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JOINT COMMITTEE ON HEALTH AND CHILDREN debate -
Thursday, 30 Nov 2006

Leas Cross Report: Presentations.

The purpose of this part of meeting is a discussion with Professor Des O'Neill on the Leas Cross report. I welcome Mr. Pascal Moynihan from the HSE who is here to observe proceedings. The Minister of State at the Department of Health and Children, Deputy Seán Power, and his officials will join us later.

I propose to ask Professor O'Neill to give a presentation of 15 minutes duration. Thereafter we will have questions from members for approximately 25 to 30 minutes.

I have no difficulty with those arrangements. If there is a need, however, I hope we will be permitted to ask further questions.

The deadline is not set in stone. We will try to limit ourselves to 30 minutes but if further questions need to be asked, members may proceed to ask them.

That is perfect.

I welcome Professor O'Neill and call on him to commence his presentation.

Professor Des O’Neill

I thank the Chairman for the invitation to address the committee.

In the first instance, I wish to outline some of the context because it is quite important, particularly in terms of what sometimes are negative, popular perceptions on ageing. The most important thing is to emphasise that ageing is the most positive development to happen in our society and the fact that most of us will live to later life is to be welcomed.

My first slide uses a potent metaphor. The National Gallery contains a wonderful selection of art from Louis le Brocquy who turned 90 this year. We will not all be artists like Mr. le Brocquy but the slide presents a metaphor for the creativity and contribution we can all bring with us to later life.

The next slide relates to a CD prepared in our department in respect of music that people composed later in life. A huge number of individuals composed their greatest and finest music in their later years. Old age brings very positive things to the fore. It is important to stop discussing demographic timebombs and talk instead about the demographic bounty and the fact that older people have a huge amount to contribute. Dr. Garret FitzGerald continues to contribute in a meaningful way. I would place him among hugely important political leaders who, after the age of 65, contributed enormously to their countries. I refer here to Mannerheim of Finland, Churchill and Reagan.

Another myth that must be debunked is that we are faced with some catastrophic tidal wave of disability. Thanks to improved health and wealth, the level of disability in the developed world is decreasing. Among older Americans, it is dropping at a rate of 1.5% per year. As members can see from the graph on the next slide, the blue line represents what the level of disability should have been and the red line represents the actual level. Older people are fitter and healthier and this is evidenced by the fact that nursing home usage in the United States is dropping, both in relative and proportionate terms, and nursing home usage here flatlined between 2000 and 2004. There is no demographic timebomb or impending catastrophe. There is, however, a significant issue to be addressed, which is manageable in a professional and appropriate way.

There have been hugely positive developments in Ireland. The title of my presentation is "Good intentions are not enough: moving to an informed and supportive care system for vulnerable older people with complex illness and disability in Irish nursing homes", but major medical advances have been made. The medical card for those over 70 is an extraordinary advance, with very good evidence that it is leading to improved health among older people. The home-care packages, although not perfect, represent a major advance. This week's decision on community rating is important for older people and there have been increases in the number of specialists. It is important to try to present a balanced score card.

We still, however, have difficulties in recognising the central role of older people in society in a number of areas. The Kennedy report in the 1980s mentioned that the major problem with our hospital system is that we do not put older people at the centre as a core-client group of our hospitals. When it comes to new-build and major capital projects, the last department to be built is that relating to specialist care for older people. The Kennedy report stated 25 years ago that our priorities are wrong.

There are major concerns in gerontological circles regarding an under-discussed shift away from defined benefit to defined contribution pensions, particularly as the most important factor in a healthy old age is a secure and adequate income. In that context, equity release schemes are highly unjust. We need to move more towards tailored health care. As mentioned in the review, there has been a shift from public to private nursing homes without significant debate taking place. All the literature indicates not that the private sector cannot manage nursing home care but that the task is much more difficult in terms of maintaining quality.

There have been warning signs regarding problems relating to quality. The National Council on Ageing and Older People, under its various names and over a period of 25 years, issued eight reports which have consistently stated that we have not addressed this issue. The Commission on Nursing, the Irish Society of Physicians in Geriatric Medicine, both in 1997, and, more recently, the Human Rights Commission and older people's advocacy groups commented upon this matter. Until now, what they stated has not had a huge impact but the cumulative effect of their remarks is important.

Let us try to obtain some idea of how important this matter is to members and me. Although at any one time in most developed countries 5% of all older people will be in nursing homes, the issue is that towards the end of our lives the risk that this will happen to us will increase. When the women in this room reach 65, they have an almost 40% chance of spending time in a nursing home. For the men, the figure is 25%. This matter, therefore, will have a major impact on everyone at this meeting.

Why are people in nursing homes? This is an extremely important matter because one of the fallacies abroad is that it is some form of social-hotel type care. The key issue revolves around disease and disability. My next slide relates to Bowman's study of 10,000 beds in the BUPA system in Britain and shows that the majority of people to which it relates had disabling neurological diseases, such as dementia, 38%, stroke 25%, parkinsonism, neurological trauma and multiple sclerosis. Disease and disability, rather than social factors, lead to people requiring long-term care in nursing homes. Dementia, stroke and other neurodegenerative diseases dominate. In light of the current system, the needs of the vast majority of people in nursing homes could not be met at home. It is often stated that between 10% and 15% of people are low-dependency individuals. It is important that this figure should be investigated because many actually have complex neurological disease that has not been diagnosed.

There are concerns with regard to standards of institutional care, particularly in the context of inadequate funding and a lack of meaningful standards, a comprehensive inspectorate and guidelines as to how care should be implemented.

Can we provide such care in Ireland? The answer is yes. Until I carried out the review, I was not aware that there are comprehensive and supportive national standards relating to children's residential centres. These are well-phrased in terms of the clients, namely, the children. It came as quite a shock to realise that one part of the system could provide such comprehensive and helpful guidelines. These do not offer a complete solution and we will have problems in children's homes. They dictate, however, that if children are sick or have disabilities or if they need special medicines or food, information in this regard should be in an individual's care plan so that everybody responsible for caring for him or her is aware of his or her needs. The HSE must give every child in care a social worker. In addition, the guidelines refer to reviewing care plans with children and their families. To the best of my knowledge, that does not happen at all in the nursing home sector. The important thing, when one considers the children's residential care sector, is that we know we can do it when we put our minds to it.

Specialist health care is an extremely important component. Investment, particularly in gerontological nursing, is crucial, as stated in the second UN declaration on ageing in 2002. The declaration points out that not only do older people need the same health care as everyone else but they need more because old age brings with it complexity. In addition, it states that such health care must be effective. The declaration goes on to point out that health care designed to meet the specialist needs of older people must be made available, taking into account the introduction of geriatric medicine and gerontology into relevant university curricula and health care systems. Ireland lags behind in respect of ensuring that every health care worker has access to training on ageing. That is one of the areas to which we must give consideration.

The challenge for me in undertaking this review was how to enhance and support those who are doing great things in a hugely unsupportive system. I work closely with one public nursing home and I often liaise with private nursing homes. People are trying really hard and are extremely dedicated. How do we retain these people, indicate to them that we do not disrespect what they are doing and ask them to consider with us how we can undertake the radical change towards a true person and needs-oriented service? That is our challenge. The National Council on Ageing and Older People and many international bodies have shown that if we do not have adequate funding and adequate numbers of trained staff, we will find ourselves in a situation that promotes elder abuse. This was adverted to in the official health policy on elder abuse, Protecting our Future.

The committee will have read in the handout the key elements of the review. First, as I did my search at the end of 2005, I could not find a clear policy declaration by the Department of Health and Children and the HSE on the complexity and sophistication of care and the vulnerability of those in long-term care. The issue was not sufficiently central or not phrased in such a way as to make it clear that they recognised that these people are exceptionally vulnerable.

The second issue is that of adequate numbers of adequately trained staff. I have laid out some guidelines as to how this issue might be dealt with. We know many other developed countries have had nursing home scandals that have led to improvements in care, most notably in the United States in the mid-1980s which led to some of the measures I have recommended.

The third issue is that of nurses with diplomas in gerontology. This is where the phrase "good intentions or kindness are not enough" comes into play. Kindness is important, but we do not think much of an airline pilot or cardiac surgeon who is kind, but not able to do the job. This is a complex and sophisticated area of care and we must invest in diplomas in gerontology for nurses in both public and private nursing homes. Care assistants need a FETAC certificate, which is a vocational training standard. We need appropriate induction of international staff and we need a staffing dependancy tool. We set a minimum standard of one nurse per nursing home at all times, but that has clearly failed. It must be made clear that we must have a certain amount of trained staff for a specific amount of dependency. I have recommended the Royal College of Nursing tool, because it seems appropriate.

We need a single unitary system for collecting data, a minimum data set, which will also help in formulating care plans. Adequate funding is central and I will elaborate on this shortly. We need medical officers who are not only trained but who are supported. They must be made aware of these supports.

Nursing home legislation needs review. Ita Mangan, one of the foremost commentators on the law, notes how priority is given to the property rights of the owners of nursing homes rather than to patients, who are vulnerable older people. This must be reversed. Inspection teams need further skills training and we also need a significant investment in therapists. Nursing home patients have complex problems, for example, swallow disorders, immobility difficulties, difficulties adapting to chairs, cutlery and pillows etc.

Specialist support is another issue. Geriatricians, old-age psychiatrists and others are keen to support and often stretch themselves to do so. In our service plan for Tallaght Hospital last year, we said we were more than happy to consider an expansion which would allow us to cover local nursing homes in a more structured and organised way. I am sure many other geriatricians and psychiatrists will try to respond similarly.

Our professional bodies must clarify the complexity and scope of practice in this area. The most numerous group of health care professionals in nursing homes are nurses. It would be helpful if An Bord Altranais stated more clearly that care of the elderly is not an area where some kind of generic general cover is provided but that it is a specialised area. We also need to strengthen the public health overview and the minimum data set will do this.

I will move on to some of the elements covered in the review. The diploma in gerontology has been successful and almost all universities offer one. We must ensure we allow and enable release of nurses to attend these courses. We must also look at how we can encourage our international staff to take up these courses as they find signing up to them quite daunting.

Nurses are key workers in terms of marshalling the complex care required by nursing home patients, particularly for example with regard to restraints. All the good research in this country on avoiding restraints has been done by specialist nurses such as Imelda Noone in St. Vincent's. We find fewer restraints are used by specialist nurses. There are also dilemmas of care and consent. Some patients do not want their tablets. Aggression towards staff is best dealt with, not by a chemical or physical restraint, but by specialist staff and training on the issue of elder abuse.

Care assistants are part of a key and often neglected area. However, credit is due to the public system which has embarked on training care assistants through FETAC. This approach should be universally applied to include the private system. Direct care workers are the key solution. Are they replaceable by unskilled labour or the key to quality care? Most of us wish it to be the latter, but to achieve that we must invest.

