Joint Committee on Jobs, Enterprise and Innovation debate -
Tuesday, 2 Jul 2013

Home Care Provision: Discussion with Home and Community Care Ireland

Acting Chairman (Deputy Anthony Lawlor)

I welcome Mr. Bryan Meldrum, co-chairman, and Mr. Ed Murphy, board member, Home and Community Care Ireland.

By virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of the evidence they are to give the committee. If they are directed by it to cease giving evidence on a particular matter and continue to so do, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against a person or persons or an entity by name or in such a way as to make him, her or it identifiable. 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.

I now invite Mr. Meldrum to make his presentation to the committee.

Mr. Bryan Meldrum

I thank the Chairman and members of the committee for the invitation to appear before them to outline the current situation in the home care sector. I am co-chairman of Home and Community Care Ireland, HCCI, and joined by my colleague, Mr. Ed Murphy, who is a director. We are here to outline to the committee not only our organisation and the sector but, more importantly, the forthcoming increased demand for home care and the pressures this will place on the system. However, there is also the opportunity to create thousands of jobs and enable increased investment in the sector via appropriate regulation and the provision of reform funding.

Home care is defined as a support provided for persons who require assistance to continue to live independently outside a hospital or residential setting. This can be over a short-term period to recover from an operation or for an extended period. The duties associated with this type of care can vary and range from preparing meals to helping clients to wash and dress to providing more intensive palliative care support.

HCCI is a national organisation which represents 25 private home care providers across the island of Ireland. Our primary objective is to promote the highest professional standards of care in the home and client choice in a cost-effective manner. In providing care for 8,500 clients in their own homes throughout Ireland HCCI members play an important role in the development of the home care sector which is an integral part of the Government's stated policy of developing the primary care sector. We welcome the opportunity to appear before the committee, given the serious challenges facing the country such as an ageing population and reduced State investment in health care. As the Government seeks to implement more cost-effective solutions in the caring sector, increased investment will be required from outside sources, including the private sector, to ensure sustainable levels of investment in technology and people can be maintained.

HCCI believes increased transparency and a regulatory system that is reflective of the nature of the sector are essential to attract investors and create more jobs. There is no formal regulation of the home care sector, something on which HCCI continues to advocate. There are FETAC training qualifications which are appropriate for home care workers. All HCCI member company employees are trained to FETAC level 5 qualifications. There are 40,000 people employed in the home care industry, including by private providers, the HSE and not-for-profit organisations. We provide care for more than 70,000 people. HCCI member companies alone employ more than 6,000 of these 40,000 staff in every town, county and rural location. In many of the members' constituencies we would have at least four or five member organisations working in their local areas. We contribute more than €36 million to the economy annually.

Home care is provided in a number of ways by private providers, not-for-profit organisations, the HSE directly and individuals operating in the black market. The types of care include directly secured private provision or State-funded home care which falls into two schemes, namely, home help and home care.

Home helps account for €195 million each year and are provided direct by the HSE or not-for-profit Government funded organisations, also known as section 39 organisations. The private sector is not allowed to tender for this work. Home care packages account for €127 million each year and is provided by section 39 organisations and private providers. Directly secured private provision in the formal sector accounts for between €20 million and €25 million.

The sector is currently unregulated and comprises formal and informal care provision. Formal care is where carers are employed to provide assistance along clear contractual guidelines. HSE staff account for 70% of all home help services, not-for-profit organisations account for 18% of the current market and private companies provide the remaining 12%. Informal care is generally provided by family members, neighbours or via the black market and accounts for 10% of the present population over 65 years.

It is important to note that the black market in home care is not as we traditionally understand with murky dealings happening in the back of vans. Often black market home care is provided by people with the best of intentions, such as friends, relations and neighbours, who try to do what they believe is the right thing. There is also the cash-in-hand side of the business where advertisements are answered by unknown people with unknown qualifications. A large number of carers operate in the black market on a cash-in-hand basis. The issues for either type of care are significant. Black market carers do not pay taxes or, more significantly, are not properly trained or insured leaving many people in vulnerable situations in the event that an issue arises.

Mr. Ed Murphy

I got into the sector about eight years ago because my mother needed a particular type of home care when she lived in Wexford but her needs were not satisfied by the prevailing system. I have worked in the sector eight years and I am passionate about it. I have taken thousands of people out of hospitals and nursing homes and looked after them for long periods until death. Our care model is not the old style home help. We provide a more managed and professional service which deals with the complex needs of older people in their homes.

