JOINT COMMITTEE ON HEALTH AND CHILDREN debate -
Thursday, 3 Jul 2008

Nursing Homes: Discussion.

Chairman

I welcome Mr. Robin Webster, chief executive officer, and Mr. Eamon Timmins, head of advocacy and communications, Age Action Ireland. I also welcome Mr. Tadhg Daly, chief executive officer, and Mr. Charles Caldwell, Ms Cora McNamara and Mr. Paul Rochford, directors of Nursing Homes Ireland Limited.

I draw witnesses' attention to the fact that members of the committee have absolute privilege but the same privilege does not apply to witnesses appearing before the committee. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official, either by name or in such a way as to make him or her identifiable.

Mr. Robin Webster

I thank the Chairman for the invitation to discuss the implications of this very important piece of proposed legislation. I am joined by Ms Peggy Cumberton, director of Age Action Ireland, Mr. Eamon Timmins, head of advocacy and communications, Ms Emer Begley, social policy officer, and Mr. Noel Grace, one of our youngest volunteers.

Age Action Ireland is an advocacy organisation on ageing and older people. Our aim is to assert the rights of older people to comprehensive, high quality services and to represent their views and experiences in all their diversity, with top priority given to the most disadvantaged older people in all our work.

Age Action Ireland believes that, if implemented, the so-called "fair deal" legislation will seriously erode the public entitlement to essential health care for older people. If it is not introduced in a comprehensive manner, alongside the adequate provision of home and community services, it could discriminate against older people, especially the most vulnerable. I will outline Age Action Ireland's concern that the proposed legislation may erode the public entitlement. I will address the issue of attempting to introduce the fair deal in a piecemeal fashion, with the danger that vulnerable older people may fall through a number of gaps in the system.

Age Action Ireland recognises that the fair deal is a genuine attempt by the Government to address an issue of serious concern to older people. Many older people who are currently paying upwards of €50,000 per annum for a private nursing home bed are struggling to meet the bills, and in some cases the financial pressures have forced them to sell their homes. On the other hand, the deal includes an increase of almost 50% in fees to be paid by public patients.

While Age Action recognises that the fair deal is an attempt to address this issue, we profoundly disagree with the solution the Government is proposing. We are not seeking to delay the introduction of legislation but we are urging an open debate about the many issues before any conclusion is arrived at. However, today's discussions are based on scant information released about the fair deal proposals in the past 18 months. We are still very much in the dark about the Government's plans.

We wish to raise a number of issues. This is a new departure for charity and health services. After the 2004 Supreme Court ruling on nursing home funding, legislation was introduced which established that older people, determined to be in need of nursing home care, were entitled to a publicly funded bed, less 80% of their pension, a provision that has neither been clearly transmitted nor facilitated for many older people. The inequity of the current system relates to the failure of the Health Service Executive to inform the public adequately and to provide this care, leaving the most vulnerable and ill-informed, or in many cases relatives of those patients, to dispose of their assets to pay substantial amounts or else follow the less well funded discretionary and subvention route. While offering welcome relief to people in private nursing homes, some of whom — or their relatives — may have to sell their property in order to pay nursing home charges, the proposed fair deal represents an erosion of the entitlement to State funded long-term care in public nursing homes through the State's proposed claim to a proportion of all disposable income as well as up to 15% of the estate after death. If, as we are being told, the cost of various therapies such as physiotherapy or speech therapy are not covered by the National Treatment Purchase Fund but will be added to the residents' bill, this is a further erosion of public entitlement and takes away any notion of rehabilitation in long-term care.

While in a democratic society debate on health care funding must be open and vigorous, there are particular concerns on what appears to be a selective inheritance tax on stroke and dementia. No other form of public health care currently involves a charge after death. Such approach is not only ageist but flies in the face of the life cycle approach, the basis of the social partnership agreement Towards 2016. We are all future older people, if we are lucky, and have a direct stake in ensuring that access to care, the standards of care and the costs of that care are no different for stroke and dementia and other forms of illness than for cancer and cardiac disease. Older people should not be charged any differently for the costs of vital health care from any other section of society.

The next major concern would be piecemeal introduction. When it was announced in December 2006, there were three elements to the fair deal — charges, the use of the National Treatment Purchase Fund to negotiate the costs of beds with nursing home owners, and the fact that only homes approved by the Health Information and Quality Authority would be entitled to participate in the scheme. It was significant at the time, coming within three months of the publication of Professor Des O'Neill's report on the Leas Cross scandal, that emphasis was placed on ensuring that only homes that met stringent independently inspected standards would be entitled to participate in the scheme, surely an issue reinforced by the recent rapid increase in the cases of elder abuse reported. Despite the Government's deadline of 1 January 2000 for the introduction of this legislation, the process of implementing standards and inspecting them is not yet in place. While HIQA published the standards in March, the regulations to enforce these standards have not yet been enacted. They will not be enacted until the HSE has completed the regulatory impact assessment for the Department of Finance. Only at this stage will the decision be taken as to which of the standards recommended by HIQA are mandatory and which will be developmental. This delay has meant that HIQA has delayed the recruitment of its inspection team. I should add that any comment we make about the lack of consultation and participation does not apply to HIQA, which in developing its quality standards set an exemplary model for consultation that could well be followed by others.

