Vol. 165 No. 4
I move:
That the report of the Ombudsman on nursing home subventions, copies of which were laid before both Houses of the Oireachtas on 30 January 2001, be referred to the Joint Committee on Health and Children to consider and report to both Houses of the Oireachtas.
I thank Senators for facilitating me in make my contribution. As I am required, by schedule, to be elsewhere, my colleague, the Minister of State, Deputy Moffatt, will listen to the remainder of the debate.
I welcome the report of the Ombudsman on the nursing home subvention scheme recently laid before the Dáil and Seanad. While it is critical of my Department, nonetheless I welcome its close examination of the scheme. I do not believe in shirking criticism, I believe in welcoming it, taking it on board and learning from it. We should apologise to those adversely affected by decisions taken regarding the operation of the scheme, decisions which, as the Ombudsman points out, disadvantaged people in their entitlement to nursing home subvention between the years 1993 and 1999.
My colleague, the Minister of State, apologised on behalf of the Executive last evening in the Dáil. However, we are only Ministers in the overall scheme of things. The scheme has been operated under more than one Administration and all political parties need to reflect on what happened in recent years. The Ombudsman points in that direction in highlighting the relationship between the Executive and the Legislature.
I was disappointed that Deputy Gay Mitchell and others, during a recent debate on Private Members' time in the other House, tended to concentrate on officials within the Department to the exclusion of all others. While those involved in the administration of the scheme have answers to give, we all have lessons to learn, irrespective of which political party to which we belong.
The Ombudsman makes an important point regarding the relationship between the Executive and the Legislature. He also raises issues about the relationship between the Department and the Minister of the day. Although Ministers presided over the scheme since 1993, the Ombudsman points out that they would not have been aware of the legal advice available suggesting that the regulations were ultra vires the Act.
The issue of whether relatives should contribute to the care of the elderly was hotly debated during that period. Parliamentary questions on the issue were tabled by many Deputies. One may get the impression from the Ombudsman's report that this is a surprise and that there was no issue about whether relatives should be means-tested or make a contribution, but Ministers are on public record as stating they believed that relatives should pay. Deputy Noonan, for example, when Minister for Health, made it clear to Deputy Harney in 1996 that he believed that sons and daughters who were in a position to contribute towards the cost of a parent's nursing home fees should do so and that the State recognised this contribution by way of tax relief. There were questions from Deputies about this aspect of the scheme in June and October that year. The Irish Nursing Homes Organisation also raised the issue successively with Ministers. There may have been an understanding in both Houses that regulations provided the basis for means-testing of relatives. Nonetheless, there were broader issues in funding the scheme etc. which needed to be honestly and openly examined.
The issue to which the Ombudsman draws attention is that there was no legal authority to means-test relatives. He makes the point that Ministers were not made aware of this. It is important, in that context, that that issue be explored further when referred to the joint committee. The Ombudsman, in his conclusions, states that this is a complex issue and that the apportioning of blame is also complex. He suggests that it be assessed in the context of the complexity of how Government is operated and, in particular, the relationship between the Legislature and the Executive.
The policy of the Government on health services for older people is as outlined in the report, The Years Ahead, first published in 1988 and reaffirmed in the review of The Years Ahead, published in 1997. The policy is to maintain older people in dignity and independence at home in accordance with their wishes, as expressed in many research studies, to restore to independence at home those older people who become ill or dependent, to encourage and support the care of older people in their community by family, neighbours and voluntary bodies, to provide a high quality of hospital and residential care for older people when they can no longer be maintained in dignity and independence at home.
It is an inescapable fact that the anticipated change in demographics in the period 1996-2011 has, and will continue to have, significant implications for all service planners, service providers and all in government, whether at local or national level. The changing health and social needs of older people present a major challenge to society. The longer older people remain in good health and disability free, the better will be their quality of life and the greater their contribution to society. Ageing is a normal dynamic process, it is not a disease. While ageing is inevitable and irreversible, the chronic disabling conditions that often accompany it can be prevented or delayed, not only by medical interventions, but by social, economic and environmental policies. These policies need to be informed by a wider, more positive view of old age.