We examined the following challenges and opportunities and commissioned an independent report that was published in March 2013. The report found that more people will need support as the elderly population increases. Between now and 2021, the number of people over 65 years is set to rise to nearly 800,000, a 40% increase on 2006 levels. The Central Statistics Office produced a startling statistic that between now and 2026, which is 13 years, the amount of people over the age of 75 will double from 207,000 to 414,000 people. If we are experiencing problems now then they will double within the next ten to 12 years. As the population grows older people will require support. Dependency rates are projected to increase from the current level of 16% to over 24% by 2012. Therefore, thousands more people will need care.

The current cost of HSE section 39 funded home care is 30% more expensive than private sector rates. The report also found that €117 million could be saved each year if all home help and home care package provision was outsourced via tender for an open and honest commissioning of services.

An additional saving of €256 million per year could result if 30% of patients with low and medium dependency under the fair deal scheme were provided 21 hours of intensive care at home under an enhances home care package. In other words, additional savings could be made if the fair deal scheme was opened up instead of ring-fenced. Many pundits believe that 30% of people in nursing homes would not need to reside there if the relevant care was provided in a home scenario. Relocating 30% of those residents would achieve great savings.

The cumulative savings between now and 2021 should reach €2 billion with a potential of creating 8,600 jobs through reform and growth in the sector. There is a great opportunity for job creation and savings in the sector.

There are four major challenges and opportunities for creating jobs and making savings. The first challenge and opportunity is regulation and professionalism. At present the home care sector is unregulated and Government regulation is unlikely to be implemented until 2016. In the interim my organisation, the HCCI, has dedicated considerable resources to ensure that all of its members undertake best practice recruitment, supervision and training procedures for all employees. The professionalism of home care is a key HCCI objective to ensure trained and motivated staff are given access to career development. Increased regulation and professionalism are also important to ensure high standards of care. It will give medical staff and hospital staff the confidence to discharge people home quicker rather than keep them in hospitals and nursing homes. This is a genuine and real issue and that is why we are pushing for regulation. If we have regulation then we will have standards and with standards comes the proper training of care givers.

With regard to the current home help system, we want to make sure that home help care is not regarded as the lower rung of the ladder and home helps are given a chance to create real careers all over the country. Regulation will mean training at FETAC level 5 which will give people a career and opportunity. I have visited many hospitals and talked to many consultants, GPs or whatever. Their biggest issue with home care is that they view it as being at the bottom rung of the ladder. They view home care providers as being quite unregulated, not necessarily well trained and incapable of providing professional and holistic care in the home. Regulation and properly trained care givers will give confidence to doctors, consultants and social workers to discharge people quicker, and more often, to the home rather than to a nursing home or remaining in a hospital. That is a very important point.

The HCCI seeks two things from the committee. First, recognition of the role that regulation and making home care a profession can play in developing the home care sector as a desirable career. Second, the first national home care tender occurred this time last year but only €50 million was tendered out of the Government's total home care expenditure of €340 million. Most of the money, as Mr. Meldrum has said, centred on not-for-profit organisations under section 39 funding. The Government will re-tender again next September and we hope, with some influence and prompting, that more money will be spent on a tender for home care and in a very open, honest and transparent system that will allow for cost savings and development. We estimate that there will be 30% less in the private care sector which will lead to overall savings of €117 million. Such savings will give an opportunity for growth and about 500 extra jobs can be created immediately when the new home care tender commences.

That is something that can be done now to create jobs. The tender is happening anyway. All we are asking is that the scope of the tender be widened.

The third challenge and opportunity is the fair deal scheme. The fair deal scheme, which provides a funding mechanism for those who receive residential care in nursing homes, currently provides places for 22,761 persons and costs €998 million per annum. There is a significant proportion of persons currently in nursing homes who, with the right support, could be cared for in their own homes, as is their preference and the preference of the majority of the population. With Ireland having 35% more persons per head of population in nursing homes than the EU average, there is a reasonable working assumption that one third of fair deal patients could be better off in terms of well-being if they remained in their home, until dependency requirements increase, and availed of enhanced home-care packages. In addition to it being the preference of most, it is a much more cost-effective way to provide care. The cost of providing care for low to medium-dependency persons with an enhanced home-care package of 21 hours per week compared to a full-time nursing home could save the fair deal scheme approximately €159 million and create up to 700 jobs in the community. While we advocate the movement of many of those in nursing homes to home care, we are fully aware that nursing homes will continue to be required at current levels because of the doubling in the number of those over 75 years in the next 13 years. We encourage the committee to engage with the Joint Committee on Health and Children and the Minister for Health in looking at the review of the fair deal scheme as giving a significant opportunity for job creation.

