This Bill represents another important step towards implementing the recommendations contained in The Years Ahead report.
It is an important principle of our policy towards the elderly that as far as possible they should be supported at home and remain in their community. When they are ill, elderly people should have the same access to acute medical services as younger people. If an elderly person becomes so dependent that they can no longer be cared for at home or in the community, that person should be able to avail of a high standard of nursing care in a health board institution or in a private or voluntary nursing home.
Existing legislation governing nursing homes, the Health (Homes for Incapacitated Persons) Act, 1964, is more than a quarter of a century old. It is important that developments in relation to the care of dependent persons during that period are reflected in the new legislation.
We must ensure that the public will have full confidence in the standards of care available to vulnerable people in private and voluntary nursing homes. The standards of care being provided at present are, by and large, of a high quality but there is a widespread consensus that aspects of the legislation need to be changed.
Private and voluntary nursing homes receive a considerable amount of public funds for the care of eligible patients under the Health Act, 1970. In 1986, the amount of the subsidy paid was £15 million. The existing arrangements for subventing the care of dependent persons were criticised in The Years Ahead report for a number of reasons. This Bill will ensure that scarce resources are used in the most effective way to care for dependent people.
Population projections reinforce the need to define the responsibilities of health boards and nursing homes. According to the 1986 census, there are 382,000 people over 65 years, of whom 143,000 are over 75 years old. The latest projection suggest that the number of elderly will increase slowly up to the year 2000, and then rapidly after that year.
By 2011 a population of 414,000 elderly people is forecast, an increase of nearly 10 per cent. The increase in the elderly population will not be spread evenly throughout the country. Along the western seaboard, the numbers of elderly will decrease by about 12 per cent by the year 2000 while in the grater Dublin area numbers will increase by 30 per cent. The rate of increase in those reaching advanced old age will be particularly marked. It is those reaching advanced old age who have most need of nursing care and who are least able to look after their own affairs. This Bill will ensure that the interests of the elderly in nursing homes is protected and their well being promoted.
Most of the changes proposed in this Bill were recommended in The Years Ahead report. That important report recommended a licensing system for all nursing homes. This would, in the working party's view, ensure, that standards in nursing homes are subject to more regular review and are maintained at a high level. It proposed that a health board should be able to subvent the care of eligible patients, following medical and social assessment, in nursing homes licensed by that board and that the level of subvention should reflect the patient's needs. The recommendations of the working party report reflected the views of the National Council for the Aged, which advise on policy towards the elderly, and which commissioned the first research study on nursing homes in this country.
The National Council for the Aged has also recommended that a licensing system for all nursing homes be introduced and called for changes in the method of subventing the care of elderly people in nursing homes. The National Association of Widows in Ireland at their annual conference last year called for a code of standards and regulations for nursing homes and for the registration of these homes. The Irish Private Nursing Homes Association have also made representations to the Minister for Health about the need for revised legislation on nursing homes.
This Bill addresses the main problems identified with the existing legislation, building on the recommendations of bodies with expertise in this field. It aims to ensure a high standard of care in each nursing home without interfering unduly in the management of the home. It is not our intention to put obstacles in the path of persons wishing to set up a nursing home. The Bill provides safeguards against unreasonable decisions by health boards while providing a framework within which nursing homes and health boards can each carry out their responsibility to care for dependent persons.
There are at present 332 nursing homes in operation in the country. There are 286 private nursing homes and 41 voluntary nursing homes. These nursing homes are being opened at an increasing rate. In 1989 some 20 new homes opened. The greatest concentration of nursing homes is in the Eastern Health Board area. The existing nursing homes cater for approximately 6,500 persons.
It might be helpful to Senators if I explained the existing legal situation and the problems which have been identified in the 1964 legislation. The Health (Homes for the Incapacitated Persons) Act, 1964 is the Act which governs standards in nursing homes. Voluntary nursing homes are excluded from the scope of the Act.
Under this Act, a person who proposes to set up a private nursing home must notify the relevant health board in writing one month before it is proposed to commence operating the nursing home. Regulations have been made under the Act to govern the standards of care in nursing homes. The first regulations were made in 1966 and these were revised and stengthened in 1985.
The regulations govern the standards of care, accommodation and food, the number and qualifications of staff and the description of homes among other matters. The health boards enforce these regulations. At present, the health boards inspect homes at least every six months to ensure compliance with the regulations.
Nursing homes charge their clients for the care they provide, either fully or partially. Some homes are approved for subvention under section 54 of the Health Act, 1970. In these cases, residents can avail of a subvention towards the cost of their care which is paid by their health board. The current amount of the subvention is £6.78 per day per patient.