Age Action stresses that a fair deal cannot be implemented in a piecemeal fashion. Charges must not come before standards. If older people are charged 80% of their disposable income during their lifetime and up to 15% of the value of their home after their death for essential health care, it must be health care of the very highest standard. Although much focus has been on the legislation and the difficulties it is facing, the structures are not yet in place to decide who would be admitted to a nursing home bed under the fair deal or which nursing home would qualify to participate in it.

Our third major concern would be about vulnerable older people falling through gaps. As part of the fair deal, applicants will be means tested and dependency tested. The latter will ensure that only those who are dependent enough will be entitled to a bed under the scheme. However, we foresee that this could create problems. At the moment we do not know who will qualify for a bed under the fair deal as the dependency criteria have not yet been decided. However, it is possible that an applicant for a nursing home bed could be refused on the basis that he or she should be able to live an independent life in their own home with sufficient community care. Adequate community services are therefore essential if the fair deal is to operate effectively, but unfortunately these services are inconsistent around the country, with resources still available in some parts while services have been suspended in others. If applicants do not have the required community services in their area, they could be left in the worst of both worlds, unable to get a nursing home bed, yet unable to live with dignity and independence in their own home.

Information currently gathered by the Irish Association of Social Workers, social workers and other health professionals indicates that funding for home care packages was not available in six of the 18 areas where information was available. This information is contained in an appendix to our note. Funding for home care packages has run out in five areas, it was being recycled in eight areas and provision was being reduced in two other areas. How can there be a national common assessment when these essential services are not being provided uniformly across the State? The reality is that despite longstanding Government policy to enable older people to live independently in their own homes for as long as possible, we are spending more on the 5% of older people in residential care than on the 20% of older people who need home and community care. For every euro we spend on community care, €2 are spent on residential care. Some 10,500 people are being assisted by home care packages, yet there are 21,000 people in nursing homes.

It is worth noting that the interdepartmental committee which reported to the Cabinet on the funding of long-term care in 2005 recommended that co-funding should not be confined to residential care but should be extended to those receiving community care. It is recommended that a national standard financial assessment framework should be developed to apply for both home care and residential care. We are unclear if the Government is planning to charge for community care, although recent correspondence from the office of the Minister, Deputy Mary Harney, suggested that this was under consideration. Despite the introduction of the home care package initiative two years ago and the provision of an extra €10 million for home care packages this year, we still do not know the extent of the need or the impact of these packages, or how they are linked to continuing services like home help services.

Ireland spends less than half of the OECD average on funding long-term care. We should look at other funding options. There is a need to support individuals in nursing homes to meet their costs. There are several options in other countries, including private savings, private insurance, public sector tax-based support and social insurance. Denmark and Australia fund long-term care from general taxation. Germany opted for a ring-fenced social insurance contribution. Japan partly funds long-term care from ring-fenced social insurance and general taxation. The Mercer report recommended that the RSI model was the best approach to funding long-term care in Ireland. The interdepartmental committee which I have just mentioned believed that this warranted further consideration, yet that committee proceeded to recommend the fair deal without any consideration of the RSI model.

Age Action Ireland is concerned at the lack of consultation that has taken place around such important legislation, which has been delayed by legal difficulties and has been with the Attorney General since December. When the Taoiseach announced in December that the legislation would not be introduced in the Dáil, he said the delay was to allow consultation with interested groups. That consultation has yet to take place, although plans for the fair deal were first announced 18 months ago. Considering the huge implications of the fair deal for older people, such consultation is essential.

The funding of long-term care is vital to the long-term planning of our health services. Age Action Ireland is seeking a full, reasoned debate, involving older people and their carers, that will come up with a system that will establish the right of older people to high quality, equitable and affordable services which gain the full support of the entire population. This would be an enormous step forward in making Ireland the best place in the world in which to grow old, our vision for the future. I thank members again for their invitation and their attention. We would be happy to answer questions.

Chairman

I thank Mr. Webster. I will ask Mr. Daly to make his presentation and we will then have questions.

Mr. Tadhg Daly

I thank the Chairman and the committee for their invitation and I congratulate the Chairman on his recent appointment. Nursing Homes Ireland is committed to working with the committee and we look forward to continued engagement with members, both in session and outside the committee rooms.

The central theme of today's discussion addresses the issue of financing long-term care. However, I will also apprise members of the work of Nursing Homes Ireland and give them an overview of the sector, particularly given that the private and voluntary sector makes up the majority provider of long-term care. I will also give our perspective on the financing of long-term care and the fair deal proposal.

Nursing Homes Ireland and the care its members provide are a vital part of the health service. The organisation was formally established in January 2008 and it is now the single representative voice for the private and voluntary sector, following the merger of four previously existing organisations. We now represent over 70% of the private and voluntary nursing home sector, which employs in excess of 19,000 staff. Our members deal on a daily basis in advocacy on issues affecting residents and families.

There has been a significant increase in the number of private and voluntary nursing home beds in recent years and the private and voluntary sector provides care for almost 19,000 residents, accounting for 65%, or two thirds, of the total provision. We recognise the challenges ahead. We are not merely participants in the process but are a significant partner and a driver for change, both as an organisation and as members providing vital services in communities.