I will make one point about job creation. We provide care for persons all over the country, both in rural and urban environments. We have 17 offices throughout Ireland. What is important here is that jobs can be created in every parish in Ireland. We, just one organisation, look after seven or eight persons in a little parish where I am from in Wexford. That means we are giving a job of 20 or 21 hours a week to seven or eight persons in that locality. It is keeping the community together. It is keeping the older persons at home in the community but instead of carers having to go to towns to work, it is keeping them working in the parish as well. We are talking not only about creating careers, but about careers for workers in their local parishes in every corner of Ireland. There were many older persons in communities in Ireland who are living alone or whatever and it is a great opportunity to keep them at home and provide jobs for local persons.

The last area of challenge and opportunity is live-in care. We would hope that the committee might help us on this. It is only in the past three or four years that members of this association started providing a live-in service. It is an invaluable service offered by members who are directly employing 400 carers. From a standing start, we are employing 400 full-time carers. There is a significant opportunity to increase these full-time jobs. Unfortunately, our members' ability to continue to offer the service is now at risk due to the unintended consequences of EU employment legislation under the working time directive. While there is an ongoing review of the working time directive at European level regarding the accrual of rest periods and definition of on-call time and sleeping hours, the HSE and employers such as ourselves in Ireland are subject to the Organisation of Working Time Act 1997 and the National Minimum Wage Act 2000 which, upon strict interpretation, preclude affordable home care. If the current regulatory system is not updated to take account of the specific nature of the home care sector, some HCCI members will be forced to stop providing this service and close down with the loss of jobs and home care provision. Failure to address this issue will also force clients to employ. That is what was happening up until now. Anybody who did get home care was employing only black market workers for the live-in needs at a considerable risk to the patient and loss of revenue to the State. HCCI has engaged with the National Employment Rights Authority, NERA, and Department of Jobs, Enterprise and Innovation officials on this issue and is committed to working with the relevant bodies to find a workable solution to ensure that workers' rights are protected and vulnerable clients have access to an affordable service enabling them to remain at home for as long as possible. We would appreciate it if the committee would support us and provide help in coming up with a workable solution on this issue.

Those are the four areas. I do not want to dwell on them but to summarise they are first, regulation; second, the new tender; third, the review of the fair deal scheme; and fourth, live-in care.

Mr. Bryan Meldrum

We wanted to not only outline who we are and what we do, but more importantly, stress to the committee, as Mr. Murphy has done, what this critical sector needs in the form of regulation and what can be achieved, both in the form of job creation and investment. We thank the committee for this opportunity.

Acting Chairman (Deputy Anthony Lawlor)

We will take questions from the members. We will take them in twos, starting with Deputy Tóibín and Senator Kelly.

Deputy Peadar Tóibín

Gabhaim buíochas leis na finnéithe as a gcur i láthair. Their work is important. A large number with whom I have engaged over the past number of years have found that nursing homes or hospitals are not for them and that they need care at home. It offers them much dignity and peace of mind. It is a good environment in general if one is able for it to be cared for at home if it is possible to do so. The State should be doing its utmost to ensure that, where persons select the option, it provides a service for them at home. I also believe that many of the workers they employ do sterling work in delivering that home care.

I will be honest. From my perspective, I believe in a public rather than a private health service. I do not believe in a two-tier system whereby those who have the funds can access the service. I also have a worry that where there is a profit motive in the provision of a health service, it can often, as we have seen in certain crèches and nursing homes, change the nature of delivery of service.

I am shocked that there is no formal regulation of this sector. The Joint Committee on Health and Children is probably the place for that to be developed. No doubt there should be strong regulation.

I read some of the documentation that we received It goes through the normal diary of a person's day and indicates that the client may be resting for a period of time and that the staff member would not be paid for that, perhaps if the client is asleep for the hour. Even the worker might be asleep for the hour. Sometimes I see Deputies and Senators here asleep for an hour and I think perhaps they should not get paid for that hour either.