The minimum data set is the only show in town. It is the international standard and is quite brief. It arose as a result of the scandals in the United States in the 1980s and everybody in a nursing home in the US must have a completed minimum data set. The beauty of the system is that not only does it provide an outline of the care needs, it helps formulate a care plan and helps us understand the dependency of the patient in question. The data set is in electronic format and can provide an instantaneous picture of what is going on. However, it is a big investment to put this into 550 plus public, private and voluntary nursing homes and to provide the training required to operate the system.

There is no no-cost solution. We found in 2005-06 what was found in the US in 1995 and in England in the 1980s. Public nursing home care costs approximately £1,500 per week, while one of the national estimates for private nursing homes is approximately €640, well below what the Joseph Rowntree Foundation suggests is appropriate. The answer is not to reduce the level of care in public nursing homes, but to set that as the standard towards which we should aspire for complex care. As matters stand, the more complex and vulnerable patients end up in the public system, somewhat analogous to special needs children in the education system.

The Joseph Rowntree Foundation suggested in 2002 that the UK nursing home sector was under funded by £1.6 billion and that nursing home care could not be provided for less than €734 per week in 2002. In Ireland in 2006, the average in the former Western Health Board area was €495 per week. Clearly we have a lot of catch-up to do and we must do it quickly. I Googled a query for a three-star hotel in the low season, November, in Dublin and found that bed and breakfast for a week would amount to €701. There is quite a gap between that and the cost of care in a nursing home. No other meals are included and no continence therapy, nursing or infection control is provided. To ask for care to be provided at three-star level for the rest of one's life is not unreasonable.

The inspectorate must be funded and we must be careful that we do not ask people to do it as well as another job or without increasing employment limits. It is important the HSE is not disadvantaged in terms of employment limits in the social service inspectorate. If we need more people, we must get them. We cannot rob Peter to pay Paul in this area. Expertise is important. I have suggested openly that public health doctors and nurses should think twice about being key leads without significant support from specialist and residential care in terms of this kind of work. I have already mentioned the area of clinical standards.

The first version of this report, which is largely the same as this in substance, has been with the HSE for nine months. We must think hard about how we can avoid distancing ourselves from older people. To do this we need to change our phraseology. We need to move from talking about the "elderly". Many headlines use this term, but in any other circumstances it is a pejorative word. We might have a mature wine or cheese, but the term "elderly" would be pejorative. Older people have asked that we use the term "older people" and we try to do so. I like to think we should use the phrase "us as we age" so that older people are not seen as a separate group but are "us". We are building a system for ourselves.

I have added some reflections at the end of the handout with regard to what we need to move from good intentions to an informed position. We need a clear route map on how the recommendations will be put in place. I am encouraged that the Department and the HSE have said they accept these recommendations.

We need more transparency of process and engagement with expert opinion and advocacy groups. I was somewhat disturbed to read in the press that the names of people in whatever group was looking at the recommendations in the report would not be released to the press. I am not sure what the confidentiality issue is in a major issue of public importance. I cannot find it using Google and searching what group is looking at minimum standards in nursing homes. I would have thought these should be very clear, open processes that are clearly engaging with expert opinion and advocacy groups.

The lines of funding need to be clarified because by accepting these recommendations we have accepted a major stepping up of the cost implications. We have done the same for cardiac care and for cancer care where there have been huge investments. This is the next one we have discovered. It is important that the employment ceiling is openly discussed. I am aware that many things in the health services get caught up in the employment ceiling and there should be open and frank discussion about whether employment ceilings are an impediment to developments in this area.

I refer to one of my favourite phrases from the little I know of James Joyce. He wrote to his brother that he left Ireland because of the hemiplegia of the will, a phrase from stroke literature. In many ways we have shown in Ireland, whether it is standards of care for children, whether it is our developments in cancer care, cardiac care or bold initiatives like the medical card for the over 70s, that we can rehabilitate ourselves beyond this hemiplegia of the will.

I thank Professor O'Neill. We will not curtail the number of contributions from members but I ask speakers to be direct in their contributions. We will give priority to members of the committee over non-members.

I thank Professor O'Neill for his valuable work. He has explained the general context rather than examining a specific example where things went very seriously wrong and where institutional abuse took place. Professor O'Neill has set a context which is a much greater challenge. I welcome Deputy O'Dowd to the meeting because he has done very important political work on this issue.

The shift from public to private care is a matter of great concern. Professor O'Neill has made the point that it is a big challenge. I ask him to comment on the shift which is significant in the Leas Cross example but also in other nursing homes, where psychiatric patients are being taken out of an environment which in many ways may have been unsatisfactory but that had certain protections and supports, being in the public sector, and was subject to scrutiny by the Inspector of Mental Hospitals. I ask him to comment on the risks in general because I have grave concerns.

I ask him to expand on the shift that again seems to be happening where high dependency patients are being moved out of hospital and there is a greater pressure to move these patients into private nursing homes, even though it would appear that private nursing homes were not set up, generally speaking, to deal with these people or to cater for them.

In the case of Leas Cross, relatives and families have expressed concern that information they gave to the HSE may not have been passed on to Professor O'Neill when he was doing his work. They felt they were out of the loop to a great extent. I ask Professor O'Neill to comment.

What are his views on the policy of restraints? I have noted from recent experience that good nursing homes and good practice may be damaged because of the muddle surrounding inspections. The lack of legislation, clarity and proper standards is having an impact not necessarily on the right target. Bad nursing homes are still out there and not being inspected properly and good practice is being over-scrutinised or scrutinised inappropriately. For example, a patient in a nursing home may be questioned by inspectors in a public space, with others listening to what they say. Is this appropriate? It is the basis of a complaint I received.

One of the concerns expressed is that there are not public health doctors and nurses in place in dedicated teams to do these inspections. Professor O'Neill made a further point that it is not enough, even where there are public health doctors, and that specialists are needed. I ask him to expand on that point. All this will cost money. I do not know if he has arrived at a point where he can say how much additional money is required. Everything he has referred to has a cost implication.

I was not clear on the point about the group looking at standards and standardisation and I ask Professor O'Neill to comment on his statement that he was not able to find the group he was seeking.

Professor O’Neill

I was trying to find what the composition of the group was or what expert advice they are using. I could not find out what——

Is this a group within the HSE?

Professor O’Neill

I understand it is a group within the Department of Health and Children and the HSE and to which reference has been made in the press. As to its actual composition and make-up I cannot clarify. They are in the public domain.

I compliment Professor O'Neill on his report and its findings. The sad aspect is that many people were frightened by what was happening in a nursing home as these are places where one goes to receive care.

Deputy McManus has touched on some of the issues and I refer to the issue of cost. The current average cost of a private nursing home is €640 per week. Has Professor O'Neill costed his recommendations and can he say whether they will add to the cost of a bed in a nursing home?

He referred to patients with differing levels of dependency. This is one of the big issues in nursing homes. One nurse for every 50 patients might be sufficient if they were all ambulant patients although it might be preferable to have one nurse for every 40 ambulant patients. Who is responsible for setting down guidelines for the care of patients who require more intensive nursing care? This seems to be uncertain and nobody seems to have grasped it but it must not be for want of knowing what is required. The care for differing levels of dependency is an issue that has not been addressed.

What assessment procedures will be used to outline patient needs? Another issue of concern and which has been referred to is the suitability of those patients who have been transferred into nursing homes. I refer to patients being transferred from psychiatric hospitals to nursing homes. Is it desirable to move people from a psycho-geriatric ward to a geriatric unit which does not have adequately trained staff to deal with their needs? These patients are being moved from a familiar environment and it seems they are being used as fodder for nursing homes. Professor O'Neill stated the cost of a public bed is €1,500 and a bed in a private nursing home costs €640. There seems to be a significant cash incentive to move patients from a public service into private care and to reduce the numbers in the psychiatric service. This is a matter of great concern.

I note that people with an intellectual disability were accommodated in Leas Cross. Is it safe practice to move such people from a setting suited to their needs into a private nursing home? I ask Professor O'Neill to comment on the improper placing of people with intellectual disability in psychiatric institutions although I acknowledge this may be outside his brief.

The public presumption is that the best safeguard elderly people and their families have is the system of inspection and the complaints procedure. I would have thought their patients might be afraid to verbalise complaints to an inspector. After all, the inspector is asking people how they are getting on in their own home and about the people caring for them. As patients may feel threatened or feel they are not getting proper care, much greater emphasis should be placed on interviewing the relatives as frequently as nursing homes would be inspected. An inspector can go to a nursing home and the care plan might be well written and appear excellent. However, whether that care plan is delivered is another issue. Relatives should form an important part of the process. I would like to see them brought into the equation more.

Representatives of the HSE appeared before the committee recently and referred to weak legislation. I do not believe people going to work bring the law book under their arm. It is all about giving care. As I understand it, when there is a weakness in the nursing home system the HSE has a legal entitlement to take over the management of a nursing home. Only having seen Leas Cross on a television screen, I always thought it looked very well and was a good modern building. I often wondered why the HSE did not simply put in its own management and leave patients in their own environment. There is a big human factor involved in moving people out. I do not know whether they were all moved to better nursing homes. They were taken out of the spotlight.

I wish to be associated with the welcome extended to Professor O'Neill, whom I have known for a long time. He attended to my late father in his final illness and I have been a colleague of his on the board of Tallaght Hospital, where the AIDS-related unit does tremendous work. I am very aware of Professor O'Neill's involvement. His presentation this morning was unique and brings it all home to us. It is good to hear him talk in the terms he does about older people. I have already said to him more than once that I hope he is still around when I am looking for such care.

The importance of this presentation and the Chairman's initiative in allowing this discussion to take place is emphasised by the presence of the Minister of State, Deputy Seán Power. It is important for him to hear this debate. While people often talk about Ministers and their interests, the Minister of State, Deputy Seán Power, has shown a particular interest. He has heard the excellent presentation and the questions, which is important.

I welcomed the report when it was published. I would like to hear Professor O'Neill's views on the appropriateness of the response of the HSE. There has been much debate about that matter and Professor O'Neill is the man on the spot. I would like to draw him somewhat on his feelings in that regard. It is important for us to learn from this experience. I have often said that we, as legislators, have a responsibility to ensure that these types of events never happen again. We often talk in the Oireachtas about issues that happened 30 or 40 years ago and worry about whether they might still happen. It is important to make that point regarding this matter. Many contributions have been made across all parties and we should acknowledge the work of Deputy O'Dowd in this regard. Many colleagues including some from my party have voiced concerns, as have I. This is a good day for the committee. This is a very important presentation and I hope we all learn from it.