Since taking office in 1997, the Government has allocated significant resources to services for older people, particularly health services, in an attempt to deal with this change and the resulting issues which will emerge. Additional funding for the development of health services for older people has increased significantly from £10 million in 1997 with an additional £36 million being provided in the year 2000 and an additional £57 million being provided in 2001. This has resulted in approximately 880 posts being approved for services for older people between 1997 and 2001.
Under the national development plan, £2 billion is being made available for investment in health services, that is, a trebling of investment compared to the previous seven year period. The purpose of this plan will be to create an infrastructure that will bring significant and tangible advances in delivering a more patient centred and accessible service. We are keen to have a balance between the community services side and hospitals. That is the reason we made it clear from the start that we wanted a 50-50 split between the spend on hospitals and the spend on community services, which is of particular importance to the elderly. We have made this clear to the health boards.
Over £200 million will be available for the capital development of services for older people over the period of the plan. A broad range of facilities will either be provided, replaced or upgraded as a result, including assessment and rehabilitation facilities, ambulatory care facilities, community hospitals, community nursing units, convalescent and respite beds, day care centres and services for the elderly mentally infirm.
With considerable investment in health board facilities and the area of community care, substantial additional resources have been made available for the nursing home subvention scheme. Members will be aware that the Health (Nursing Homes) Act, 1990, under which subvention regulations were made, has two principal objectives: to ensure high standards of accommodation and care in all nursing homes registered under the Act and to provide a new system of nursing home subvention in order that dependent persons most in need of nursing home care will have access to such care.
In January this year, 385 private nursing homes were registered under the Act, with approximately 6,000 in receipt of a subvention. I intend to increase the rates of subvention from their cur rent levels of £70, £95 and £120 per week, depending on the level of dependency, to £90, £120 and £150 per week with effect from 1 April. This year, the funding available for the scheme is £52 million.
The report of the Ombudsman deals with the role of the Department of Health and Children in making regulations and overseeing the introduction of the scheme and examines the administration of the scheme by the health boards since its inception in 1993. However, more importantly for us as Members of the Oireachtas, it also considers the nature of the relationship between the Houses of the Oireachtas and the Executive and within the Executive and also the relationship between the political and administrative levels. The Ombudsman states, in relation to his findings, "any attempt simply to apportion blame, without regard to the complexities of the framework within which Government in Ireland operates, runs the risk of the central message in this report being overlooked." I will return to this issue.
Two articles in the nursing home subvention regulations were the subject of critical comment: article 8.2, the "pocket money" provision, and articles 9.1 and 9.2, which allowed for the income of adult sons and-or daughters to be assessed when determining the level of subvention to be paid. My immediate priority is to ensure the two aspects of the regulations that have the most direct impact on nursing home patients and their families are fully addressed without delay. I will outline the action taken to date.
Article 8.2 of the Nursing Home Subvention Regulations, 1993, allows health boards to disregard a sum equivalent to one fifth of the old age non-contributory pension when assessing means and calculating the amount of subvention to be paid. An additional allocation of £4 million was made available in 1998 to six of the eight health boards where the regulations were applied incorrectly, to meet the costs of arrears payments in respect of the full implementation of the Health (Nursing Homes) Act, 1990, and subsequent regulations. The sum of £4 million was not provided solely for the purposes of article 8.2 arrears. Health boards were also incurring additional expenditure as a result of the easing of the family circumstances regulations in 1996. These regulations, signed in July 1996, increased the personal allowances applied by designated officers of the health board when assessing the circumstances of adult sons and daughters of an applicant for subvention. The funding was intended to address both problems and to meet funding shortfalls in the scheme generally.