I would be strongly against an on-site employee not being in a position to contract himself or herself out to gain a wage elsewhere or not being in a position to be with his or her family or to use his or her free time as normal. I would be strongly opposed to any move to reduce the welfare of such an individual. No doubt there is a conundrum regarding what is affordable and yet fair to the worker.

It is important that we try our best together to make sure it is affordable and also fair to the worker. It is not fair to ask a staff member not to be paid for working on site.

What is the average that the delegates' organisation pays staff for home care? How does it compare with that in other sectors of the industry, including the public, NGO and not-for-profit sectors? There is no doubt but that all care must be developed more in the public fashion to ensure the needs of the patient or client are uppermost, that provision is on the basis of need, and that the staff members are properly compensated for their efforts.

Senator John Kelly

I welcome Mr. Bryan Meldrum and Mr. Ed Murphy. As with Deputy Peadar Tóibín, I have reservations about the privatisation of the home help service, purely because one could set one's own price if it were privatised. If there is privatisation, circumstances will change.

I agree with Deputy Peadar Tóibín’s remarks on elderly people. I spent 28 years working with the HSE as a community welfare officer. I was working with elderly people and assessing them for the fair deal and nursing home subvention schemes. The last thing an elderly person wants is to go to a nursing home. The elderly really do want to stay at home.

I do not fully understand some of the remarks of the delegates. Who will pay for the home care package to keep the elderly at home? Will some receive the HSE subsidy in regard to the home care package while others will not?

I do not understand how the year-on-year figure of €117 million in savings is arrived at. If the same number of hours are required for care provision, how will the organisation make a saving? Does it pay its staff less? I cannot figure it out at all. It was stated there could be a saving of €159 million in respect of the fair deal by keeping people out of nursing homes and caring for them in the community. Have the delegates pencilled in the cost of community care? Are they suggesting that some part of the fair deal budget should be open to be used for keeping people within the home? If so, I would agree with that. If a person can be kept at home for half the cost, it makes sense to consider it.

My final concern relates to the existing home helps employed by the HSE. Will they risk losing their jobs if we privatise home help? Is their only option employment by companies such as that of the delegates?

Mr Ed Murphy

With regard to Deputy Tóibín's questions, our average client is 83 years of age. When we talk about a growing elderly population, we are not talking about over 65s but about over 75s. The Deputy may check this with the CSO.

Deputy Peadar Tóibín

There is no argument there.

Mr Ed Murphy

The population of over 75s will double in 13 years. With regard to the current HSE home helps, there has been an embargo on recruitment for a few years. It is important to point out that although we provide home care privately, we are absolutely not opposed to the HSE providing home help as it is doing at present. However, unless the HSE opens the floodgates and hires all the home helps itself, it will not be able to cope with the significantly increasing demand. The HSE has been providing home help in recent years and the not-for-profit companies are doing so still. We started seven or eight years ago and have looked after 7,000 or 8,000 people that the HSE had not the capacity to look after. We are very much of the opinion that we need both State and private provision.

I am not quite sure whether my next point is against the thinking and logic of Deputy Peadar Tóibín. More than 50% of the people we look after approach us privately stating they do not want State provision and that they want to use us because of the services we provide. I spoke to a lady from the HSE, a home care package co-ordinator, and she said to me that it is great that we are looking after a couple of hundred people in this area and that these people and their families are prepared to pay for the service. The lady stated this means the HSE does not have to provide services to them. This is because they want something a little different or more complex, for example.

If one pays for the care of an incapacitated individual, one can receive tax relief of 41%. I compliment the Government on this. The relief subsidises a person who decides to look after his mother, father or family member. There are people seeking private care and the Government is prepared to give tax relief to people looking for it. The services for the average person for whom we provide private care are usually paid for by sons and daughters who are pooling together. I genuinely believe that public and private provision can exist together.

The concept of the break time is quite confusing. The HSE is struggling with the Organisation of Working Time Act. The Act specifies that one must be finished work for 11 hours before one can start again. With regard to live-in care, most staff finish work at approximately 9 p.m. Our staff have separate living quarters in the house where they can stay from 9 p.m. and they do not return to work until at least 8 a.m. in the morning. Therefore, there is a break of 11 hours. The private sector and HSE are doing this. It is not just a private sector issue but also a public sector issue. We give an 11 hour break and tend to give an on-call allowance to the member of staff just in case he or she gets a call during the night to take the individual in care to the toilet, for example. That is all. If we had to pay for 24 hour care, including during the 11 hours when the carer is in bed or watching television, it would make live-in care unaffordable.