I welcome Professor O'Neill. Were the complaints made by consultants in St. Ita's Psychiatric Hospital clear? If so why were they not acted upon? Was correspondence overlooked or ignored? The introduction to the report states: "No judgement has been formed where there is a difference of opinion". I ask Professor O'Neill to clarify those differences of opinion. Did the HSE ask him to comment on these before the report was published? When did he present his first draft of the report? I understand there is a draft dated January 2006. The report refers to "systems failure", which is a lovely term we hear used all the time. I ask him to elaborate on this term. Based on his knowledge, does he feel a robust inspection system is in place to prevent further nursing home debacles such as we witnessed in Leas Cross?

I recently put a question to the Minister for Agriculture and Food about inspections in her Department. There are approximately as many farms as there are patients in private nursing homes. While the Department of Agriculture and Food has 1,685 inspectors, there are only 54 nursing home inspectors. We have one inspector for every 11 farms and one inspector for every 370 patients. In addition farmers have the back-up of Teagasc while patients have no back-up facilities.

How many complaints were made about Leas Cross between 2002 and 2005? How many patients were injured during their residency in the nursing home? I was shocked to hear that 46 patients who died in Beaumont Hospital had renal failure and Professor O'Neill has suggested that dehydration was likely to have been a factor. A point made yesterday in the Seanad was that as most competent nurses would be well able to recognise dehydration, why was it not recognised in those cases? I believe Professor O'Neill mentioned that criminal charges had been brought against nursing home staff in Miami. The question is whether it is criminal or criminal negligence. Someone is certainly at fault for a basic problem like dehydration ultimately causing death.

Professor O’Neill

I have been asked quite a number of questions. I will try to find some themes in them. One of the themes centres on the transfer of patients with psychiatric illness and intellectual disability. This is an area of great concern in the literature. It is also a point at which we pause and think about how we design nursing homes. If we consider the major strides we have made in terms of hostel-type accommodation for patients with psychiatric illness and hostel and supported living-type arrangements we have for patients with intellectual disability, it gives us pause for reflection as to whether the size of nursing homes is a form of pragmatism and cost effectiveness by scale. One of the great dangers with the health and safety legislation is that nursing homes might no longer be homes. Yesterday I heard at a conference that health and safety legislation prevents patients from coming into the kitchen to get a cup of tea. However, all these women spent all their lives in the kitchen.

If we step back and look forward we should consider having much smaller units. While they would be more expensive they would be more worthwhile. A very interesting project is being funded in Dundalk or Drogheda by Atlantic Philanthropies to explore embedding such small complex units. Patients who have been long-term clients or users of intellectual disability or general psychiatry services should be catered for in gerontologically adapted units of the relevant services. For example, we have a link with Peamount Hospital. This is one of the areas we would like to examine.

In general, we should learn from the experience of moving from environments which are strongly influenced by a certain type of culture. We should try to avoid asking people with long-term psychiatric illness or intellectual disability to end their days in a nursing home. There is an important synthesis between the discipline of intellectual disability nursing and gerontological nursing. St. Michael's House, for example, recently recruited a medical officer with significant geriatric medicine training. This is the way forward.

On dependencies and the practice of moving people who are too dependent to nursing homes, it is important we recognise occult and silent pressures to discharge patients which arise from pressures in other parts of the system. One of the issues we as geriatricians raised in 2001 was frequent pressure applied to discharge people to a facility which may be distant from, for instance, a frail spouse who cannot drive. Ideally, people should be in small units which are geographically close to friends, family and community. To consider sending someone to a facility 30 km. away in these circumstances appears to be a type of cruelty.

In a nursing home that is adequately funded and appropriately staffed the key decision maker — this issue brings me back to my recommendation to remind people of their scope of practice — would be the senior nurse. He or she must feel sufficiently confident in the scope of practice to be able either to agree to take a person or to refuse an admission. This raises funding issues. In the United States funding of nursing homes is related to dependency, based on a measure from the minimum data set. While the system is not perfect — people play the game somewhat — at least it tries to reflect this care need.

One of the challenges facing me in hospital is that I have a document in which it is stated that I cannot tell a person whose mother is being transferred to a nursing home that care in that home is appropriate. I may only state that the HSE nursing home inspectorate has indicated that the care is appropriate and the senior nurse in the relevant unit has accepted, within his or her scope of practice, the person's mother. I have to arrive at an understanding. In such circumstances, I will give a person who is unhappy with the decision the details of the HSE nursing home inspectorate. If the patient is being moved to a public facility, I will tell his or her relative that I cannot provide assurance that the care is appropriate. The person who ensures care is appropriate is the senior nurse who accepts the patient. It is within the scope of his or her practice to indicate whether he or she can deal with the person. This is the reason I have included this specific recommendation on scope of practice. The reason I refer to scope of practice in the report may not be clear to lay people but to have the scope of practice needed the relevant person must have gerontological skills.

On restraints, we have two internationally recognised experts in nursing and medicine, Imelda Noone and Dr. Sean O'Keeffe in Merlin Park Hospital. The key to avoiding restraints is to have skilled staff in appropriate numbers. This became such a problem in the United States that it has been decided that one form of chemical restraint, known as neuroleptics or major sedatives, can only be prescribed by law for specific reasons. They may not be prescribed on the basis that a person is troublesome or demanding but only on the basis that he or she is a physical danger to other people and has psychotic illness. The prescription must also be reviewed after one week.

While it is important to factor in the use of restraints, encouragement and checks and balances are required. There is no point in prescribing that no restraints be used without providing sufficient funding to enable a facility to have appropriate numbers of appropriately trained staff.

Buxton chairs were used in Leas Cross. For those who do not know what is involved, the use of a Buxton chair is a most uncomfortable and disorienting experience and one which is even worse for those who have dementia. It is a chair in which one is effectively restrained before being tipped backwards to prevent a person from getting out of it. Members may like to imagine the experience. It is deeply unfortunate that Buxton chairs are used in the new millennium. The use of restraints needs to be carefully examined, although it will always be necessary to restrain some people.

Some residents of nursing homes will fall or become dehydrated. A nursing home where no one falls is one in which everyone is in bed. The question is the frequency with which such incidents occur and the context. In terms of patients who are dehydrated it can be difficult at times to tell whether an older patient is dehydrated. Many older patients survive quite well on 500 mls or about one pint of fluid per day. Whereas the textbooks indicate that one should have three pints of fluids per day, one can survive on one third of that amount. None the less, I was concerned at the nature and context of some of the cases in Leas Cross.

A further minor issue to be raised is the law of unintended consequences. When we do something for a good reason, it must be thought through. The recommendation that all deaths should be reported to the coroner is a good one. The fact this would mean that some nursing homes might have to retain the body of the deceased in a facility which may not have a room so dedicated has led to a concern, for which I cannot say there is evidence, that patients may be discharged from nursing homes to hospitals to die. If we want all deaths to be referred to the coroner, we must ensure nursing homes have an additional space or room in which a body can be held with respect. This is a further example of the importance of factoring in the law of unintended consequences.

Two members raised the important issue of privacy in nursing homes. If I might step back again, I am associated with the Meath community unit and do rounds with its excellent team. In common with a minority of other public and private homes, it has placed great store on having a residents committee. Perhaps we need to think along these lines to enable persons who may not have full cognitive capacity to indicate that he or she would like a son or daughter to speak on his or her behalf. We must empower people to be able to question, for example, the reason they have tea at 4.40 p.m. and receive no other meal until 8 a.m. This extraordinary practice is commonly used for cost saving reasons. It is important to start examining how we empower clients. The idea of a residents committee, in which relatives would have a role, is important.

I agree that inspections can be difficult. People should be interviewed in private rather than in front of other people and inspection teams need to be aware of the markers of abuse. When abuse is suspected they should return to the facility rather than making a single assessment.

On costing and money, I have not costed my recommendations but the report has been with the Health Service Executive for nine months and has been accepted by it. I stated publicly yesterday that I will take a keen interest in events to ascertain if a costed plan has been requested and included in the budget next week. That will be a true indicator of seriousness of intent.

On the families who expressed concerns, the HSE gave me a large folder of correspondence from families. The figures seemed to be correct. In fairness to the HSE, it was supportive of me during my time preparing the report and I believe I received all correspondence from families.

In terms of how the HSE has responded to my report, I welcome its commitment to implement the recommendations. I am a little troubled, however, that it has not agreed with one of the recommendations, namely, the local recommendation on intermediate care-heavy dependency tendering. It is my understanding that there were five other nursing homes which failed this for reasons other than cost. It is not clear to me that those outside are aware what degree of scrutiny has been afforded to this. I think it is an important one.

The budget will tell us whether the HSE has truly responded. I am somewhat anxious about the use of the term "robust inspection system". Many sectors have recognised that we have a problem. As I stated publicly at the conference yesterday, I do not know whether it has, but intuitively and instinctively I would have felt more comfortable if the HSE had said it was working towards a robust inspection system.

An important point was raised at the conference yesterday with regard to the reports, few enough of which, particularly in the eastern area, mention good practice. There is much good practice out there. We should be looking at a balanced score card. I consider the reports that are available to be unfortunate, given that they are often limited to several lines saying, for example, "largely falling within the regulations". I do not understand, but I have not had time to ask, why there are no names put to the reports. Reference is made to anonymous managers. I am not sure that is a good way to proceed. We must have a balanced score card saying what was liked, as well as the areas of difficulty.

A famous paper in ethics literature is called, Who is the Schmuck?, and if one asks medical students who behaved like a schmuck, they will mention names. However, when we ask who behaved in an exemplary fashion, despite the fact that the evidence suggests that in most professions most people behave well, they have more difficulty coming out with that name. We must change this around.

The Chairman should remind me if I have missed any questions.

All the questions posed have been answered. I now invite other members to ask questions. Deputy Gormley will begin, followed by Deputy Fiona O'Malley, Senator Henry and Deputy Devins. The other members will be brought in immediately afterwards. I hope that is acceptable.

I will try to be brief. I thank Professor Des O'Neill for his excellent presentation. At one stage he stated that kindness is not enough. I know what he means but from my interaction with older people, one of the major issues for them was lack of kindness and respect. I attended a focus group for the elderly yesterday in Rathmines. Professor O'Neill touched on this point when he stated how residents' committees are important. Empowerment is a key issue for older people. Would he agree that part of the problem is that we now have people who have no medical background or experience in the caring professions going into this business and they are cutting corners for profit? This is something we raised with the HSE. When I put this question to Aidan Browne last week he could not disagree with me. The figures Professor O'Neill gave us are quite disturbing. Private nursing homes would appear to be doing things on the cheap and they are in the business of making a profit. On the basis of the figures he has given us, it would appear that corners are being cut severely. Perhaps he would comment on this.

Professor O'Neill described Googling a three star hotel and finding that the cost of staying there was much more than the amount spent in a nursing home. Would he agree that the implication of what he has said to the committee is that the standard of care in many nursing homes is inadequate? Is that what we can take from what he stated, based on the figures he produced? Does that not contradict what he then stated, that the HSE's view is that, in many cases, the standard of care is appropriate?