Our vision is of high quality nursing home care which is available to those who need it as an essential part of a well functioning health service. Our aim is to deliver the care people need in a way that is affordable, accessible and of the highest standard. Members of Nursing Homes Ireland are committed to maintaining and enhancing the quality of life for residents, preserving the autonomy of residents, guaranteeing freedom of expression, maintaining a safe physical environment, ensuring that the privacy and dignity of residents is respected and being an employer of choice, providing continuous professional development and training for staff.

Significant challenges lie ahead. Mr. Webster referred to public policy on provision of care for older people. Life expectancy in Ireland is increasing and now exceeds the EU average. Recent CSO statistics indicate that the population aged over 65 will treble to 1.4 million, or 25% of the total population, by 2041, compared to 11% in 2006. The number of people aged over 80 will quadruple in the same period. In the early part of 2008 the Alzheimer Society of Ireland stated that the number of people with dementia will increase from 37,000 to 49,000 by 2016, which poses significant challenges for policy makers and service providers.

A survey of our members in 2007 shows dependency levels have risen considerably in recent years and there is anecdotal evidence in support of this. Some 12% of the population in private and voluntary nursing homes are regarded as low dependency but 88% are regarded as high dependency. To cater for growing dependency, our members and the range of specialist services have increased. High dependency rates are reflected in specialist staffing in terms of number, quality and training. Staff costs alone, according to our annual survey of 2007, rose by 21% in 2007, with over 60% of costs now staff-related.

Mr. Webster referred to the documentation released in connection with the fair deal, which suggested the average cost would be approximately €50,000 per year. The average weekly rate for a private or voluntary bed across all bed types was €778 in 2007. This cost compares very favourably with the cost of €1,700 per week in public nursing homes. The figure must, however, be qualified because it excludes certain overheads and centralised support from the Health Service Executive. In 2006 our colleagues in Age Action Ireland commissioned a report which was published in April 2007. That report calculated the appropriate cost of care at €1,101 per resident in an urban area and €994 per week in a rural area. Those figures are based on 2006 statistics and it is our intention to update them in time.

There have been a number of positive developments recently in the area of long-term care for older people. The appointment of Deputy Máire Hoctor as Minister of State with responsibility for older people is a positive development. The Health Information and Quality Authority draft national quality standards for residential care settings for older people are also a positive development. With Mr. Webster and Age Action Ireland, we were centrally involved in the process. The prospect of the fair deal legislation is positive and I do not need to tell members, as legislators, that the financing of long-term care has been on the agenda for a great many years. Mr. Webster referred to the Mercer report and numerous others have been commissioned over the years, all suggesting different models. It is time to grasp the nettle and deal with the issue so that we can cater for the growing needs of our older population.

Members of Nursing Homes Ireland, as the majority provider, have a critical role to play and we want to be a partner in these developments, rather than merely a bystander. It is critical the partnership is extended to all stakeholders, the Department of Health and Children, the Health Service Executive, the Health Information and Quality Authority and the National Treatment Purchase Fund, when it becomes formally responsible for long-term care. The sooner those parties sit around one table to discuss the critical issues, the quicker we will come to a resolution on services for older people, particularly in the field of long-term care.

Our organisation was centrally involved in drafting the national quality standards, launched this year by the Health Information and Quality Authority, and we contributed significantly to the work of the group with our colleagues across the spectrum of people with an interest in long-term care.

Nursing Homes Ireland recently published our assessment and care planning integrated resident record in advance of the implementation of the HIQA standards. These were circulated to all our members, of which there are in excess of 300 nationwide. We also ran a number of study days examining best practice right across the system to support members to achieve the necessary standards. In recent weeks we have run more study days and it is our intention in the months and years to come to continue to support members to achieve those standards.

In the context of funding of long-term care, words like "inequitable" and "unfair" arise. On 11 December 2006 I heard the Minister saying that the current system was scrappy, inconsistent and unfair and that the fair deal would deal with those problems. Nursing Homes Ireland welcomes the announcement that the Government will address the issue. As Mr. Webster said, some of the detail of the fair deal is patchy but its underlying principle is to introduce an equitable system which is blind as to where a resident ends up, whether it be in a private, public or voluntary nursing home. I am sure members of the committee share our vision as people need high quality care and should not be disadvantaged by virtue of the fact they end up in one setting or another.

The varying subvention rates are a huge issue. Elected representatives right across the country are dealing with this on a weekly if not a daily basis. Recently it had been noted that due to the imposition of cuts in the HSE, enhanced subvention is being discontinued in some parts of the country. The rationale behind differing rates of subvention is geography rather than need. If one happens to be in one part of the country one gets a higher level of subvention or state support than in another part. Two people in the same nursing home, perhaps in the same room, may get different levels of state subvention. This is affecting residents and their families nationwide. The gap between the level of basic subvention, which was increased to €300 last year, and the cost of care is significant. Robin mentioned the rights and entitlements of older people in long-term care. There is not enough clarity in the national treatment purchase fund regarding what is included or excluded and this raises concerns.

It does make sense that only those with maximum dependency should be admitted to long-term care, but that makes an assumption that other services and facilities are available for older people in the community. Based on the example provided by Age Action Ireland, such services are quite patchy across the country. Consultation is important. We have been involved with the Health Information and Quality Authority. We have had a meeting with the national treatment purchase fund and an ongoing relationship with the Department of Health and Children and the HSE. Until all of those stakeholders are in one room discussing these issues it will be difficult to make progress. A fair deal should attempt to address the inequities in current subvention. The current maximum subvention rate is €300 per week, with variations in enhancement across the country. Another inequity is contracted beds versus non-contracted beds. If one is fortunate enough to get a contracted bed then one does not contribute at all, whereas in another part of the country one may be contributing entirely to one's own care. The case of two people in the same nursing home with similar needs and dependency receiving different levels of state support has been mentioned. In the information pack there is a case study of a lady who contacted the organisation recently——

(Interruptions).