If we have to charge families for 24 hour care for older people, we can forget about the sector. It will close down straight away. People cannot afford to pay for all 24 hours. There is no question about what will happen, as we saw how things operated previously. We have professionalised the service to observe the Organisation of Working Time Act and other regulations. We train, supervise and support staff. They are paid a wage, PRSI contributions are made and everything is done properly and professionally. If this stops for the HSE or ourselves, provision will go straight to the black market. There is no question about it. People will be paid cash by families. It is the only other way a service can be provided. I am not sure if that answers the question, but I use the opportunity to make the point.

Deputy Peadar Tóibín

Mr. Murphy said the employees are given 11 hours off. As I see it, the employees are entitled to those hours off. It is their time. No one is giving them anything. They are enjoying their own entitlements.

Mr. Ed Murphy

Absolutely. There is no question about that. I agree.

Deputy Peadar Tóibín

What is the average hourly rate for workers in the industry?

Mr. Ed Murphy

In general, it tends in the private sector to range from €10 to €14 per hour. It tends to depend on the complexity of the care being provided.

Deputy Peadar Tóibín

Is there an average?

Mr. Ed Murphy

The average is perhaps €12 or €13.

Deputy Peadar Tóibín

How does that compare with the public sector?

Mr. Ed Murphy

There are two aspects to the public sector. There are section 39 funded companies which are funded 100% by the HSE and there is direct public sector provision. Section 39 funded companies provide hourly rates in the same €10 to €14 range. It may be a euro an hour more. HSE employees are paid in the region of €13.95 to €14.50 an hour. The Deputy may know precisely and can correct me if I am wrong. Public service workers are paid a little more. A recent trend, as our company has found, involves workers who have left the public sector and come to work for us on lower rates. What is different is that we provide them with FETAC level 5 training, support and supervision and help to turn their job into a career. We give them more hours per shift. Home help tends to be provided over a number of hours, but we tend to provide longer shifts. Workers tend to come to us for the quality of the job.

Deputy Peadar Tóibín

Are there other differences in terms and conditions between the public and private sectors? Mr. Murphy mentioned tax relief for private delivery. Does he know how much that costs the State annually?

Mr. Ed Murphy

No. It is not taken up on a huge basis. We do not know. Our best estimate is that it was in the region of €14 million last year. We would need to research it further to say exactly. The data are not captured by the State in any way that we have been able to find. The relief is a fantastic thing as it encourages families to take responsibility and to at least contribute to the care of their older parents. Many people are very happy about that. It is a fantastic thing to encourage participation in care.

Senator John Kelly

I asked about the €117 million in savings, which I do not understand. How are those savings being made?

Mr. Ed Murphy

Very simply, through transparent commissioning of home help. Currently, approximately €50 million is put out to tender. The average cost in the tender situation is approximately €20 per hour. Currently, the provision that is not out to tender costs closer to €30 per hour, internally in the HSE or through section 39 funded companies. It ranges from €27 to €33 per hour. If provision is transparently commissioned through tendering, we will achieve a 30% reduction in costs. It should be open to everyone - not just private companies, but also not-for-profit organisations, section 39 funded companies and charities - to tender for home help provision. That is where the €117 million figure comes from. It is based on the amount spent on provision that has not been tendered for. I am sorry if I did not clarify that.

Deputy Michael Conaghan

We are too quick to commercialise care. In my area, I see many people, particularly women, who go to the homes of neighbours and elderly people. I acknowledge that they get a small amount of money, but most of the care is driven by more altruistic motives. They know the people for whom they are caring, who have been their neighbours for years. We should not look at all areas of human activity as a business venture or opportunity. There is a disposition in our culture to care. Mr. Murphy spoke as if he were creating professions. Perhaps that might not sit easily with some of the work. There is something in the Irish people whereby a great deal of caring is provided due to altruistic or humanitarian motives and good neighbourliness. I would not like to see that undermined, diminished or commercialised. Many of the women I know who do brilliant work in the homes of their neighbours do not see themselves as professionals. They see themselves getting a few bob through the HSE rather than the black market, but they provide the care mainly out of altruistic motives and old fashioned ideas of neighbourliness. It is almost an instinct to reach out and care for people as well as being something virtuous. I am not saying the witnesses are advocates for the idea of driving commercialism into every quarter and every corner of life, but I note that business people see business opportunities everywhere.