Following a meeting between officials of my Department and representatives of the Office of the Ombudsman in December 1999, my Department became aware of continuing delays in paying arrears. The Department took up the matter with the relevant boards and is continuing to pursue it. I am advised that the current position is that where arrears were due to be paid, health boards have made retrospective payments in respect of persons currently resident in nursing homes. I understand some boards have also paid arrears in respect of former subvention recipients now deceased and former recipients who are no longer resident in nursing homes. My Department has instructed the relevant boards to take immediate steps to pay all outstanding arrears and the health boards have advised that, to date, approximately £900,000 has been paid out in respect of article 8.2 arrears. It is not possible at this stage to give a figure for the total cost of article 8.2 arrears payments as a number of boards have not completed the process of calculating the amounts due. My Department is, however, continuing to pursue this matter with the health boards concerned to ensure every effort will be made to pay all outstanding arrears as soon as possible.
This allocation was not intended to be used solely for the payment of article 8.2 arrears. The Department has been informed by the health boards concerned that the funding provided was used to cover arrears payments under article 8.2; additional expenditure arising as a result of the easing of the family circumstances regulations in 1996; the payment of enhanced subventions; expenditure shortfalls arising from increasing demands under the scheme; and legal and other costs associated with the administration of the scheme. I understand a proportion of the allocation was used by three of the health boards to fund other services for older people, including the provision of aids and appliances, improved home help services and the opening of a unit for the elderly mentally infirm. While this money was not expended on the subvention scheme, I am assured that it was used by the relevant health boards for the benefit of older people.
As the Ombudsman has outlined, articles 9.1 and 9.2 of the Nursing Homes (Subvention) Regulations, 1993, allowed health boards to assess the ability of the adult sons and-or daughters of older people who apply for nursing home subventions to contribute towards the cost of their parents' nursing home care. A review of the operation of the subvention scheme was conducted in 1995, following which an amendment was made to the schedule which provided that, in calculating the income of sons and daughters, health boards were to disregard income tax, rent, mortgage repayments, etc. This schedule increased the personal allowances applied by designated officers of the health board when assessing the circumstances of adult sons and daughters of an applicant for subvention. The subvention regulations were further amended from 1 January 1999 and the provision to assess the capacity of adult sons and-or daughters to contribute towards the cost of nursing home care of their parent was deleted.
This amendment was made because the provisions in question were not consistent with the assessment procedures adopted in the granting of medical cards by health boards or in the social assistant payment schemes administered by the Department of Social, Community and Family Affairs, wherein there is no consideration of the financial circumstances of adult sons and-or daughters of applicants. Nonetheless, I am concerned that the issue of making payments to those adversely affected by this regulation remains. While the legal advice received is that there is no legal liability on the State to make retrospective payments, there is a moral obligation on the State to do so. I have decided that moneys should be paid to those adversely affected by this provision and my colleagues in Government agree. We have secured the funding required to make these payments as quickly as we can. We have established a group representing the Department and the health boards as well as the Eastern Regional Health Authority to ensure this process is initiated on a uniform basis as speedily as possible. I alert the House to the fact that this will take time. As there were over 35,000 applications for subvention since the introduction of the scheme, this will be a complex exercise going back through all applications involving difficult issues of traceability and it may take some time to complete. Payments will not start flowing until later in the year.
An issue raised here in the recent past is that of inspection procedures for extended care facilities. The Health (Nursing Homes) Act, 1990, requires nursing homes to be registered with their local health board and regulations made under the Act require that there must be proper standards in private nursing homes, including adequate and suitable accommodation, staffing, kitchen and sanitary facilities, access to medical care and so forth. Nursing homes are required to renew their registration every three years and a health board may impose conditions in relation to registration. I have been concerned for some time about the fact that while there is provision under the nursing home legislation for monitoring standards in private nursing homes involving inspections, no similar arrangements are in place for health board facilities. I intend to rectify this. The social services inspectorate has the authority to monitor standards in children's residential centres and is operating effectively. I intend to expand the role of the inspectorate to cover extended care facilities for older people. Given the heavy demands on the inspectorate in relation to the monitoring of standards in the child care area, additional resources will be required to enable it to take on this additional function. I intend to bring proposals to this effect to Government as soon as possible.