Chairman

I wish to interrupt Mr. Daly. I am conscious that some of our members are under significant time constraints. I do not want to curtail the debate. It may be useful, given that a comprehensive scene has been set, to go to the members for some questions.

Mr. Tadhg Daly

There is a larger debate with regard to the implementation of the fair deal. One of the critical issues is the money set aside by the Oireachtas in December 2007 which amounts to €110 million for the fair deal. This money needs to be released and needs to be spent to deal with the current inequities. That is an interim solution. It is not new money. This money is already provided for and we cannot understand the delay. The Minister spoke in this forum on 18 June 2008 and said she was considering it. The time for consideration is over. Action needs to happen and we are suggesting that the money be released as a priority. We welcome the opportunity to attend here today and are available outside this forum. We have significant information and statistics on long-term care and we are happy to engage in a question and answer session.

Chairman

We look forward to working closely with the delegates. I should apologise for the deferral of the earlier meeting which clashed with our work on the Lisbon treaty. I know members are anxious to ask questions.

Deputy James Reilly

I welcome the delegates from Age Action Ireland and Nursing Homes Ireland. I thank them for their presentations. I have to go at 4.p.m. because I have to be in the Chamber for a private notice question. In the Dáil Chamber, we have raised the concern of the group that there has been a lack of proper consultation. That has been mentioned on more than one occasion and will be raised again. The hiatus created by the legal issues may allow for consultation to take place. Everyone in the committee would like that to happen. The best prospect for the best outcome for everyone arises if all who are involved and engaged in the care of the elderly, the elderly themselves, and people who represent them, have an input into what ensues.

There is a serious issue regarding funding. I spoke to a gentleman recently whose mother moved from one nursing home to another. There was a bill for €87,000. She sold her house to pay it, and paid some money towards one of her children and one of her grandchildren. She has spent €350,000 on nursing home care. Last week she had €1,200 left. This week I presume they have no money left. This lady has no more money and her family are pulling their hair out. They are not in a position to borrow more funds to look after their mother when they have their children to rear. This is a huge issue.

I have asked here and in the Dáil Chamber that the €110 million already allocated should be used to increase subvention, or at least to put in some interim measure. The time for considering this is over. We are now into July and we are going to break up next week. This has to be done within the next week. We will raise it again in the Dáil after this because the information you have given us has been very informative.

Due to shortages of beds and especially money, people are being placed far away from their families and their communities. This isolates them, leading to a deterioration in their mental condition and their emotional state. That is not good for longevity. The issues of physical therapy, occupational therapy and speech and language therapy are huge. These services should be available. If we have more rehabilitation facilities, especially in nursing homes where it would be more cost effective to deliver them, these facilities will have to be funded. The charges for these types of facilities will now be put on to the nursing home charge, which is another diminution in service.

I really have only one question. If Age Action Ireland had a shopping list of three things, what would they be? We can also ask Mr. Murphy from Nursing Home Ireland.

Senator Phil Prendergast

I thank Deputy Jan O'Sullivan, the Labour Party spokesperson on health. I want to ask a question about the home care packages. I find it confusing that there can be a difference depending on geography and that all areas of the country do not have funding available. There is funding available in the west but not in Wicklow for the same service. I find that difficult to understand. If I find it difficult to understand, I cannot imagine what it is like for people who have a desperate need for the service. The service appears to be very patchy. If there is a common assessment of a dependency, then it should follow that there are criteria whereby the amount of money needed to deliver a service is available on an equal basis. There cannot be a discrepancy in how people's needs are assessed. I have had representations from as far away as Kerry, and the discrepancies are very wide.

I am a former member of the executive council of the Irish Nurses Organisation. I still work very closely with them. Much of my information comes from people who deliver the service in key areas countrywide. My information is fairly accurate and the conflicts I find in different geographical areas are very confusing. What worries me is that the budget allocation of €110 million for services for the elderly will be diverted to other services and will not be available to meet their desperate needs.

I am very aware of the substantial increases in energy costs, with a 47% increase in the price of oil since May, a 39% increase in the price of fuel, a 17% increase in the price of gas and an expected two digit increase in the cost of electricity. However, in the last budget the increase in the fuel allowance was a mere 60 cent per week. Older people face an awful dilemma in trying to live within their means. In May last year, when I canvassed for the general election, I met a substantial number of people who were cold in their houses. We no longer have summer weather, and today one would need a fire to stay warm.

I thank my colleague for affording me the time to contribute. I appreciate the opportunity to raise these issues and that we will be able to meet outside this forum.

Deputy Rory O’Hanlon

I thank the representatives from the agencies for coming before the joint committee. It is important to recognise the phenomenal improvements at every level in the provision of care for the elderly — people living at home and people living in the community — and the increase in the number of residential beds. In my lifetime both as a family doctor and a Member of the Oireachtas, I have seen phenomenal change. I acknowledge that many issues remain to be addressed.