Mr. Murphy talks about creating jobs. The corollary of jobs is wages. From reading some of the material provided, I have some concerns about the HCCI perspective on wages. There appears to be some latent hostility to minimum wage arrangements, which does not sit easily with my way of thinking either.

Senator Feargal Quinn

I agree entirely with what Mr. Murphy says. Most people prefer to be in their own home rather than enter a nursing home. I am stunned to hear that 35% more people are in nursing homes in Ireland than in the rest of Europe. Why is that?

Mr. Ed Murphy

We are 35% higher than the EU average. In many cases, we have twice the proportion of people in nursing homes compared with our European counterparts. Some of the Scandinavian countries have half as many people in nursing homes per capita.

Senator Feargal Quinn

What brought that about?

Acting Chairman (Deputy Anthony Lawlor)

Senator Quinn, could you ask all your questions at once? I do not want a to and fro type engagement.

Senator Feargal Quinn

My experience is that people prefer to be at home. We had experience of a family situation in which there was great difficulty in getting carers. Is there great difficulty in getting carers or were they just looking for full-time carers in that particular case? I do not understand what the objectives of the tender system are. Could Mr. Murphy touch on the home care tender system? I did not quite understand what he was saying there. What is delaying the introduction of the regulation he would like to see? Is there a particular delay in it or is it something he is urging and encouraging?

Senator Deirdre Clune

I have a few comments to make. I will not delay the meeting. We are an aging society and people generally want care at home. They also want to be sure, and we need to ensure, that those who are caring have a level of professionalism. I know there is a balance in terms of commercialisation. Most of the people providing care are women. We need to respect that fact and not just lean on their hospitality or sense of neighbourliness. It is important for them to have the proper level of training. We saw it in the child care industry. We need to ensure that those working have particular standards. There is a need for what Home and Community Care Ireland is doing and there will be a greater need in tandem with the care provided by the public sector because the public sector cannot match the needs of individuals, particularly if we want to ensure that people stay in their homes, which is psychologically far better for them. Those are my broad thoughts on the area.

In respect of the working time directive, I was thinking about the 11 hours the speakers said were needed. Obviously, in rural areas, people probably cannot go to their own homes, but in urban areas they could. Is the fact that they may get a call-----

Mr. Ed Murphy

They may get it. It may happen twice a week.

Senator Deirdre Clune

Could someone else do that? The fact that they are getting accommodation means they have somewhere to stay. Is there some flexibility with it? Are there other working areas that are similar? I am thinking of people working on car ferries who get their rest time away from home.

Mr. Bryan Meldrum

The private sector has always responded to a need. The need starts with how much money we have to afford all the services that an aging population and other support and social care services demand. We have grown up on the basis that there is a finite supply. In terms of the overall spend within the health care sector, we have decided that there must be other opportunities in respect of spending this money wisely. With regard to development and meeting the needs of older people - because we are at a crisis point - the question arises as to how one spends one's health care budget when every year it is contracting. We are all joined at the hip. It does not matter who provides the service. The very people who entered health care did so because they really wanted to provide care. It does not matter whether they work for the HSE, the not-for-profit sector or the private sector. What linked them and brought them to an induction was the fact that they wanted to make a difference.

The standards of care we are now delivering are far in excess of what was there when I started in the past five or six years. We are growing at a phenomenal pace because demands to get people out of hospital and deliver continuing care within the home are rising all the time. Therefore, the investment is not just in people to take them from delivering what started off as home help. We are now delivering far greater levels of care and that level will rise because-----

Deputy Michael Conaghan

I am suggesting that it is not a continuum. There are different break points and categories of work, some of which are very informal. It is not a professional continuum.

Mr. Bryan Meldrum

Indeed. That alliance will continue. One will need a number of different providers. That is the point I am making. A number of different providers will be required to have that continuum of care, whether it be genuine support or advanced personal care. One needs a structure to be able to do that. With regard to why older people went into residential homes quicker than anywhere else in Europe, there was no formal assessment process in the early days. That has now ceased and there is now a formal assessment for anyone who is of the age and meets the entitlement. The fair deal scheme has been reorganised to ensure that the person who requires a home can get access to it and avail of that service. There is now a greater assessment, where there was no such assessment in the early days, and that is what seemed to contribute to the higher than EU average.