I compliment Professor O'Neill on one of the best presentations we have had. It was riveting. My instinct was to clap when he finished. The presentation was wonderfully clear and provided a clear roadmap for where we need to go. I am interested in a few of the areas to which he alluded in the wider sense and the whole question of employment ceilings. He is dead right. We need to have a very open debate about that because the employment ceilings are costing us a fortune in the health care system. He is more aware of that than I. They do not represent value for money. If we want to develop a much more comprehensive service, this is something we must tackle. I welcome Professor O'Neill's call for a proper and honest debate about employment ceilings.

I was also interested in what he said about maintaining equality of care, that it would be more difficult to determine if we develop a private service. Following on from Deputy Gormley's point, why does Professor O'Neill think this is necessarily the case? Surely if we have a standard and some way of accounting for whatever treatments and services we purchase on behalf of the public, there is no reason not to have an efficient mechanism for measuring the level of care and any disparities that might occur.

I am sure what happened with Leas Cross and at other places has caused enormous anxiety for families whose older people need care. On a scale of one to ten, where would Professor O'Neill rate the current level of services? I do not mean to be specific but this is important. As he stated, the inference is that services are absolutely atrocious. It would be helpful to get a clearer picture of current standards from somebody as esteemed as the professor. It is important that we know where we stand, rather than having a perception that nursing homes are absolutely atrocious.

I was interested in the reference to the over-70s medical card. It is an expensive commodity. Government does not have a limitless budget and arguments are made about targeting resources. We now question the wisdom of providing free medical services for everybody aged over 70, regardless of their income. I was most interested that Professor O'Neill stated it is a positive mechanism. Does he think it could have been applied differently? Given the limitations to Government resources — the sooner the better people recognise that — is the over-70s medical card good value for money?

Reference was made to the minimum electronic data set system. I have always believed it is imperative to introduce a greater level of IT into the monitoring of patient care across the health service. Does Professor O'Neill have any idea of the cost involved in extending such a system? It appears to be a simple way of managing individual care and would be an extremely good use of resources. Would he consider this to be a priority for future care?

Is there any reason why reports should be anonymous? I agree that we should encourage people to be accountable for how they measure something.

I thank Professor O'Neill for the clarity of his presentation and the work that went into the report. I wish to take up a point made by Deputy Gormley about the commercial side of all this. There has been a great change in the system of nursing home care in the Dublin area such that 75% is private and 25%, public. While some nursing homes were established by altruistic individuals and some by organisations which already had an input, the great tax breaks available were such that a considerable number set up nursing homes like those in America. I once had to deal with private nursing homes in Florida and, unfortunately, they were most undesirable institutions. I am glad to hear they are changing. Those who established nursing homes did not realise how expensive they would be to run. Nursing homes are being asked to take people whom they are incapable of minding for €634 per week. It is utterly impossible. It is not that the public institutions are not being too flaithiúlach in the way they are spending money but that not enough is being invested in the care of high dependency residents.

When I read the Leas Cross report, I felt everything centred on the contract with St. Ita's. The institution agreed to take 24 high dependency patients. It certainly could not care for them for €634 per week each. Should we change completely the way in which we rely on private nursing homes for high dependency residents, particularly those with an intellectual disability and mental illness, as Deputy Connolly stated? The slide indicated that those with neurological problems presented the main problem. I do not understand how private nursing homes, unless staffed to the same level as public nursing homes, can manage with such residents.

I was interested to hear that senior nurses had refused 75% of patients from acute hospitals. This figure is considerable. No wonder we have such a problem. We will have to re-examine totally the configuration according to which high dependency patients are admitted because a considerable number of private nursing homes expect to make money. Some individuals have several nursing homes and one cannot make money out of seriously ill people.

Reference was made to the provision of assistance in nursing homes and immigrant workers. It is essential that they have English to an adequate level. People have told me that neither they, their siblings nor mothers could understand the staff looking after patients. This is unfair on the care worker and extraordinarily unfair on an old person who may have a serious illness.

I am delighted to meet Professor O'Neill at last. I have been listening to him and had hoped his report would be as good as it turned out to be. It is the result of tremendous work and was produced against the odds, administratively and politically. The document is very clear and contains the truth. As such, I very much welcome it.

I appreciate that Professor O'Neill's brief was to cover the period 2002 to 2005. However, Leas Cross was operating for a much longer period. Martin Hynes's very thorough and informative assessment of the issues involved is that Leas Cross should never have opened at all. It failed at the very first hurdle in that the rooms were too small and not to the required standard in terms of numbers of beds. Other serious issues also arose. I appreciate Professor O'Neill's brief did not cover the period before 2002 but I have done some work on the period and know that one, if not two, of the former matrons on the staff in this period expressed serious concerns to the then health board about what was occurring in the nursing home. The history of occurrences in the home was under the eye of the health board and the professor's report is an indictment of the system.

The worst aspect is that in a list of bad nursing homes identified by the health boards, given to me in 2001, Leas Cross did not figure. Were it not for "Prime Time Investigates" and some of the families who made complaints, including Mr. Moore whose half-brother Peter McKenna died therein, we would not know about the matter. The inspection reports on Leas Cross which I obtained under the Freedom of Information Act contain very little to indicate any problem. While Leas Cross was an appalling place, there are many more such places. While the majority of nursing homes are excellent and the care and staff therein are 100%, the reality is that we must root out the bad ones.

Reference was made to the number of patients who had died shortly after being transferred to Leas Cross. Could a recommendation be made in respect of a national body to monitor deaths in such institutions, perhaps in all institutions and hospitals? I am not a member of the Oireachtas Joint Committee on Health and Children and do not know all the issues involved. I would like to believe there is a way in which we could detect problems. Obviously, the level of dependency differs from nursing home to nursing home but we need to examine death rates and hone in immediately on homes where activity such as that in Leas Cross takes place.

I spoke to a number of coroners about deaths in nursing homes. When they examine the Garda file on a death, they are not given copies of the nursing home inspection reports, as inadequate or clear as they may be. The findings of coroners' inquests could change according to the information made available to them. A coroner told me a death certificate had not issued for a person who had died in a certain nursing home and that it was six months before he found out the person had passed away. He believed the person would probably have died anyway and, therefore, did not order an exhumation, notwithstanding the fact that he was concerned. He did not have copies of the inspection reports, which raises certain issues.

The question of voluntary health insurance must be addressed. I have raised it with VHI which has a list of approved nursing homes, one of which was Leas Cross. A family looking for a nursing home for a patient checks with a consultant and VHI which generally only covers convalescent care for a period of two weeks. We need to dovetail what the organisation is stating about nursing homes it approves with what the HSE is stating about standards of care therein.

In most nursing homes — even in those listed on the HSE's website — bed sores and their treatment are referred to time and again. I am not a medical practitioner but it is clear to me that there is a consistent problem in that nursing home staff do not know how to treat them. The HSE consistently states staff must undergo training courses to deal with the problem. However, it is never dealt with and, therefore, arises year after year.

Will Professor O'Neill conduct further analysis, through the department of gerontology, to identify a better system of care and monitoring, notwithstanding his excellent report? A person such as he ought to have an advisory role in the HSE. There is no formal relationship between the HSE and persons with his expertise. If there was, issues pertaining to care could be identified on an ongoing basis.

On the question of inspection reports, it seems there is no follow-through after the inspectorate identifies recurring problems. It seems there is no other investigative unit in the HSE to follow through, with even more resources. That is a critical issue.

Patients from St. Ita's were transferred in to Leas Cross and Bedford House. I know Professor O'Neill has not been involved with the second home. The nursing home reports from Bedford House are appalling. I have not seen anything like them for many years. They were appalling for five or six years before patients were placed there. I would like to see an inquiry into how the patients were transferred from St. Ita's into Leas Cross and Bedford House. These people were delivered into care which was unacceptable in a year when admissions to Bedford House were stopped.

There is terrible neglect of patients coming from psychiatric institutions into nursing homes. We need an inquiry to get at the truth of the quality of care for people who are in the care of the State. An involuntary patient in a psychiatric hospital is in a different category from a voluntary patient. This involves issues of human rights, abuse and the remit of the European Commission's committee on torture which did a report on Portrane. We need to examine what happens to people who are involuntarily in the care of the State and are placed in institutions where the care is appalling. It is difficult but it must be done to provide the standards of care and the excellent programme which Professor O'Neill has outlined.

Institutional abuse in Leas Cross is a damning finding but it exists in many other nursing homes. There has been a systematic failure by the Government, the former health boards and professional bodies to address the issue of appropriate quality of care for older people. Something good will come out of this report and out of the upset for all the families affected by this trauma but we must ensure our standards and investment are the best in the world, and that all parties and professional organisations come together to identify those needs and make sure they are delivered. In that way the ongoing neglect will change forever.

I commend Professor O'Neill's report. He stated that five nursing homes failed the former health board's care test yet there was no financial reason for the inadequate care for the many high-dependency patients. Could Professor O'Neill expand on that please?

I thank Professor O'Neill for the passion he has put into getting to the root of this problem and for raising its profile. I carefully followed his efforts to get his discoveries on the radar. To judge by what I read in the newspapers this was not easy. Last night in the Seanad we had an excellent broad discussion on the Leas Cross Report. We cannot blame individuals. As Professor O'Neill said, the system has failed. There is no point haranguing anybody. We must solve the problem. The Minister of State, Deputy Seán Power, said he was sincere about getting to the bottom of the problem on behalf of the Government and I believe him.

Professor O'Neill's research was a great inspiration to me in preparing my document, A New Approach to Ageing and Ageism, a copy of which the professor has received. I mentioned abuse of the elderly in my chapter on crime against older people. I have travelled around the country talking about this document and the issue it addresses. I will be in Donegal next Wednesday.

I am amazed at the number of private nursing homes that are out in the country, away from towns. Professor O'Neill uses the word "cruel" to describe this. It is amazing the planning authorities gave permission for homes to be located in the middle of nowhere, making it impossible to visit people. That should be easy to sort out.

Last night Senator O'Toole asked how we could be sure of the quality of the inspectorate. Professor O'Neill referred to a systems failure in an airplane but a mechanic can easily follow the specifications in an airplane. I agree with Senator O'Toole, however, about the human factor coming into play between the owners, the managers and the inspectors of the nursing home when they start to socialise. There must be a very fine, cold line to ensure a proper report because some people are weaker than others and do not want to upset people.

When my uncle negotiated with the British army during the Sunningdale talks they did not sit down together because once they sat down and socialised, or had a cup of tea, the relationships changed. I worked in the building business and saw that when people got friendly snagging was not adequate. Some people are able to resist that temptation but how do we achieve a fool-proof inspectorate?