Mr. Tadhg Daly referred to the rising proportion of elderly people in the population, with 25% of the population in 2041 as against 11% in 2006 over the age of 65 years. Thankfully, people of 65 years and over are much healthier than they were and may not need the same level of services as they did in the past. Traditionally, the mother was a housewife and carer at home, but due to social changes, she is in the workplace and not available. This creates a major issue that must be addressed. It is important that we try to address this in partnership between the people, the Government, the Oireachtas, the different agencies and providers of care. The quality of health has improved and the level of care has improved tremendously.

On the question of the fair deal, I do not have difficulty with a payment from the estate of the deceased rather than forcing a person to sell his or her own home to fund a stay in a nursing home. Many people go into a nursing home in the expectation that his or her stay is temporary and that he or she will return home. From what I know few believe they will be there permanently and will never come out again. It is cruel that people should be forced to sell their home. If a charge is due, I do not have a problem if it is taken from the estate rather than the person being forced to sell his or her home to pay it. One aspect of health care is that if we provide for need we are doing well; we never will be able to satisfy demand. No country in the world has been able to do that. We must face that challenge.

In all public services, but nowhere more than in the health service, there are competing priorities within the resources available. There are competing priorities in the different disciplines in the health services. There are also different priorities in care of the elderly. My question to the delegates is how does one prioritise the needs of the elderly, where are the immediate priorities and how should they be addressed?

Deputy Kathleen Lynch

I defer to Deputy O'Hanlon, who is a doctor and has expertise in this area, but the difficulty is that there are competing priorities and I cannot name one service for the elderly that is as good as it should be. Mr. Eamon Timmins would have known the former Member, Mr. Joe Sherlock, who when he was a Deputy spoke about the 1974 Health Act every week. The Supreme Court ruled under the 1974 Act that a person had an entitlement to a bed in long-term care once it was determined on the basis of need. It is not about priority but need.

I can understand Mr. Daly's frustration with the fair deal. We have been hammering out the fair deal month after month, but the difficultly facing the Legislature is the same facing elderly people and their families, nursing homes and Age Action and all groups that advocate on behalf of the elderly. The system is so chaotic and so impoverished that we are now left in the position that the best possible deal on the table is the fair deal scheme. We are in an alley. However, if one got chronically sick in one's 30s or 40s and was in need of long-term care, none would suggest that one would pay for it or be forced to sell one's home to pay for it. It is ageism to make that suggestion to the elderly, although we have three separate Acts that states we cannot discriminate against people because of age. We will live longer, we will be healthier for a longer period but we are not allowed to work longer, we are not allowed to participate longer and we are treated the minute we reach 65 years as if we are dispensable. One can no longer get sick if one is old, for example it is not a case of pneumonia, one is sick because one is old. We have to look again at the fundamentals. We must ask why we put a person in a particular box once he or she is a certain age and is in need of care. It annoys me that one is treated differently because one is in a particular age group.

We do exactly the same to people with a disability. It is as if one loses one's citizenship once one passes 65 years. Who would suggest that a young person in need of long-term care would have to sell his or home or that his or her family would have to come together, no matter what their circumstances, and pay for the type of care the person needs?

The system of care for the elderly that has developed is so chaotic and so impoverished that all say that the fair deal scheme is the best available option. Every day of the week I am contacted by families who wonder when that legislation will be enacted. They do not care about the family home being sold to pay for their parents' care because they are so impoverished by trying to keep a person in a good quality nursing home. It is an awful pity that we have been boxed into that situation.

Chairman

I call Senator Fitzgerald.

Deputy James Reilly

I regret cutting across my colleague, but on this point, is there any chance that we could have some answers before 4 p.m.?

Chairman

We have two more speakers, and if they are brief, I am sure we will get the answers.

Senator Frances Fitzgerald

I will be brief. Deputy Lynch has raised many issues about social justice, which need to be debated. The mandatory retirement age, for example, was raised in a court case in Europe this week.

I thank the witnesses for their useful and helpful presentations. This committee will continue to discuss these issues. We must consider how the committee should respond to the points made because they need urgent action. We have a Minister of State with responsibility for older people but we do not have a national policy on older people. We have confusion, inconsistencies and different standards being applied across the country. We need national policies. Mr. Daly described the inconsistencies in the nursing home subvention scheme and Mr. Webster spoke about the variation in home care packages. It is my experience that families are very stressed and confused. It is as if each family must reinvent the wheel when they seek nursing home care and apply for nursing home subventions. Yesterday, the Minister for Health and Children, replying to my parliamentary question, said no more money would be allocated for contract beds. This is very confusing. Families do not know if they will get a contract bed and do not know what choices to make for their elderly relatives. Sometimes they have no choice. The situation is very confused. The committee must work on national policy in this area. There must be consistency. Urgent decisions must be taken regarding the fair deal scheme, notwithstanding the points made by Deputy Lynch.

Mr. Webster outlined the inconsistencies in home care packages. In some areas families cannot access home care packages and their availability varies in other areas. What is Mr. Webster's experience when he approaches the HSE for more funding for home care packages? Has he been told money will be made available later in the year or have cutbacks been introduced? We have been told there will not be front-line cutbacks. I consider home care packages front-line. I would like to hear Mr. Webster's comments on this matter.

Can Mr. Daly explain the difficulties regarding contract and non-contract beds? Are there clear guidelines? What is his experience of this matter? He has said there are huge inconsistencies. What difficulties are families facing? Is it clear which individuals are assigned contract beds? What is happening?