The Eastern Health Board has made arrangements with a number of private and voluntary homes, under section 26 of the Health Act 1970, to subvent the care of dependent elderly people.
Other boards grant aid to voluntary homes under other sections of the Act.
A number of unsatisfactory elements have been identified with the present legislation. For example, a health board is given short notice, only one month, that a private nursing home is about to commence operation. A nursing home may be set up which does not in all respects comply with the regulations. The health board may, after the fact have to set about ensuring that the regulations are met. It would be better if the health board could ensure that standards were satisfactory before the home opened.
The only sanction available to a health board against a nursing home which fails to comply with the standards laid down in law is prosecution. This is a remedy which should only be used in relation to serious and intractable breaches. While the vast majority of nursing homes comply with the regulations and co-operate well with the health boards, it would be better if health boards, as the regulatory authority, had more flexibility in carrying out their functions.
Health boards should be able to ensure that a nursing home complies with the required standards before admitting its first patients. The best way to do this is to require a nursing home owner to register before opening for business. Future compliance can be encouraged by a requirement that registration be renewed on a regular basis.
The health boards are statutorily responsible for the provision of health and personal social services in their areas. We are recognising both the statutory position and the practical working arrangements in proposing that health boards will act as a regulatory and monitoring authority in relation to private nursing homes. The staff of health boards have the expertise, the local knowledge and the integrity to discharge these important functions.
There are many charitable nursing homes in operation which are not covered by the 1964 Act but which are caring for dependent persons. Many are in receipt of public funds. I agree with the recommendations of The Years Ahead report and the National Council for the Aged that all homes providing nursing care for dependent persons should be covered by the legislation. Many of these homes have in the past set the standards for the care our society gives dependent people. An obligation to register with a health board should not pose any problem for the overwhelming majority of these homes. Nursing homes already in existence on the day the Act is commenced will have a year to register with a health board. This phasing-in period will give homes time to adjust to the new legislation.
I will now outline the main provisions of this Bill. A nursing home is defined as a home caring for more than two dependent persons. The term "incapacitated person" is replaced by the term "dependent person". A dependent person under the Bill will be someone who requires assistance with the activities of daily living such as dressing, eating, walking, washing and bathing due to physical infirmity, disease, defect or mental infirmity. These are the activities which are now used in modern nursing to assess the level of dependency of a person. Most persons covered by this Bill are elderly but dependent people in younger age groups will also be included.
All homes providing nursing care for dependent persons will be included whether run for profit. Acute hospitals, health board hospitals and homes, maternity homes, psychiatric hospitals, children's homes, certain homes for members of religious communities, voluntary mental handicap homes and homes such as those of the Cheshire Foundation, are excluded from the scope of this Bill. There are good reasons these categories of homes should be excluded which, by and large, were accepted in the other Chamber. People being cared for by their families are also excluded.
This Bill as initiatied in the Dáil provided for a system of licensing nursing homes as recommended in The Years Ahead report and the National Council for the Aged. During the passasge of the Bill in that House the Minister was persuaded by the arguments in favour of registration of nursing homes rather than licensing. This Bill was so amended on Committee Stage.
The person wishing to set up a nursing home will apply to the health board for registration. The health board will have to satisfy itself that the nursing home complies with the standards laid down in regulations and that the proprietor and the person in charge of the home are fit persons to carry on or be in charge of a nursing home. This information, required by the health boards, will be requested in the application for registration. The information required will be standardised between all health boards. A registration fee will be payable by the applicants.
The duration or registration will be three years, at which stage it must be renewed. It will not be possible to open the nursing home until registration has been granted. Only a registered nursing home will be entitled to call itself a nursing home. The registered nursing home will be included on a health board register of nursing homes for the health board area. This register will be available to anyone who wishes to consult it, free of charge, at all reasonable times. It will enable anyone to obtain information on nursing homes registered by the health boards.
The detailed requirements which a nursing home will have to meet will be set out in the regulations. The 1985 regulations under the existing 1964 Act will continue to apply until new regulations take effect. Draft regulations have been circulated and there has been widespread consultation with interested groups on the contents of the regulations.
Under the provisions of this Bill, health boards will not just play a regulatory role. They will also be authorised to provide Training for nursing home staffs and to provide a range of anciliary services, such as chiropody, occupational therapy and physiotherapy to nursing homes on mutually agreed terms and conditions.
The best features of the existing regulations will be retained, such as the requirements that health boards inspect homes at least once every six months, a nurse must be on duty at all times and proper records be kept. A health board's ability to set and maintain good standards of care in nursing homes will be greatly strengthened by the proposed registration procedures.