Senator Henry asked was there something wrong with the business model that people cannot make money, despite the tax incentive. We all know the tax incentives went overboard and the money went into that area, which was crazy but are there profitable private residential nursing homes, are the people greedy or what is the problem? What drives them?

People at my talks light up when I mention President Johnson's Older Americans Act of 1965, about which I read in Professor O'Neill's report. He returns to that point several times. I would like to introduce a cross-party older Irish people's Act in the Seanad. How significant would that be? I do not want to waste the professor's time so I ask him to respond only to my questions about the Act and the inspectorate. The rest of my comments are simply opinions.

I mentioned earlier the costings of the recommendations. Is there an inference that if there is no money to pay for them there will be no specialist staff and therefore there will be no change? The Health Service Executive is equally liable for what has happened in those nursing homes because I have no doubt it has received complaints. It is trying to brush this aside by blaming the health boards of a couple of years ago while the same personnel is in place. I would appreciate Professor O'Neill's comment on that.

Professor O’Neill

One of the questions which arose was on the private sector. While I speak partly from personal experience there is a large body of literature available. The American Agency for Healthcare Research and Quality has published extensively on the point that no matter what happens things go better in the not-for-profit and public homes. For those who are interested, this is the point of The Gift Relationship by Richard Titmuss.

The professor should tell that to the Minister.

Professor O’Neill

That does not mean it is at the floor but there is a clear gradation. My experience is that when we try to source extended care for people who need it the personal preference is always a voluntary home, such as one run by nuns, a religious institution or an advocacy group. The second preference is for a public bed and the third, a private nursing home. There are some good private nursing homes which sometimes can be located near patients' relatives. Deputy Gormley and Senator Henry asked if the report raised questions about corners being cut, which term carries a certain loading. What it raises for me is inadequacy of care but it is cushioned by selectivity in order that they have lighter dependency patients. One of the most significant developments in the case of the ERHA and the director of services for older people was the final break with the shibboleth that all private nursing homes took residents from all categories of dependency and started contracting for heavy dependency residents. It is from this that concerns arose about several nursing homes. Contracting for heavy dependency residents continues in the Dublin metropolitan area.

The key issue is the linking of the resourcing of nursing homes with dependency. I am aware of one nursing home which has heavy dependency patients under the current contract. However, from a previous contract several years ago its funding has not changed, even though patients have become more dependent. The private sector can do the job but the key issue is that of the ethos in going the extra mile. I find that ethos prevalent in the voluntary and public sectors. I would be gravely concerned if we significantly altered the balance between public and private nursing homes with more emphasis on private care.

An open system such as the minimum dataset will allow us to examine dependency in all sectors. One marvel of a minimum dataset is that at the flick of a switch one knows the prevalence of deaths and, say, pressure sores in X nursing homes. Pressure sores are like the poor; there will always be patients with some. When it moves beyond a certain level, one becomes concerned. There is one factor of private nursing homes that the public sector should acknowledge. BUPA in Britain has 10,000 nursing home beds in which it can monitor deaths. If there is an increase in the number of deaths in a particular nursing home, it can investigate to ascertain if the patients were very ill or there was an infection. The importance of the minimum dataset is that one can scrutinise what is happening in nursing homes.

My final recommendation was that the HSE should take on a central public health monitoring role for all nursing homes. Sanctions are very limited. We need to examine a range of sanctions that are flexible but also respectful, as for many elderly people a nursing home is their home. We have under-explored the option of taking over homes. I was a consultant in the NHS. When I returned to Dublin, I gave a talk to a group of nurses from extended care units. I told them we must start developing physiotherapy and occupational therapy services, etc. The facilitator of the group thanked me for a vision of Shangri-La. It was a rude awakening. To their credit, many of the public health institutions have begun to form multidisciplinary teams. Robust and open talk is needed on this issue.

The nursing home Act states that for other services needed, between the health board and the nursing home, these must be provided. That is a dangerous gap. The HSE may claim that a nursing home should have a speech and language therapist. In response, the nursing home may claim it cannot afford to do so on the €436 subvention. Many of the patients at Leas Cross nursing home had swallowing disorders which were not being treated because of the gap in the legislation. The private sector can do it but it requires robust talking. The ERHA did a service in raising the issue of heavy dependency residents. It must be recognised that a nursing home cannot be paid a figure of only 80% for a heavy dependency resident.

I have concerns about intermediate care being provided in private nursing homes. "Intermediate care" is a term geriatricians formally renounce because it actually means indeterminate care. If people need rehabilitation, it should be called rehabilitation and the service staffed accordingly. I have already had some disasters with indeterminate care. My advice to hospitals is not to provide it in nursing homes. It is fine if patients are offered rehabilitation, appropriate to their needs. Speaking to people involved in private nursing homes, my advice is to call it rehabilitation or long-term care but do not mess with Mr. In-Between, if I may paraphrase Ella Fitzgerald.

The quality of the inspectorate is an important issue. It is difficult to effect change but I do not understand why the HIQA does not take over this function tomorrow. The HSE should beef up the inspectorate with the HIQA. The most important factor for the inspectorate is that it is grounded in practice. A good example is the Mental Health Commission. Psychiatrists are released from their day jobs to sit on inspection panels. I hope the HIQA will look at increasing the complement of directors of residential care, geriatricians and so forth in order that they can assist the inspectorate. An inspector working solely on inspections will lose touch with residential care practices.

The only appendix I attached to the report included an extraordinary, capable, competent and insightful overview of how Leas Cross had done by a director of a public residential service. Her experience and insight were light years ahead of the quality of previous reports. Her report highlights how such a model for an inspectorate would benefit from the participation of those working in the field.

Location is one of the most important reasons we need public sector residential care. With house prices rising, nursing homes are beginning to go the way of garages, bars, hotels and swimming pools — they are located outside main residential areas. I would be happy to comment on the lack of swimming pools and obesity and lack of exercise. People should be allowed to avail of extended care near where they live but there is pressure to send them long distances. When I went to Leas Cross to collect data, I thought God help me if I was an elderly and frail person trying to negotiate the site.

Deputy O'Malley asked how I felt the health service was doing. With Dr. O'Keeffe from Galway, I recently sent a paper on health care in Ireland to the Journal of the American Geriatrics Society. The article included data from the OECD booklet on health services around the world. The journal’s referee sent the paper back to us, pointing out that there were serious gaps in the Irish data from the OECD booklet. He thought we were being academically lazy. We sent him a copy of the OECD booklet, pointing out that there were gaps. There is always a danger of talking down the service.

We have done a good job in developing specialist medical, old age, psychiatry and nursing services, certainly in European terms. In community care and the whole area of needs-based entitlement, we are below the middle point in Europe. As regards extended care in those countries we should like to be allied to, the UK, Holland, Scandinavia, we are well below the 50th percentile in terms of our awareness of the subtlety, sophistication and complexion of long-term care. However, we must not let everyone think this is terrible. There are problems with bed capacity, but sometimes between the issues of trolleys and MRSA, one begins to wonder whether people believe they are going into an abattoir rather than a care institution. It is a difficult task to gain perspective in terms of advocacy.

On the Older Americans Act, one has to be careful about special cases pleading. We are older people and we hope we will be treated with dignity, but when I looked at the need for children's constitutional rights, I reflected that there was a greater order of magnitude in respect of the needs of older people. Perhaps we should think in terms of constitutional rights for people at the extremes of life.

On the medical card for people over 70, I was shocked and indeed had to fight this issue at an IMO annual general meeting where people were very concerned about poor people who do not have the card. I argued that this was not an either-or situation. There is a very clear case that in terms of the wider system the spend on the over-70s card, while expensive, is not massive. I have been involved between Trinity College Dublin and the Royal College of Surgeons in Ireland in the first longitudinal study of ageing in Ireland, called HeSSOP, health and social services for older people. We were able to show between one cycle and the next an enormous increase in the uptake of preventive services, which we know are very effective. High profile industrialists and captains of industry who are over the age of 70 are not going to go on the national treatment fund waiting list. They will use their private insurance and indeed they might not even use their card. It is a sign to me of our deeply ingrained ageism that people did not understand this was actually one of the best spends we could ever have made.

That is an important point and what Professor O'Neill is saying is very welcome. The big problem, however, is that the family doctor gets paid four times more for a wealthy patient than for a poor older patient.

Professor O’Neill

I might come back to the Deputy on that. I am not a family doctor. One of the difficulties of the capitation system is that it is not linked in and we do not know what happens. However, in the old GMS days we know that older people had six times the number of visits compared to people in the middle-aged bracket. I believe that cost about €500 a year and I think the annual maintenance contract for my gas boiler is €160. The one-quarter payment being provided for the other people is at such a level that I cannot see people having case conferences and providing a very comprehensive service. I am less concerned for the people who graduated on to the card, but I am quite concerned that if people are paid very low fees to look after older people in the community this is a bar to the development of good primary care.

I am not arguing that point. It is the inequality that is being introduced which is causing a leaching of GPs from poorer areas. It is more attractive to look after richer patients. This is creating strains within general practice and that is the difficulty.

Professor O’Neill

Looking at the figures from general practice, the numbers are relatively small, unless one is dealing with completely high socio-economic groups. There may be other issues as this is part of a wider, deeper problem. Certainly, the capitation system and how it attracts people to work in deprived areas has wider implications than the fact that GPs might be paid appropriately for one sector. To confuse this issue with the over-70s medical card does not help the situation.

I am not suggesting it is the only issue and I do not want to delay on this. A new element was introduced, essentially because the IMO——

The IMO negotiated that.

That is what I am saying. It was because the IMO negotiated certain terms. However, that is the problem, not that the over-70s should not get a medical card. Resources are being inappropriately spent within the GMS scheme and that has a knock-on effect because inequality has been introduced for the first time as a result of a scheme negotiated by the IMO. That is the only point I am making, but it is important and should not be overlooked.

I just wanted to make the point that the IMO did that.

The Deputy is agreeing with me.

Professor O’Neill

We might be missing the point that the level of remuneration afforded to doctors for people who visit them six times as often is bizarrely low. I have made the point about public versus private funding. The issue, I believe, is to move the fee for all older people up to what it should be.

Nobody is arguing that point.

We are all in agreement that it is a great scheme, in any event, for the over-70s.

I want to ask Professor O'Neill about one of his local recommendations which he mentioned earlier. It says residents of any nursing home that scored poorly in the tendering process for heavy dependency should be informed of this as a matter of urgency as there is a high likelihood of residents with high or maximum dependency in all such institutions. Will he clarify what is involved here?