The Minister of State with responsibility for the elderly, Deputy Moffatt, is preparing guidance and training materials in relation to elder abuse, including abuse in institutional settings. Following the publication of the report, Abuse, Neglect and Mistreatment of Older People: an Exploratory Study, by the National Council on Ageing and Older People, the Minister of State established a broad-based working group in 1999 to advise on the formulation of procedures and guidelines on elder abuse. This process will culminate in the presentation of a final report to the Minister of State who has been provided with significant resources to ensure work in this area is completed within the timeframe envisaged. The report will be completed following the testing of draft policies, procedures and guidelines in pilot projects and training programmes will be provided for staff members and ongoing evaluation will take place.
An expenditure review of the nursing home subvention scheme is being undertaken by my Department in association with the Department of Finance and is expected to be completed shortly. I intend to bring forward proposals to Government in relation to whatever additional measures will be necessary, arising from both the Ombudsman's report and the expenditure review, with experience gained from the operation of the scheme since its inception in 1993. The expenditure review, in particular, may throw up a number of issues to be considered and will, in all likelihood, have a significant impact on what happens in the future.
Chapter 8 of the report draws some far-reaching conclusions as to how Government operates under the Constitution. The report goes on to make a number of suggestions as to how the position might be improved: through better use of the Oireachtas committee system, a mechanism for monitoring secondary legislation by affirmative resolutions of the Oireachtas and a more effective system for dealing with the annual Estimates, particularly for expenditure required to meet entitlements under the State schemes introduced by the Oireachtas. These issues are broader constitutional issues, not just matters for consideration by my Department, nor are they issues that can be addressed by the Government alone. They have implications for all future Governments and will affect the way we as Members of the Oireachtas deal with matters in the future.
The report raises significant issues not just for me as Minister for Health and Children or other members of the Government. It raises issues not only about how we deal with funding entitlements, but also about people's human rights, which is of concern to us all.
The Ombudsman's report highlights examples of inequity of treatment by health boards for subvention applicants. Any inequity of treatment concerns me greatly and it is my intention to put in place fair and proper systems to ensure that this accusation cannot be levelled again.
The report makes uncomfortable reading for us all. I look forward to further discussion on it and to examination of its contents. In this regard the Dáil this morning agreed, and it is our intention, to refer this report to the Joint Committee on Health and Children. We hope it will consider this matter in depth and report back to the Oireachtas within a suggested timeframe of six months.
I welcome the Minister. I am glad this report is to be placed before the Joint Committee on Health and Children. The Minister referred to the fact that it was debated in the Dáil in Private Members' time over the past two evenings as a Fine Gael motion. We are very anxious to have a thorough debate on it here.
This is a damning report. We must listen to what the Ombudsman has to say. He is an independent person. He certainly is to be congratulated for bringing before us the harsh facts of how vulnerable elderly people and their families have been treated. The report questions the Department of Health and Children in relation to its knowledge of these matters and particularly in regard to the failure of the Department to respond to the Ombudsman.
The Minister has outlined the measures he has put in place to deal with the compensation payments due to parents and their children for nursing home care. The State, through the health boards, extracted moneys improperly from elderly people and their families.
It seems extraordinary that elderly people who contributed all their lives to society and were due the utmost respect and dignity should be faced with untold distress. Their pride was affected as they had to turn to their children in order to have the necessary financial support to keep them in nursing homes. With today's social structure most young couples work and, much as people would like to, there is no longer a question of being able to keep elderly parents at home.
I am aware of many such cases, although I do not intend going through them now. I have received many representations relating to the grief caused to elderly people and their families. There was family in-fighting in relation to who should care for whom, who was the most well off, whether people would contribute equally and whether the person who got the family farm should be the main supporter.