A registered nursing home proprietor must apply for a renewal of registration at least two months ahead of all expiry dates. This gives the health boards a reasonable period in which to respond to applications for renewals. If the boards do not inform the applicants of their decisions within two months of each application, then registration will be granted automatically. This provision will encourage health boards to assess applications promptly and protect nursing homes from unnecessary delays. If a nursing home is sold during the period of registration, registration automatically lapses. The new owner must apply for registration within four weeks.
One of the amendments which the Minister for Health introduced on Committee Stage in the Dáil was to allow a prospective nursing home owner seek a declaration from a health board in advance of purchase of the home that he or she was a fit person to be a registered proprietor. This will allow a person buy a nursing home in the confidence that he or she will be registered by the health board.
A health board can only refuse to grant or renew registration or revoke registration for specific reasons. It can do so if it considers that the premises or the manner of running the nursing home does not comply with the regulations. The health board can also act if it has not been been furnished with necessary information. Finally, it can use its powers of refusal if the owner or person in charge has been convicted of an offence under nursing home legislation or of a serious offence which would render the person unfit to carry on a nursing home.
A health board will be able to attach conditions to registration at the date of issue or later. A condition could, for example, require certain improvements to be carried out to the home by a certain date. If an applicant for registration or a registered owner feels aggrieved about a health board's refusal to register or reregister the home or considers a condition attached to registration is unreasonable, he or she can ask the health board to review the decision. If still not satisfied, the proprietor may appeal the decision to the District Court.
Concern has been expressed from time to time that the title "retirement" or "rest home;" is being used to avoid the obligations of existing legislation. I am not concerned with the genuine retirement home where the residents are independent and receive no nursing care. I am concerned that a home could call itself a retirement or rest home but in practice be looking after dependent persons requiring nursing care. At present health boards have no authority to inspect such homes. Under this new Bill, they will be given power to inspect any premises where they consider dependent persons are being maintained. Heavy fines will be imposed on people found guilty or caring for dependent persons in an unregistered nursing home.
Situations have arisen when standards in a nursing home have fallen so low that urgent action is needed to protect the interests of the residents. It may be impracticable to transfer the residents to other homes. One solution which has been found to work is to allow the relevant health board assume the management of the particular home, until the problems have been resolved.
Under this Bill, a health board will have the power to assume the management of the particular home with the consent of the registered proprietor or in pursuance of an order from the District Court if a nursing home fails to comply with the standards of care in the regulations.
The period of the management order may not exceed three months or, if the board is acting on an ex parte court order, not more than two weeks. Any expenses incurred in managing the particular home during the period will be paid from the nursing home's income. The health board will be able to recover from the nursing home the salary costs of the person which the board appoints to run the home.
These provisions allow health boards to protect the welfare of dependent persons in nursing homes where the standards are such that the health of the residents is in jeopardy. It is intended as a temporary measure pending longer term action being taken, such as the transfer of patients to a more suitable location or a change of management of the home.
Technically, every person entering an approved nursing home is eligible for subvention since the extension of eligibility for care in public hospitals to the whole population in 1979 — something brought about by the Taoiseach, Deputy Haughey, then Minister for Health. Under section 54 of the Health Act, 1970, a health board may pay a subvention to a person in a home approved of by the Minister for Health. The scope of section 54 has been curbed as no new homes have been approved since 1980. Unfortunately, due to constraints on the financial resources in the health services, it was not possible to approve new homes. Senators may be interested to know that there are 78 approved homes out of 332 private and voluntary nursing homes. The present system of subvention discriminates against the many excellent modern homes which have opened since 1980.
Under the Bill, if a dependent person requires nursing care but the person is not able to pay all the costs involved, that person, or his or her relatives, will be able to apply to the health board for a subvention. Health boards will be able to contribute to the costs of maintaining a dependent person in any registered nursing home. The health board will assess the individual's level of dependency and their financial circumstances in making their decision to contribute to the costs involved.
It is important that an individual seeking a subvention is assessed before they go into a nursing home. It may be that the health board can arrange for some other form of support to solve the problem and allow the person to remain independent and in their own home. If the person is assessed as requiring nursing home care and is unable to pay the full cost, the health board will be enabled to pay a subvention. The health board will be able to vary the subvention to match the individual's dependency.
I am proposing that there would be payments for three categories of physical dependency — light, moderate and heavy dependency and possibly one category for those with severe forms of dementia. The amount of the payment will vary because the more dependent a person is, the more expensive the care. The level of payment will be fixed by regulation, following consultation with the relevant interests involved.
I wish to stress that any person in receipt of a subvention at present under section 54 of the Health Act, 1970, will not be affected by this Bill in any way. These subventions will continue to be paid as long as the person is in the particular home. However, no new applications will be accepted for section 54 subventions when the provisions of this Bill take effect.