Professor O’Neill

It is very much as I stated. The report I read from ERHA on Leas Cross was consistent with what I saw in the documentation. There are, I understand, reports on five other nursing homes which are a cause for concern for reasons other than tender costs. We know from the Department of Health and Children figures on long-term care that virtually every nursing home in the Dublin area claims to have patients with heavy dependency. There needs to be transparent scrutiny on these reports, matching up with current processes. It is a cause of concern to me and I am not clear about it. Perhaps such scrutiny has been done, but it needs to be seen to be openly done.

Professor O'Neill referred to conditions as being similar to someone entering an abattoir. At least the suffering in an abattoir is short term.

We must thank Professor O'Neill for giving us nearly two hours of his time this morning. I also thank all the contributors. I have just one comment on the point made by Senator White on location. We notice that the population shift from the cities to rural areas is followed by would-be investors in nursing homes. I certainly hope that what Professor O'Neill had to say this morning will sound a warning to "get rich quick" merchants who are trying to open nursing homes as a follow-on to population shifts, to the effect that this is not the way to go. Clearly there have to be minimum standards. The comparison I make is with bed and breakfast facilities. The minimum standards required for these should apply similarly to nursing homes. I thank Professor O'Neill for clarifying that issue as well.

Sitting suspended at 11.19 a.m. and resumed at 11.28 a.m.

I welcome the Minister of State, Deputy Seán Power, and his officials. I thank the Minister of State for attending the meeting since 9.30 a.m. to listen to the debate. The meeting will now discuss the Leas Cross report with the Minister of State.

I thank the Chairman for the opportunity to address the committee on the important matter of Leas Cross nursing home. I was glad to listen to the presentation from Professor O'Neill and the contributions from members.

The Health Service Executive published Professor Des O'Neill's report into the deaths of residents of Leas Cross nursing home on Friday, 10 November 2006. I deeply regret the upset caused to older people and their families affected by the deficiencies set out in the report. We are learning lessons from this and the Department of Health and Children and the HSE intend to implement significant changes as a result.

Many of the recommendations contained in the report relate to standards for long-term residential facilities and to inspections of nursing homes. I emphasise that the safety and well-being of our older citizens are of the utmost importance to both the Department and the HSE. The Government is committed to ensuring high quality care to all older people in public, private and voluntary nursing homes and is working towards having in place the best standards and inspection processes to achieve this. Many developments have taken place in the past several months to further improve the quality of life of older people.

This year saw the largest ever budget allocation for the development of key areas of services to older people in palliative care, in which an additional €150 million was provided. The services announced in this package have gone a long way towards expanding and improving services for older people in palliative care in 2006. The package was designed to ensure this work would continue into 2007 and beyond.

This has resulted in a major improvement in home and community-based support for older people. A comprehensive health and social care service is being developed in a manner that is reliable and that respects and values older people. This was the largest ever increase in funding for services for older people. These initiatives set out the Government's continued commitment to older people and to putting older people at the centre of health policy both now and in future. The investment package is focused on caring for people at home and in accordance with their expressed wishes. It is a major step towards focusing new resources primarily on home care, while still supporting appropriate residential care. This is in line with international trends and reflects the growing independence of older people who wish to continue to live in their own communities.

One of Professor Des O'Neill's comments in the report stated that what happened in the nursing home can be equated with institutional elder abuse. I wish to take this opportunity to outline the ongoing work within the Department to deal with instances of elder abuse and to improve and develop services for older people. Following publication in 1998 of the report, Abuse Neglect and Mistreatment of Older People: An Exploratory Study, by the National Council on Ageing and Older People, a working group to advise on the formulation of procedures and guidelines on elder abuse was established. In 2002, having carried out a comprehensive work programme, the working group published its report entitled, Protecting Our Future. While the prevalence of elder abuse in Ireland is unknown, studies in other developed countries demonstrate that approximately 3% to 5% of older people living in the community may suffer abuse at any given time. This means that in Ireland, between 12,000 and 20,000 people living in the community may be suffering from abuse. While no figures are available on the incidence of abuse in institutions, unfortunately it happens. However, the majority of abuse happens in people's own homes.

The report recommended that the issue of elder abuse should be placed in the wider context of health and social care services for older people. Elder abuse is complex and difficult to define precisely. It may involve financial, physical or sexual abuse or may arise due to an inadequacy of care. The report also made recommendations in respect of health service structures, awareness, education and training, financial abuse, advocacy, legislation and research, which includes the establishment of a national centre.

The report recommended that an elder abuse implementation group should be established to guide the implementation of its recommendations. This group was established under the chairmanship of Professor Des O'Neill in December 2003. Awareness training for Health Service Executive, HSE, staff has been provided in line with the report and the HSE has been involved in awareness training for volunteer staff, including staff from the national senior citizens' helpline.

The issue of elder abuse is also being incorporated into professional training courses, including gerontology courses. In addition, a number of research projects have been undertaken, including the examination and review of medication for older persons in continuing care settings. The HSE recently advertised for senior care workers and it is expected that 27 senior care workers and four dedicated elder abuse officers will be appointed by the end of the year. Discussion is ongoing in respect of the structure of the new research centre for elder abuse and work continues on the preparation of a tender document for the new facility.

In the period 2003 to 2005, approximately €2.5 million in additional funding was allocated to the elder abuse programme. An additional €2 million was allocated in the 2006 budget to facilitate the implementation of the full range of recommendations in this regard.

Emphasis has been appropriately placed on developing new nursing home standards. It is important to note that standards already exist for private nursing homes. These are set out in the Nursing Homes Regulations 1993, on the basis of which inspections are carried out by the HSE. The regulations cover several aspects of nursing home care, including health and safety issues. However, they apply only to private nursing homes. The Department is anxious for the introduction of a new set of standards for long-term residential care for older people. It was to this end that the Minister established a working group last year to produce draft standards for all long-term residential settings, public, private and voluntary, in conjunction with the relevant bodies. The Department is in discussion with the interim Health Information and Quality Authority, HIQA, on a consultation process on these draft standards.

The standards are based on legislation, research findings and best practice. While broad in scope, the standards acknowledge the unique and complex needs of the individual person at the centre of care. They also acknowledge additional specific knowledge, skills and facilities needed for service providers to deliver a person-centred and comprehensive service that promotes health, well-being and quality of life.

The standards are set out in two parts. The first focuses on the standards concerning the resident as an individual and includes personal identity, social connectedness, rights and health care. The second focuses on the organisational aspects of the residential care setting and includes management, staffing, care environment and health and safety. The health Bill 2006 will establish the HIQA, and will put the social services inspectorate, SSI, on a statutory basis within HIQA. It is intended that the SSI will be required to monitor residential services provided to older persons against standards adopted or set by HIQA. This is in accordance with the commitment in the health strategy, Quality and Fairness — A Health System for You, to extend the remit of the social services inspectorate to other social services, including residential services for older people.

The fundamental objective of the proposed health Bill 2006 is to have a health and personal social services system which has quality and safety embedded at all levels and in all settings. The registration and inspection system for residential services will provide a quality assured residential system for persons in receipt of these services. The proposed inspectorial system will take account of situations where centres are not in compliance with regulations and standards. It will provide for attaching conditions to registration or cancellation of registration, if appropriate. Ultimately, this will ensure that only services that are provided in line with the regulations and meet the standards set by HIQA will be allowed to operate. It is, therefore, a priority to establish HIQA and the office of the chief inspector of social services on a statutory basis. The Department has been working closely with the Office of the Parliamentary Counsel and work is at an advanced stage on the draft provisions. The Bill will be published before the end of the year.

The Bill will yield a number of tangible benefits. It will help ensure all persons receiving services under the Health Acts 1947 to 2006 will have them delivered in accordance with quality and safety standards. It will also have a positive impact on public confidence by enabling persons to have greater confidence in the safety and quality of the health care they and their families receive, especially in respect of the safety and quality of the residential services being provided.

HIQA's main role will be to enforce internal quality assurance practices at all levels in the health delivery system and, at the same time, bring to bear external quality assurance in an objective manner. To that end, the Bill will ensure that quality of services will be monitored and evaluated against transparent standards on an ongoing basis.

Safety is the most fundamental aspect of health care quality. HIQA's proposed functions will include: setting and monitoring standards on safety, quality in health and personal social services provided by the HSE or on its behalf; advising the Minister and the HSE on the level of compliance with those standards; carrying out investigations of services provided by the HSE; carrying out assessments to ensure the best outcomes for resources available to the executive; carrying out assessments of health technologies; evaluating information on health and social services and the health and welfare of the population; advising the Minister and the HSE on deficiencies identified; and setting standards and monitoring compliance with those standards. Other functions relating principally to information technology and management, as referred to in the 2004 national health information strategy, will be assigned to HIQA under a future health information Bill being prepared by the Department.

The new statutory office of the chief inspector of social services will continue the SSI's work of inspecting residential centres for children in need of care and protection. The inspectorate has been operating on an administrative basis since 1999 conducting inspections into residential child care services managed by the HSE under the statutory powers contained in the Child Care Act 1991. However, the new office will have wide-ranging additional responsibilities. These include: inspecting residential services for persons with a disability and older people, including public and private nursing homes; registering these services based on regulations provided for under the Child Care Act 1991; and inspecting the HSE's foster care services, the scheme for boarding out of older people and the delivery of its pre-school inspection system.

The chief inspector will inspect residential centres for children, older people and people with disabilities for compliance with regulations made by the Minister under the legislation and standards set by the authority. He or she will have the power to refuse to register, attach conditions to a registration or cancel a registration in the event of non-compliance with the regulations. The standards in respect of residential centres will be admissible in court in any proceedings taken under the Bill. The HSE and those providing services on behalf of it must have regard to the standards set by HIQA. HIQA will also be required to monitor compliance with them and report to the Minister and the HSE on the level of compliance found.

The HSE is responsible for carrying out inspections of private nursing homes and has made many improvements to its nursing home inspections process over the past year. The HSE has worked on updating the inspection and registration process of nursing homes. To this end, it established a working group in July 2005 which reported in July 2006. Among the recommendations of the report were the recruitment of dedicated inspection teams throughout the country. These teams will have staff with nursing, medical and mental health experience and will have other professional staff available to them if and when needed. The inspection teams will work from the same standardised checklist to ensure conformity across the entire system. Most importantly, all inspections will be unannounced.

The HSE has made important improvements to its nursing homes inspection process since the working group's report was completed and has been working on the production of a standard inspection report. The HSE has also commenced publishing nursing home inspection reports. This is to provide the public with an opportunity to gain information in respect of non-public nursing homes, particularly in the case of individuals who may be considering a nursing home as a future living option. Information of a confidential nature will not be published.

As I stated earlier, under the Health Bill 2006, it is the intention that responsibility for inspecting both public and private nursing homes will be passed to the chief inspector. Accreditation is the longest established and most widely known form of external assessment of health care services throughout the world. In Ireland, in 2002, the Irish Health Services Accreditation Board, IHSAB, was established as a statutory body. This board operates to the standards for international validation set by the International Society of Quality in Health Care. In due course, IHSAB will be subsumed into HIQA.

