal of profit from the delivery of home care.

Lastly, the issue of section 39 workers and how unfair that whole system is was discussed at a meeting a few weeks ago. In some cases, workers have not received a pay increase in ten years and do not have a pension, and so on. I do not know whether it is the same here, but in other sectors, what happens is that section 39 workers are headhunted by the private sector.

Is that also another factor in relation to this area?

Mr. Damian Ginley

It is all running in tandem. Both SIPTU and Fórsa are engaging nationally in respect of section 39 organisations and trying to improve the pay issues but we are being met with resistance. Unfortunately, unless a principled position is adopted by the Government, as Mr. Donnelly alluded to earlier, we will continue to be chasing organisations. The impact of that is that the good people will move on. They will vote with their feet and move elsewhere.

The Government needs to be using its voice.

Mr. Éamonn Donnelly

I wish to come back to a point on the CHOs that intrigued me. Perhaps it is a little bit of food for thought. Notwithstanding the fact that we need a regulated sector, that it should not be a profit-making sector and all of the points on which I share the views of others, I am not so sure that having a different approach from CHO to CHO is altogether a bad thing. The reason I say that is there are different demographics and societal factors in each CHO. If we are moving towards the Sláintecare vision, we are eventually supposed to end up with integrated care areas that have a devolution and an autonomy. We must prepare ourselves for that day. I am not so sure that a different approach across the CHOs is necessarily problematic. What is problematic is differences in standards and standards of employment.

Ms Aideen Carberry

I wish to add to Mr. Ginley's comments on the difficulties faced in the voluntary sector, in particular. What we find anecdotally with section 39 voluntary sector organisations, across Dublin in particular, is that they may have longer-term members of staff who are more than happy to stay but the real difficulty they are facing in respect of recruitment and retention is with younger staff. In many cases, they do not offer the likes of guaranteed hours contracts. Where they do, the number of hours guaranteed is quite low. Younger people coming into the sector are obviously looking for good terms and conditions. We are hearing a lot about the cost of living crisis and the housing crisis at the moment. As a result, these individuals are going to the likes of the acute sector and the HSE.

I think we have come to the end of the questioning. The engagement has been helpful and informative. Do the witnesses wish to make any concluding remarks?

Mr. Damian Ginley

No. We thank the committee for the opportunity to attend.

We appreciate the witnesses' attendance. Hopefully, some action will be taken as a result. As was discussed in the first half of the meeting, there are a number of actions that we, as a committee, will follow through on. I appreciate the witnesses taking the time to attend and inform the committee today.

The joint committee adjourned at 12.23 p.m. until 11 a.m. on Tuesday, 15 February 2022.
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