The Minister for Health has already given an assurance in the Dáil that the overall level of financial support for people cared for in nursing homes will not diminish as a result of this Bill. This provision is not about saving money. It is about enabling health boards to target their available resources most effectively and to respond flexibly to the changing demands of dependent people for whom they have responsibility. This is the approach which the new subventions arrangements provide for.
Under a general provision of the Health Act, 1970 — section 61 — health boards may make arrangements to assist in the maintenance at home of a person who would require to be maintained otherwise than at home. These persons are frail elderly people who do not need nursing services but who require care and companionship. One of these arrangements is boarding out, which is a practical response to helping an elderly person maintain his or her independence by assisting them to live in their own community, near to their family and friends. This Bill give health boards specific legal authority to make boarding out arrangements for persons who can no longer live at home and who consent to be boarded out, subject to regulations to be made by the Minister.
Health boards will be empowered to contribute to the cost of a boarding out placement. Boarding out regulations have been drafted and discussed with interested parties. The regulations will ensure that boarded out persons are protected and that health boards supervise all placements.
It might interest Senators to know what this Bill does not do. It does not set out to limit in any way the establishment of nursing homes. The State, under the 1964 Act and the 1985 regulations, already has a statutory responsibility to ensure a minimum standard of care in nursing homes. This Bill updates the existing legislation to take account of developments in the care of dependent persons by establishing a framework for registration of nursing homes.
The Bill does not interfere with a person's right to choose nursing home care. It does not attempt to direct individuals towards particular nursing or geriatric homes. It will, in fact, widen the choice of persons entitled to a subvention from the limited number of homes with section 54 approval to all registered homes. Where someone needs financial assistance to pay for nursing home care the purpose of the assessment is to ensure that a nursing home is the most appropriate option and that the health board is directing its resources to those in need.
This Bill promotes the welfare and well being of dependent people in nursing homes. Legislation, by its nature, is concerned with minimum standards. I intend that, in partnership with the health boards and the nursing homes, we could go further and agree a code of good practice for nursing home care. A code has been drafted and a group of experts representing the interests involved has been invited to comment on the first draft. The draft code sets out the best practice to which homes should aspire and which health boards should encourage. Such a code was recommended by the National Council for the Aged and I believe it will make an important contribution to achieving high standards in all homes.
The code will reassure people that the arrangements made for the care and protection of those who can no longer care fully for themselves are the best possible. It will also encourage a uniform application of the legislation in all health boards.
Nursing homes and health boards have a complementary task of caring for the elderly. The growth of the nursing home sector has been rapid in response to the growth in the number of elderly people and their increasing income. The right of elderly people to make private arrangements for nursing care in their later years is not in question, but the nursing home sector cannot be considered in isolation from publicly organised services and the standards that should be expected from all service providers both public and private. It will be necessary to consider the role that nursing homes can play in the future in caring for dependent persons through full-time residential care, day care or respite care. We will have to be aware of how private and State funded services can work together effectively.
There is a need to explore the implications of a closer relationship between health boards and nursing homes in the future. This was an issue raised with the National Council for the Elderly which the Minister for Health appointed earlier this year. I am glad to say that the council has already commissioned research on the issue and the Minister looks forward to receiving the findings and the recommendations of the council in the near future.
The provisions of this Bill will make for a new relationship, a new partnership between nursing homes and the health boards. Both parties will have to work closely to ensure that the Bill's requirements are met. This co-operation will contribute to a clearer appreciation by each party of the other's difficulties and responsibilities. A co-ordinated approach between health boards and nursing homes and only improve the quality of care available to dependent people.
It is worth noting that only 5 per cent of our elderly are in institutional care at any time, under the care of health boards or private and voluntary nursing homes.
A much higher proportion of the elderly, 17 per cent, are being cared for at home by their families. We must do more to support these families through help at home and respite facilities. I would like to see more arrangements between health boards and nursing homes to provide day care for dependent elderly people cared for by their families or respite facilities to allow carers a break from their heavy responsibilities. The framework provided in this Bill, should encourage this kind of co-operation.
Nursing homes are an indispensable part of services for the elderly. This Bill seeks to strike the right balance between ensuring that the interests of some of the most vulnerable members of our society are protected without undue interference in the management of homes. The Bill was substantially amended in the Dáil to take account of the suggestions of the Opposition parties. I am prepared to accept the suggestions of Senators which would improve the Bill further. It is in all our interests to produce legislation which will promote the best interests of dependent people in nursing homes.
I look forward to the Senators' contributions and to bringing to conclusion this very important Bill.