IHSAB has developed standards for long-term residential settings. However, it should be noted that accreditation standards are voluntary. These standards should not be confused with the national standards for residential care, to which I have previously referred. These national standards are core standards and will, therefore, apply to each residential unit, whereas the IHSAB standards will apply only to the units which decide to go for accreditation.

The Government is considering policies on long-term care. Several principles underlying this policy were agreed with the social partners in Towards 2016. These principles specify, for example, that there should be one standardised national needs assessment for older people needing care. The use of community and home-based care should be maximised. Where residential care is required, it should be quality care and there should be appropriate and equitable levels of co-payment by care recipients based on a national standardised financial assessment. The level of support for residential care should be indifferent as to whether that care is delivered in a public or private facility. The financial model to support any new arrangements must be also financially sustainable.

From what I have outlined, it will be clear to members that the Government's commitment to older people cannot be denied. The focus is on supporting older people in their homes and communities for as long as possible, and at the same time supporting those who require residential care if the time comes when such care is the most appropriate care required. This Government is committed to ensuring high quality care for all older people in public, private and voluntary nursing homes and is working towards having the best standards and inspection processes in place to achieve this. Through its investment programme this year, the Government has demonstrated its commitment to older people. We acknowledge that we must continue to develop policy in this area to meet the growing demand for services and that we cannot be complacent in this regard. We are very conscious of the challenge that lies ahead.

Everything must be done to avoid a situation like that which occurred at Leas Cross ever happening again. The Government is committed to developing appropriate structures to ensure our older citizens receive the best possible care in the most appropriate settings in the future.

I thank the Minister of State. Deputy Devins will speak first, followed by Senator Browne and Deputy O'Dowd.

I welcome the Minister of State and his officials to this morning's meeting. I am delighted to hear him state categorically what Government policy is in respect of older people. As Professor O'Neill outlined earlier, the demographics of our country, while showing an increase in the elderly population, show a very interesting trend in respect of nursing homes. It is reckoned that the number of people who will require nursing homes in the future will be much lower than many commentators would have thought.

I have a few brief questions for the Minister of State, the first of which relates to home care packages. I was delighted to see the Minister of Health and Children quoted in The Irish Times this morning as stating that she would like to see far more people cared for at home. Could the Minister of State enlighten the committee as to what plans the Government has in this regard?

The main topic under discussion this morning is the Leas Cross report. Unfortunately, it is a litany of very serious abuse. I believe inspections are the way forward. I understand the HSE appeared before us last week and outlined its policy in respect of putting in place inspection teams. From the Minister of State's speech, I note that inspections are only being conducted in private nursing homes. They should be carried out in both public and private nursing homes by dedicated teams and they should be unannounced. The Minister of State might refer briefly to this issue.

Where people have to go into nursing homes or long-term care, there is a policy whereby they will get some help through subventions. Could the Minister of State outline why there appears to be an inequality between various parts of the country in respect of subventions and what the Government's policies are in this respect in the future?

I thank the Minister of State and his officials. We also heard the Minister of State's speech in the Seanad last night. A section in Professor O'Neill's report states that no judgment has been formed where differences of opinion exist. Has the Minister of State identified these differences and what action has been proposed to resolve them and clarify the matter? I previously put this question to Professor O'Neill.

Has the Minister of State identified specific areas of wrongdoing by identifiable people? Has he submitted these details, namely, whatever is referred to in the report, to the Garda or the Medical Council?

My next question relates to matters we encountered in the Travers report. When the Minister of State assumed his post, which involves responsibility for services for elderly people, was he briefed on the problems facing him, such as Leas Cross? If so, why was he so tardy in his response? Why did it take the efforts of Deputy O'Dowd and "Prime Time Investigates" to effectively bring the matter to his attention before any action was taken? Eighteen months later, we still seem to be looking at working groups and policy groups and examining the issues instead of taking direct action.

A page in Professor O'Neill's report which puzzled me concerned the finding that 65 year old women have a higher probability of being in a nursing home than men. I believe the figure is 39% for a 65 year old woman, while the figure for a 65 year old man is 25%. Was the Minister of State aware of this fact? If so, what is the reason for it and what are its implications?

They look after themselves. Men do not look after themselves.

Possibly, I do not know. I know the Minister for Health and Children constantly speaks about better home care packages and how she wants people to stay at home. This is lovely, but in reality there are many single people who are working and there are many women in the workforce and it is very difficult for families to look after elderly people if they have high dependency needs. It is slightly simplistic for politicians suddenly to start talking about how people should not be in nursing homes and should be moved back home. It may be possible with enhanced home support in some cases, but it is not always possible for a multitude of reasons and we should be careful when throwing out bland responses.

As Professor O'Neill mentioned, the proof of the pudding is whether there will be major proposals in next week's budget to address the needs of long-term patients in nursing homes. If there is none, should we take it the Government is not worried by nursing home scandals such as Leas Cross?

I appreciate that the Chairman has been lenient in terms of time, but I wish to debate some of the issues arising from the Minister of State's reply. Will the Minister of State hold an inquiry into why patients were transferred from St. Ita's Hospital to Bedford House and Leas Cross? Professor O'Neill has examined events in Leas Cross from 2000, but no one has examined the deeper issues surrounding the matter.

Who will the Minister of State hold accountable? Two of those involved at a high level in the HSE's inspection regime are working as private consultants for the HSE, inspecting homes such as Leas Cross and others in the area. How can the people in charge of the inspection of Leas Cross be working as private consultants to the HSE in the same area? It is unbelievable.

Will the Minister of State name those who reviewed the Leas Cross report before it was published? Professor O'Neill stated that it was reviewed by persons unknown to him. Were they political or administrative figures?

Will the Minister of State reverse the secrecy of the HSE? The first decision made by Mr. Aidan Browne upon entering office was that all information on nursing homes could be given only through the Freedom of Information Act. Will the Minister of State insist that Mr. Browne reverse the decision?

Will the Minister of State insist that the nursing home inspection teams arrange for the physical examination of patients on a regular basis? They inspect buildings, call bells and so on, but no report states that patients are physically examined by properly qualified people.

Can the Minister of State identify his actions in respect of recommendation B on page 8 of the review of deaths? Professor O'Neill believes five nursing homes in the greater Dublin area scored poorly in the tendering process. The HSE stated that it was not satisfied with the standards of care provided to high or maximum-dependency residents.

A number of questions have been asked. Beginning with the funding of long-term care, a number of reports have been written. It is one of the major challenges facing the Government and we have examined it in some detail. We discussed it with the social partners in the recent talks. The Government is actively considering the matter and will make a decision in the near future. The decision will be difficult to make, but there are many benefits to be gained by introducing a new system. Much is wrong with the current system and the proper funding of long-term care will be of significant benefit.

Regarding home care packages, there were 1,100 pilot projects throughout the country last year. In the budget, the Minister for Finance provided additional funding that allowed us to increase the number of packages by 2,000. The HSE indicated that by the end of September, more than 3,000 new packages were in operation.

Feedback from the pilot schemes was good and those in receipt of the packages were appreciative and believed they were worthwhile. All indications were that we should continue to invest in the area, which we did. Home-care packages can prevent the need for people to be admitted to hospital or facilitate the early discharge of a patient. People receive the packages in their homes and among their families and communities where they are happier. We hope to continue our investment.

We have made a number of changes in respect of inspections and have been working to address several of the recommendations included in Professor O'Neill's report. The HSE is working towards setting up dedicated inspection teams that will receive proper training, which has not occurred previously, and will standardise the inspections.

I want to know——

Previously, the practice was for each area to go its own way and for different inspection systems, but this situation will change. Dedicated teams will report back to managers and the system will be more efficient. We will publish the Bill during the coming weeks and we have drawn up draft standards. We have made much progress regarding the matter.

Deputy Devins mentioned the subvention scheme, which is before the House. A number of people have been critical of certain of its aspects. The provision to the scheme in 1993 when it was set up by regulation was €5 million, but this year's provision was the considerable sum of €160 million. The scheme needs to be altered and, on the advice of the Attorney General, it will be put on a sounder footing via primary legislation. I hope to be in a position to make a number of changes in the near future.

Regarding differences of opinion and accountability, what one takes from a report depends on one's attitude. I am not overly concerned about who was responsible or looking for heads. We must learn serious lessons from the report.

What about accountability?

I will be accountable.

The Minister of State is in possession. Deputy O'Dowd can revert to the matter.

If I were to continue to interrupt the Deputy during his questions, I would never hear what he says. The Deputy has asked his questions and I will happily deal with them.

We will be accountable. The Leas Cross situation should not have occurred and some of the families put through terrible hardships continue to feel pain. Professor O'Neill made a number of recommendations in his report and we indicated that we will work towards implementing them with the HSE. Some of the recommendations are already being implemented.

I explained the different ways in which inspection teams operated in different health board areas. We did not have a standardised system and teams were going their own ways in many respects. Where difficulties arose, it was the policy of the health authority to work with nursing homes to try to improve them. In the majority of cases, that policy worked well.

In Leas Cross it did not work as we would have wished. Difficulties existed over a long period and, in hindsight, this should not have happened. The report has been forwarded to the Garda Síochána and the Medical Council. Senator Browne asked if I was aware of the difficulties beforehand. I was informed of the report's contents a few days before the "Prime Time Investigates" programme was broadcast. I was disturbed by what I saw and immediately wrote to the Garda Commissioner to ask him to investigate.

We must provide a choice rather than forcing people into nursing homes, which should be the last option, not the first. Studies indicate that people are happier living in their homes for as long as possible. We will provide every assistance to them. A small but significant number of our population require nursing home care. It is a major decision for any individual or family to take. It is expected that the person will receive a certain level of care and obviously this did not happen in Leas Cross. There are concerns that other nursing homes are not providing the level of care people deserve. We will publish the legislation and a draft set of standards within the next few weeks. The legislation will be treated as a priority and debated in the Houses early in the new year.

Deputy O'Dowd referred to the possibility of an inquiry into St. Ita's Psychiatric Hospital. I have discussed this with officials. Serious questions remain unanswered. I have not yet made a decision on it.

That was an answer to one question. I asked five. When will the Minister of State decide on this?

It will be over a matter of weeks. It is not a matter I wish to put on the long finger. Serious issues must be discussed.

The inquiry, if it is held, will focus on the transfer of patients from St. Ita's to Leas Cross and Bedford House. That is what I requested.

That is the question the Deputy asked and that is where we will concentrate our efforts.

The second question I asked was about accountability. Who is held accountable for this?