Deputy Jan O’Sullivan

I welcome the groups and agree with my colleague, Deputy Lynch, when she says that elderly people have the same entitlement to health care as people of any age. Has Mr. Webster's organisation received legal advice as to how the Supreme Court ruling of 2004 can be implemented? We have been given legal opinion that the fair deal legislation has been delayed because it has serious implications for property rights and the family home.

I fully support the call made in the Dáil that a substantial amount of the €110 million allocated for the fair deal scheme, which was to have been introduced in January last, be used to address the serious difficulties faced by families.

Mr. Webster referred to means testing and dependency testing. This issue arose during the committee's discussions with the Minister. Reference was made to the fact that only people on high dependency would be funded under the fair deal scheme. That is very worrying for families. Public beds are scarce and are only available to high dependency patients. What is to happen to people whose dependency is medium or low? This is a very serious question to which we have not received answers.

I am not sure exactly what is meant by means testing. None of us can know until we see the legislation. I strongly support the call of Mr. Webster and Mr. Daly for full and proper consultation, preferably in the round table setting referred to. We need full consultation before this legislation is implemented.

Deputy Dan Neville

I will be very brief. The witnesses will be interested to know that Deputies must go shortly to the Dáil where we will hear about the decentralisation of the Health Service Executive.

In October of last year, funding for home care packages in my area came to an end. The effect of this on the many people who would have benefited from it was stark and depressing. Several families who would have benefited from the scheme were told no money was left. Their elderly relatives went into nursing homes and obtained subventions at a higher cost than the home care packages. Many HSE decisions that affect the elderly are illogical and have a negative financial effect, especially with regard to the home care package. I have personal experience of the home care package scheme. It is an excellent service and should be used as much as possible.

Chairman

Can Mr. Daly or Mr. Webster deal with some of the principal points raised?

Mr. Robin Webster

Members have asked about our priorities. The most important issue is ageism. We treat older people as second class citizens. I say this with sympathy for the HSE. We treat all older people as either patients or potential patients. All Departments must think about an aging population and what they can do. This should apply to transport, housing and social contact. Research shows that social contact is a life saver and lack of it can reduce life expectancy by seven or eight years. We are not dealing with this issue. Ageism is implicit in our policies and services. One way to deal with this is by consulting older people as real people who know what they are talking about. The experts on aging are older people. The experts on nursing care are residents of nursing homes. We need a new mind set in treating aging and older people.

Second, there is an urgent need to provide basic services for people in desperate need. Many people who are sick at home receive one hour of home help per week. We need a survival campaign.

Third, the national positive aging strategy in the programme for Government is critically important. We must establish the right of older people to services and then impose a duty on service providers to meet those needs. The idea of rights based policies seems passé. It is as if we have done that. However, older people and their carers do not know what they are entitled to. They do not have the information. Those are the three areas where we should start.

I accept that we need emergency provision but we must also think about our aging population. We mentioned the interdepartmental report, which refers to the problems we will face in 2050. This is crazy. We have to start thinking about the present and developing. We have at least 20 years ahead of all the other European countries to plan properly. Only 11% of our people are over the age of 65 years; other countries have 25%. We have to be positive and take the opportunity to take emergency action and also develop proper policies in consultation with everybody involved.

Mr. Tadhg Daly

Deputy Reilly has mentioned people whose funds are exhausted. Daily we see operators and owners in our sector absorbing the costs where people have sold their dwellings. Deputy O'Hanlon made the point that people should retain their homes to leave open the option of returning and the possibility of rehabilitation.

Another issue mentioned was access to care in the community. That is one of the principles of nursing home care and needs to be dealt with in the legislation. Residence choice is of huge importance. The Health Service Executive policy document Quality and Fairness refers to it. Often residents do not have a choice. Selecting three priorities is always difficult. For a number of years we have talked about financing long-term care and have alluded to the Mercer report. This issue is not new, but it is important that we bring a sense of urgency to bear on it and find a solution. In that respect, the second priority is to have a concerted approach with the best interests of residents at heart. We all share that common interest. It is important, therefore, that we should all sit around the table in the one room to discuss the issue.

I have highlighted some of the inequities, of which members, as public representatives, are well aware. It is important to have a uniform approach right across the system. As my colleague, Mr. Webster commented, people need to know their entitlements and should be treated the same right across the entire system. That is not happening.

Senator Prendergast mentioned the issue of increases in the cost of energy and staffing. Our members see this daily. Something must be done quickly. My colleague, Ms McNamara, might wish to comment on the issue of clarity in regard to the availability of services. Senator Fitzgerald mentioned contract versus non-contract beds in that context.

Ms Cora McNamara

I am the owner of a small nursing home in the west and live in a small community. In the nursing home sector we want people to stay in the community for as long as possible. I would like my father and mother, and myself when the time comes, to stay in the community but unfortunately not everything is available to facilitate this. There will always be a percentage who need nursing home care.

On the issue of contract beds, there can be two people in one room in a nursing home, both with the same dependency level. One may have a contract bed, which means it is paid for completely. The other is only partially paid for and the resident or his or her family must come up with the remaining four fifths of the cost. That can be expensive for a small family. In some instances there is perhaps one son or daughter with his or her own family living on one wage and they cannot come up with the money. That is the difference between the contract and non-contract bed, even though the residents have the same dependency level. What we are looking for and what we hope the fair deal might bring is equality right across the country. In some places there is a more enhanced subvention that is not available in others. The geographical issue comes into play again. Does that answer the Senator's question?