The aim of regulation of the tender was to bring some regulation at a stage that the HSE could monitor. It contracted out to private providers and not-for-profit providers. Everyone was eligible to participate within the tender. As part of that, they were able to introduce some standards much earlier than they could have otherwise, because the earliest they could do so through the legislation was 2016.

Mr. Ed Murphy

The Minister of State, Deputy Kathleen Lynch, said it would be 2016 before she reached the point of bringing in regulations for home care services. We have been pushing for it for six or seven years and came up with standards for quality home care provision in 2009, but they were never brought into play, even as guidelines. We have been pushing for that because it will really make a difference to private, not-for-profit and public provision if we can all apply a standard.

Senator Feargal Quinn

What is causing the delay?

Mr. Ed Murphy

I have only an opinion. The HSE provides 70% of the care and it will cost it hugely to implement any standards or guidelines because it must employ a few extra thousand people to carry out the necessary supervision and training to comply with the standards that might be introduced. The HSE is by far the largest provider of care in the country. It may cost the State over €30 per hour at the moment but the HSE is the largest provider and it would cost far more if it had to comply with the standards. That is my opinion. Therefore, it would be very expensive to bring that in. We would love to see it happen because we believe it is absolutely necessary.

We should always go back to the older person. Older people want to stay at home. We want to keep them safe and secure and we want families to be able to obtain care at a rate that is as affordable as possible if they must pay for it. The largest problem we have at the moment, in addition to the cost of care, is the fact that older people are not given a choice. If they are provided with care, they are told they must use Mrs. Murphy or Jane O'Neill or whatever. We would like to see a tender situation, although not necessarily to give it all to the private sector. I would not want that. We should have a tender system and a number of options for older people, but we should make sure they are approved from the point of view of quality, policies and procedures. We can then offer older people and their families a list of those high quality providers and let them choose whom they would like to use their funds for. If we hand back choice to older people and their families, it will be far more equitable and fair than the current situation.

I have a quick story to tell about the fair deal scheme.

This will take two minutes. There is ring-fencing of the fair deal scheme, which is currently being reviewed, with spending at €1 billion. I have an older aunt in Wexford and about six months ago she was in hospital with a urinary tract infection. There was a discharge planner and when she was coming out of hospital, her family wanted to take her home, which was what she wanted. She had just gone 95 but was reasonably able-bodied and had only had a urinary tract infection. The family asked about the possibility of getting a home care package, or home help, from the State, and they asked for ten hours per week - two hours per day for five days. Much of the family worked and they thought such assistance would help out. It would have cost approximately €200 or €220. They filled in the applications and hoped they would be successful. The discharge planner indicated that just in case the application was not successful, the family could fill in an application for the fair deal scheme and a stay in a nursing home. The family indicated that my aunt did not want to go to a nursing home, but they were asked to fill out the application anyway. The following day the woman was told there would be no home care package funds to give her the service but two days after that she was given the "great" news that she had been accepted into the fair deal scheme at a cost of €850 per week, which was four times the cost of the home care package that she and her family wanted.

That is the point with the fair deal scheme. We should give choice to people and not ring-fence funds into one form of care when it is possible that approximately 35% of people in nursing homes do not need to be there. The previous Minister said the same thing. We are not talking about heavy-duty cases but medium and low-dependency people, who should be given an option. There is a common assessment tool coming out so we are asking that people be given a choice in terms of nursing homes. If we can get people home, we will save at least half the money per head for each person.

Acting Chairman (Deputy Anthony Lawlor)

I thank Mr. Meldrum and Mr. Murphy for coming before the committee, as they have enlightened some of our members. Perhaps they will have the opportunity to speak to the Joint Committee on Health and Children, particularly on the issue of regulations, which is very important. We did a report, related to the area of social protection, about people who work for maybe only ten hours but cannot get social welfare because of that. Many people do part-time work before picking their kids up from school, so there are opportunities in that regard. The social welfare system does not benefit from that.

Mr. Ed Murphy

It is one of the other challenges and opportunities we have, although we try not to confuse people. It is a major issue in the sector and there is an opportunity for thousands of part-time jobs. The social welfare legislation is having a major effect in preventing that from happening.

Acting Chairman (Deputy Anthony Lawlor)

We can provide a copy of the report. We appreciate the witnesses' coming in here and we wish them the best of luck for the future.

Sitting suspended at 3.04 p.m. and resumed at 3.06 p.m.