We all have jobs to do. We have received the report from Professor O'Neill, who did not seek a scapegoat. It is important that we learn lessons from the report. The systems we had for inspecting nursing homes was not satisfactory and we allowed the situation in Leas Cross to continue for longer than it should have. One can understand why the inspection team may have wished to work with the nursing home to improve standards and resolve difficulties in the early stages. That these were not resolved in a short time tells its own story.

Accountability is not about finding a scapegoat. Who is responsible for decisions made? Mr. Jack Buckley, senior inspector, and Mr. Walsh, a senior administrator, were responsible for the inspection regime in Leas Cross. Both are working as private consultants to the Health Service Executive, HSE, on nursing home inspections. How can that be allowed? Those responsible for the failed inspection regime are employed to inspect further nursing homes.

The HSE has functions that are separate to mine. They are related but a line must be drawn between the Department of Health and Children and the HSE. The appointment of consultants by the HSE is solely a matter for the HSE.

I beg to differ profoundly with the Minister of State. In respect of the credibility of the regime, it is unacceptable. Accountability is important because people have suffered and died as a result of what happened in Leas Cross and other nursing homes. I cannot accept the explanation offered by the Minister of State. A letter I received from the HSE in 2001 named ten nursing homes, of which three — Bedford, Rathfarnham and Rostrevor — are still open, although Rathfarnham closed last week. They were disgraceful and shameful then and still are now, although Rostrevor has passed muster in the past 12 months. There is a lack of accountability in this. Will anyone be held accountable, such as the HSE or the people who stood over these inspections? Will the Minister of State not insist on changes, resignations or retirements? It is not acceptable that the Minister of State does nothing after people allowed this to happen for so long.

To say we did nothing about it would be wrong. From the beginning the Government was accused of preventing publication of the report. Nothing could be further from the truth. The HSE appointed Professor O'Neill to report on the deaths in Leas Cross. Once the report was published, it was the Government's desire to publish it as quickly as possible. The difficulties that existed had to be overcome. We made an effort to ensure the report was published.

A number of changes have been made. It is clear that the system of inspection of nursing homes did not work. It failed badly. The HSE has changed the manner in which it inspects nursing homes and is in the process of setting up dedicated teams and training them. This did not happen in the past.

In respect of what Professor O'Neill said this morning, specifically what he said about his report, can the Minister of State name those in charge of the review of the report?

I cannot tell Deputy O'Dowd.

Can the Minister of State revert to me?

I will discuss the matter with Professor Drumm and see if he can assist. I cannot provide the names because I am not sure.

Will the Minister of State find out and revert to me as a Member of the Oireachtas?

It is information I do not have at present.

Will the Minister of State find it out?

I will make an effort but cannot guarantee that I can find the information Deputy O'Dowd seeks.

A certain group of people was in charge of the review of the report. I do not know who they were. Professor O'Neill referred to the fact he could not find out who they were. Will the Minister of State find out and be accountable to the Oireachtas?

I will be quite happy to do so. I do not want to tell Deputy O'Dowd I will provide him with information that Professor O'Neill was not able to find out. I will make inquiries of Professor Drumm and I will be happy to provide the information I receive to the Deputy.

The other question I asked was on secrecy in the HSE. The first decision of Mr. Aidan Browne was that all information on nursing homes could only be given under the Freedom of Information Act.

We have seen changes take place. A major change took place in the HSE's thinking on inspections and we now see publication of reports. Professor O'Neill referred to it and perhaps he was concerned more information could be provided. However, a major change has taken place and we can only build and improve on the type of information being made available. It will give a much clearer picture not only to patients but also to families and communities as to how nursing homes operate.

On that issue, the question I asked of the Health Service Executive through a parliamentary question was whether I could have the names of companies successfully prosecuted for not running nursing homes in a proper manner. I was told I could not have that information. Will the Minister of State provide me with the names of people who were successfully prosecuted during the past ten years for breaches of nursing home regulations?

I am not sure who told the Deputy he could not have the information.

It was the HSE.

From my point of view, I strongly resist that and disagree with that message. We all have a right to know. Prosecutions are not secret. If we are to put in place a system of proper long-term care for older people, it is important to provide as much information as possible to people making choices. There should be no attempt by any arm of Government or anyone involved in the provision of services to cover-up inadequacies or deficiencies.

I very much welcome that. The key issue is that the default directive is secrecy and not openness or transparency. I appreciate that the Minister of State will take up this issue which must be tackled that a parliamentary question is not answered on the basis of secrecy.

Will the Minister of State insist that in whatever inspection regime will be introduced, a physical examination of patients will take place on a regular basis by qualified personnel?

That is covered in the draft standards we published. I assume it will be addressed.

I thank the Minister of State.

The Minister of State's reference to not looking for scapegoats is pathetic. If people are proven clearly to have done wrong, either in the "Prime Time" programme or in the report they should be prosecuted. In my former teaching job, if I abused a child in a classroom I would be fired, and rightly so. It happens in every other walk of life. It is not acceptable that a Minister of State is laid back about passing it to the Garda Commissioner.

That is not a fair remark.

The Department of Health and Children and the Minister of State have a role to play in not only bringing about a prosecution but seeing it is successful. In every other walk of life people are held to account. By not doing so, we send a message that people can abuse their positions in nursing homes or other health institutions. We see it throughout the health services. Nobody is accountable for the spread of MRSA. People's lives are affected and damaged by a bug in a hospital but no one is accountable. Someone should be accountable because somebody causes it. Everyone has responsibility.

The terrible term "bed-blockers" was previously used. Last year, the Minister for Health and Children, Deputy Harney, made noises about improving the home care package which would lead to people leaving nursing homes in droves, returning home and living happily ever after. How many people left nursing homes during the past year because of enhanced home care packages? Does the Department have any idea how many people in nursing homes should not be there because adequate home care packages are available to them?

For the record, I do not find the Minister of State's attitude at all laid back. It is unfair to make that allegation. It should be put on the record that the issue existed long before Deputy Seán Power became the Minister of State.

The "Prime Time" programme exposed it. It had proof in the form of video footage.

That is not the point. It is wrong of the Senator to create an impression.

I would like the Minister of State to correct this. It is my understanding that the Leas Cross report was forwarded to the Garda Síochána. It is wrong to state that people will not be held accountable. The Garda Síochána will decide whether prosecutions will occur. To give an impression that nothing is being done could not be further from the truth.

The ultimate sanction must be that it has gone to the Garda authorities.

The truth of the matter is after the "Prime Time" programme, the health board established a special investigation into the issues covered in the programme separate from Professor O'Neill. How many times did that committee meet? How soon was it disbanded? This is a serious issue. Will the Minister of State come back to this issue if he does not have the information to hand?

I will make inquiries.

As I understand it, the committee did not continue its investigation for whatever reason it had at the time.

Earlier, I neglected to press the Minister of State on the following matter and I will do so now. Professor O'Neill stated five homes in the greater Dublin area failed a test of care in 2005. He recommended those families and residents should be contacted as a matter of urgency. Did that happen? Will the Minister of State name those homes? It was expressly not answered by the professor.

Again, this is a matter for the HSE which dealt with it and has the information.

With respect, it is a recommendation in the report. We are here to discuss the report and be accountable.

We will be accountable. I will be as helpful as I can. It is not appreciated in some quarters. I will obtain as much information as I can on those five homes. Professor O'Neill stated it was for non-financial reasons.

The key point made is that highly or maximum dependent patients were involved, and not low or medium dependency patients. The reply to a parliamentary question avoided the issue.

I know. However, Professor O'Neill developed it by mentioning the action taken by the ERHA to deal with high dependency and the work done with nursing homes.

Are highly dependent people still in those homes which failed the standards of care as applied in 2005?

Deputy O'Dowd asked very specific questions. I will try to get answers. I do not have the information with me.

This was one of the recommendations in the report. The Minister of State has had the report for nine months but he does not have an answer today.

I am sorry. Deputy O'Dowd is one of the few people with all of the answers. I am not in that fortunate position.

I do not have all the answers. However, I certainly seek them and I will persist in getting them.

Deputy O'Dowd asked a specific question. I am trying to be as honest and helpful as I can. I do not have the specific information at my disposal. I will make inquiries and come back to the Deputy.

With respect——

Other members wish to ask questions. The Minister of State is in possession.

Senator Browne asked about accountability and responsibility. Regardless of whether we are in Opposition or in Government, we share certain responsibilities. The Deputy can make as many throwaway remarks as he likes but a difficulty has arisen which we are trying to address as a priority.

Prosecutions under the Health (Nursing Homes) Act are a matter for the HSE, which has been successful in prosecuting a number of nursing homes. More serious charges are matters for the Garda, although, as I mentioned earlier, I wrote to the Garda Commissioner following the "Prime Time" programme to express my concerns and I am aware that a meeting took place subsequently with a representative from the HSE. I considered that what I had seen was sufficient to warrant a Garda investigation.

It was agreed at the meeting between the Garda Commissioner and the HSE that the executive would revert to the Garda if the issue warranted investigation. In other words, the Garda did not commence its own investigation but agreed to await contact from the HSE if the issue was sufficiently serious. I understand that was the reason behind the establishment of the committee, although I would appreciate more clarity on the matter.

I will investigate the circumstances surrounding the establishment committee and the meetings it held.

The report states: "Residents (and their families) of any nursing homes that scored poorly in the ERHA tendering process in 2005 for Heavy Dependency/Intermediate Care Beds should be informed of this as a matter of some urgency, as there is a high likelihood that there are residents with high or maximum dependency in all these nursing homes". I will not labour this point but the Minister of State has responsibility for this matter. He has been in possession of the report for the past nine months, so it is unacceptable that he cannot give me an answer. I accept, however, that he will seek the relevant information.

What report do I have for nine months?

The Leas Cross report.

I have not had it for nine months.

How long did the Minister of State have it?

The Deputy can throw away remarks if he so wishes but I wish to correct him.

The Minister of State is correct. The report was sent to the HSE in February and the Minister of State was briefed on it in June, which is six rather than nine months ago. During those six months, the Minister of State did not find answers.

The report contained a number of recommendations. We are happy that it has been published because it will perform a great long-term service for older people by fostering higher standards of care throughout the country. We are working with the HSE and others to ensure such standards are met as quickly as possible.

I asked a question about caring for patients in their homes.

We are here to discuss the Leas Cross report. Issues regarding home care packages are not relevant to this session.

How many patients are cared for in nursing homes?

I will investigate how many patients have left nursing homes as a result of enhanced home care packages and revert to the Senator with the answer.

Can the Minister of State estimate how many people are resident in nursing homes who could be cared for at home?

A person may make a choice to go into a nursing home. Some stay for short periods and others for longer durations. It may be difficult to provide a precise answer.

I thank the Minister of State and his officials for being very forthcoming with their responses. We have had a full and fair discussion among all contributors.

The joint committee adjourned at 12.25 p.m. until 9.30 a.m. on Thursday, 7 December 2006.
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