Senator Frances Fitzgerald

From Ms McNamara's point of view, is there clarity in regard to the criteria in terms of why one family gets a contract bed and another does not? Could it happen that in the case of families with the same income some get a contract bed and others do not? It seems that is what is happening. Has that been Ms McNamara's experience?

Ms Cora McNamara

That could happen and has happened in some places.

Deputy James Reilly

There is no clarity in the system.

Ms Cora McNamara

There is no clarity whatsoever.

Deputy James Reilly

I apologise. I must leave. My colleagues, Deputies O'Sullivan and Neville, are remaining.

Chairman

If other members of the panel would like to address some of the points raised, they are free to do so.

Mr. Robin Webster

There is one point. We do not want to be forced into the position of arguing as to whether we should have community or residential care. Both are badly needed and must be planned together.

Regarding the awful plight to which Nursing Homes Ireland's Mr. Daly referred, there are other older people living alone, dying quietly without any support. I do not want to swap case studies, but Deputy O'Hanlon has made the point that services have improved and we must accept this. A huge amount of money has been spent. However, we are not sure about the impact of, for example, home care packages. As the research has not yet been done, we do not know whether it works. While we add this to the home help service, the link between the two services is not clear. We need to do some of the work to ensure the services we provide have an impact on the right people because we are also talking about quality. There is a shared concern about the lack of therapies in community care. Getting a physiotherapist is a major problem. It is also a problem in residential care. If we do not have these therapies, we are destroying the notion of older people getting better. We are giving up the idea of rehabilitation and saying we cannot do it. That is fundamentally wrong and ageist. We must do something about developing a much more positive attitude in both sectors.

Deputy Charlie O’Connor

I take the opportunity to acknowledge the presence of the groups represented. I apologise for my absence during Mr. Webster's contribution owing to a crisis in my constituency, but I listened to it on a monitor. I was not going to mention Tallaght but Mr. Webster makes a good point. I live in Tallaght which is seen as having a very young population. It also has an ageing population. I am often reminded of my old uncle who was 93 years of age when he died. He had lived in the inner city in Bride Street. On one occasion when I visited him in the nursing home in Bray and asked him how he was doing, his response was that he was grand but that the place was full of old people. Listening to the contributions I am reminded that there comes a point — perhaps we are all near it——

Deputy Dan Neville

The Deputy should speak for himself.

Deputy Charlie O’Connor

I am not afraid of my age. However, old people tend to be categorised. There are many older people in politics and government who are doing everything. It is important to acknowledge this. Young people are very important, but people of all ages and certainly the elderly have a role to play. If a man of 80 years of age can become Pope, a man of 84 can still run a country, legally or not, it proves there is a role for everybody.

It is important that the groups attending today have this opportunity at a time when the economy is challenged — I use that phrase so as not to upset anybody on the Opposition benches. We all have the same concerns. I do not mean to be patronising in any way, but it is good that we should listen calmly to the views of groups on the ground which are familiar with the issues and represent their interests in so far as that is possible. That is the challenge for us. With the cake getting smaller and everybody fighting their corner, it will be a tougher fight for the groups in question and it is good that they are able to engage in it.

Chairman

I hope Mr. Doherty is not provoked into saying anything about Tallaght.

Mr. Denis Doherty

I am not. As chairman of Nursing Homes Ireland, I join my colleagues in thanking you and the members of the committee for receiving us this afternoon.

Nursing Homes Ireland represents the vast majority of private and voluntary nursing homes in the State. Our members regard it as a privilege to be in a position to contribute to the extent they do to the care of some of the most vulnerable in society. It is a business, but also a vocation. I have worked most of my career in the public sector. I have gained a sense of the commitment of health care staff in the public sector and I see the same qualities of commitment and concern for patients in those who work in Nursing Homes Ireland. Nursing Homes Ireland is committed to high standards and, as Mr. Daly said, to working with its partners. Our mission is to support and encourage our members to aim for the highest standards of care and provide support to them in their endeavours to achieve that end. Opportunities to convey our view, such as this meeting, are important and we look forward to working with Members of the Oireachtas in groups and individually. We appreciate the interest Members are taking in this very important area of service.

Mr. Eamon Timmins

While much of the focus on the fair deal has been on the legislation, the stage it is at and what is delaying it, if the Attorney General were to wave a magic wand and put the legislation onto the Statute Book today, we would not be ready to implement it. We do not know who we would recruit nor what the standards would be, meaning we do not know which homes would be included in the scheme. We are a long way from knowing those things, despite the fact that a date has been set of 1 January. We are receiving many calls urging us to bring in the fair deal by enacting any kind of legislation but if the legislation was resolved in the morning, we would not be ready to introduce the fair deal.

We have talked about home care packages but 5% of all people are in long-term residential care and 20% require community care. We know from the partial survey carried out by social workers that there is chaos on the ground. The fact that only 18 of 32 areas are included is because they cannot get feedback in their own areas as to what is happening. They do not have social workers specifically working with older people and cannot get the information about home care packages from their own HSE organisation locally. We are not supporting people in the community and we have the impending problem of how we are to fund long-term care.