Looking through media coverage, Fintan O'Toole's article of 3 February was extraordinarily strong, with the headline "Elderly regarded as Enemies of the State." He refers to the Ombudsman's report as a searing indictment of the Oireachtas and its inadequacies, ripping off vulnerable elderly people who could not look after themselves. He used the word "subversion". The health boards undermined a law passed by the Oireachtas. The word "sabotage" is also used in the article. It stated that there was sabotage of decisions.
The report deals with the payment by health boards of subventions to patients in private nursing homes provided for in the Health (Nursing Homes) Act, 1990. I was in the Seanad at the time that Bill was debated and we welcomed it most warmly in that it would deal once and for all with the area of nursing homes.
The report is a case study in public administration. It examines the operation of the subvention schemes by health boards and is very specific. It deals with the role of the Department in making regulations under the 1990 Act and overseeing the introduction and operation of the scheme nationally. It also examines the relationship that exists between the Department and the Oireachtas, and the Department and health boards and the way in which the Department interacted with the Ombudsman. That point was raised by Senator Hayes on the Order of Business and I know he will deal with it in his contribution. Page after page of the report reveals frustration in the Office of the Ombudsman, which did not get an adequate response to many questions that were put.
The wider and most fundamental issue is the relationship between the Executive and the Parliament and relationships within the Executive. It would take more than a quick debate this evening to explore that issue, which we should consider as Members of the Seanad. I hope we do not find the same problems within, for example, the Department of the Environment and Local Government as it relates to local authorities. We should also consider the relationship between the Executive and other agencies.
The Ombudsman states in the report that he received a steady flow of complaints – over 150 – since the scheme commenced in September 1993. That is quite a number, given that not everybody would have been aware of the Office of the Ombudsman. That office was very concerned about the number of complaints it received about health boards.
Prior to 1993 there was inadequate provision of long-stay nursing home care. Radical improvement and reforms were proposed. We were aware at the time of escalating costs. What concerns me here is the corporate response of virtually the entire sector, the Department and most health boards. I do not think, as the Minister said, it is a harsh or undue criticism of civil servants, and I am aware that not all health boards were to blame.
The Ombudsman seemed to have tremendous difficulties in dealing with complaints. There were many delays. For instance, he states that it took more than five years to acknowledge and address the defects of which he was aware prior to September 1993. He focuses on the fundamental issue of good administration and good government and states that this was not due to maladministration. He refers to the more fundamental defects relating to the Houses of the Oireachtas and the Executive. He refers to the Executive, where Ministers acted individually or in concert, or collectively in conjunction with the Civil Service and the operating agents.
That is one aspect of the debate. The second aspect is the pocket money issue and that adult children were supporting elderly parents in cases where they did not have to. The Minister said that successive Ministers for Health stated that perhaps children should give financial support to their parents for good nursing home care. That could have been done by way of a policy change. I am not sure why there was not more openness about the policy when the economy was in recession and we did not have the billions in the Exchequer that we now have. That policy should have changed by now in that it should not be necessary for children to support their elderly parents having regard to what should be done by the Department Health and Children and the moneys available to make provision for adequate subventions. The highest subvention rate is £120. While the Minister mentioned the increases in subventions will come into effect on 1 April, £120 has been the highest rate for many years, which is very little when one considers the weekly and annual costs of nursing home care.
People are living longer. My mother is 96 years of age. While she does not need to be in a nursing home, if she were in one, imagine the length of time she could have been in one and the escalating costs of such care. I am not talking about ten years, but 30 years in cases where parents might move to a nursing home at the age of 60 years, depending on the state of their health and if they do not have children in a position to mind them. Such a period of care in a nursing home would require a massive financial investment which family members would not be able to afford.
On the payment of subventions, patients and their families were affected. When the law was passed, I had hoped it would be translated into action on the ground, but that did not happen.