Ms Emer Begley

Mr. Webster made a number of points about the alternatives to the fair deal. Age Action Ireland has been working on best practice but alternatives have been put forward, such as in the Mercer report, and we need to examine these thoroughly before implementing the fair deal. As everybody knows, the fair deal is confusing because, as Mr. Timmins said, there are so many legal questions surrounding it.

Senator Frances Fitzgerald

The committee is very disturbed by what the witnesses have said. They describe a very difficult situation with huge uncertainty for a huge part of our population, not least those working in the area. We have not looked in detail at the question of implementing standards, which Mr. Doherty touched on and which deserves a meeting of its own. Have the delegates met the newly appointed Minister of State?

Mr. Robin Webster

Yes.

Senator Frances Fitzgerald

Have they been able to relay their concerns to her?

Mr. Robin Webster

Certainly, yes. The committee members sound disbelieving but we have no notion of how we are going to develop common assessment standards, both for needs and for finance, and one cannot introduce anything without those. One must concentrate on quality before funding as one follows the other. People do not know whether they will get a bed, a home help or a home care package — that is how bad it is. It looks like it will get worse and we are focusing on taking emergency action. We accept the point about the €110 million emergency response but we must start the long-term planning which we have never carried out. We must make an assessment of what we mean by "dependency" and "means".

Senator Frances Fitzgerald

Whose responsibility does Mr. Webster consider that to be? Where does Mr. Webster expect the decision on that assessment to come from? Is it the Minister, the HSE or elsewhere?

Mr. Robin Webster

It should come from the Government via legislation and regulation.

Chairman

I take it there is, at present, a process of assessing high level dependency and access to public facilities.

Deputy Kathleen Lynch

The geriatrician makes the assessment.

Chairman

Therefore, there is a process.

Mr. Tadhg Daly

Yes, and the process is through the HSE.

Chairman

It is a question of how that process is applied.

Mr. Tadhg Daly

It is applied differently in different areas, which is a critical issue. I agree it is about a continuum of care for older people, so that they are appropriately placed at the appropriate time. Questions have been asked about capacity in the acute sector but many people in the acute sector would be better placed in the community, with home care and in nursing homes. As Deputy O'Connor said, in the current climate of making savings — I think that was the word he used, rather than "cuts"——

Deputy Charlie O’Connor

I said there were challenges.

Mr. Tadhg Daly

He said there were challenges — I stand corrected. It costs €8,000 per week to keep somebody in an acute hospital, so a nursing home is much more cost effective and is the right place for an individual to be. A resident would receive a better service in the community and at better value than is currently the case.

Deputy Kathleen Lynch

What Mr. Webster said about language and mindset is vitally important. We should be talking about how we support older people, wherever they find themselves, and we need to get the language right. We desperately need a policy. I am not certain a policy should be rolled out nationally and this needs to debated. We should consider centres which develop multidisciplinary teams and roll it out from there. It is not possible to develop and roll out services for elderly people on a national basis. Community and support services are necessary. The first thing we need to do is develop a policy and the second is to start accepting that just because a person passes a certain age, it does not make him or her less entitled to services than the rest of us.

Ms Cora McNamara

I am worried that therapies might not be included in the NTPF because we cannot give proper care if therapies are not included, such as physiotherapy, speech therapy and occupational therapy. I ask the Senator and Deputies to ensure therapies are included in the package.

Chairman

I thank members of the delegation very much. They have effectively challenged the committee to take on these issues. Members of the committee, in turn, have thrown down a challenge to devise a national policy and adopt a clear focus on these matters. Perhaps the committee could discuss the subject ourselves and, before the end of the term, begin to engage with the Minister of State with responsibility for older people, senior officials in the Department of Health and Children and the HSE to see how we can progress the issues raised. They are fundamental issues which touch each and every one of us.

Mr. Robin Webster

As Mr. Daly said at the beginning of his presentation, both organisations would welcome an opportunity to engage with the committee and produce feedback from our various perspectives. A point was made about regional variations and maybe we need a better regional approach because there is a regional as well as a national view. We will commit our resources to helping the committee in whatever way possible and can make other presentations on specific issues if members think it would be helpful.

Mr. Denis Doherty

I welcome the point made by Senator Fitzgerald on standards and we know what HIQA recommended. It is now with Minister. We do not know what will emerge as the standards will be on a statutory basis. We all subscribe to that, but we have concerns about it and would like an opportunity for consultation and debate before it is finalised.

We have the same difficulty in relation to the fair deal. We know what the Minister had in mind when this was introduced and we are aware of what has emerged in the discussion since, but we have not yet had the benefit of seeing the Bill and there will a need for careful consideration and debate so that we can get away from the current difficult situation. What we put in its place needs to be much better and provide the basis for good arrangements. We are encouraged by the shared views of the committee and ourselves and we hope that through the mechanism of dialogue and consultation the commitment that exists can be brought to fruition.

Chairman

I understand today from the Government Chief Whip that the Bill will be published next week. We are more than happy to engage on an ongoing basis individually and collectively as a committee. Please feel free to keep in contact with us on these matters.

I thank the delegates for their presentations and members for their detailed questions. The committee will convene again next week to meet the Central Mental Hospital carers group to discuss the relocation of the hospital from Dundrum to Thornton Hall.

The joint committee adjourned at 4.25 p.m. until 3 p.m. on Tuesday, 8 July 2008.