The Ombudsman is fair, he states that there were difficulties for seven years and adequate financial resources were not available. He refers to inflation being rife and that inventiveness might have been necessary during that period to overcome financial problems. He states, however, that the inventiveness went beyond the bounds of what was reasonable or acceptable. He implies that someone got a brilliant idea, went off at a gallop, but that it went beyond the bounds of what was reasonable or acceptable.
We are aware that there are not enough public hospital beds. In the Limerick area many in need of care would prefer to be cared for in St. Camillus's Hospital, which offers excellent care, but it does not have enough beds. There is a long waiting list for admittance. Even if some had the necessary financial resources to cover the cost of nursing home care, they would opt for St. Camillus's, as they have been in the hospital for a week or two and wish to return. It is regrettable that sufficient funding is not available in the public system to provide an alternative for those who would willingly go to and be happy in that hospital in the knowledge that they would receive tremendous care.
The Act provides for a health board to subsidise the cost of care in a private nursing home. I wish to raise a major issue, on which I do not have much time to dwell, that is, one fifth of the old age pension is disregarded and not treated as means. That is the pocket money of pensioners. That provision was deliberately and systematically undermined by some health boards and the Department of Health and Children. That is evident, in black and white, in the report.
I was surprised at the advice on one area given by the Attorney General's office, although I am sure the Attorney General's advice is the most expert in the country. The Minister has not made it clear whether he was advised there was no liability. That has not been cleared up. The Minister said that the arrears to the health boards will be paid. Is he doing that out of goodwill? There seems to be an ambiguity as to whether the Attorney General's advice on there being no legal entitlement is correct. I would like that clarified.
While the Minister has left the Chamber, I would like to know the current position on the Mid-Western Health Board to which an additional allocation of just under £1 million was made in January 1998. The Ombudsman states that it is not clear how much of this was intended to cover payment of arrears to those who had not been given the benefit of the pocket money provisions in the subvention means test. Why is that not clear when this issue has been under the microscope for so long? The Mid-Western Health Board states that it has paid arrears only in those cases in which a subvention was still in payment on 1 September 1998 and where it could obtain adequate details of income. I understand the reason for the delay in obtaining adequate details of income, as it would have to check the paperwork. Arrears were not paid in respect of applicants who died prior to arrears being calculated. The total amount paid by way of arrears is not clear. Having regard to investigations taking place, I would have thought the Mid-Western Health Board would be clear about the amount is being paid, the amount that will be paid and to whom it will be paid. It was allocated just under £1 million. I am not sure if it will be allocated more to cover the moneys due not only to patients, but their families and those of deceased patients for whom this must be a very trying and distressful period. It brings back into focus the pressures, torment and distress suffered during the period in which they were unaware of their entitlement and had to look at their ageing parents suffer the indignity of having to ask their children to pay for their health care at a time when they were most vulnerable and, probably, very ill.
When this report is placed before the Joint Committee on Health and Children, I hope we will receive answers not only to the questions raised by the Ombudsman, but in the Dáil and here this afternoon.
This is an extraordinary report. It gives us an insight into mainly administrative procedures in different health boards and the major variation in their application to mainly vulnerable, elderly persons at an age when they could not defend themselves and were depending on their relations, who were often not equipped to take on the administrative apparatus of the health board in the area in which they lived, to do it for them.
The report draws together the legal, medical, social, financial and administrative threads of our private nursing home system in one extraordinary erudite, easy to read, simply stated and well written document. I would go so far as to say that this report should be standard text on administrative and social work courses, as in years to come people will not believe what happened in the Ireland of the late 1990s.
The report highlights the making of regulations containing provisions, likely to be invalid, ultra vires the Act, including at least one instance in which the likely invalidity was known in advance; the inclusion in a regulation of a provision, which was almost immediately negatived by advice issued by the Department; the unreasonable prolongation of discussions with the Ombudsman's office in relation to practices, which it appears were known from the outset to be invalid or incorrect; and the failure of some of the health boards to alter practice, even where the legal advice was that the practice was incorrect and where the Ombudsman had expressed the same opinion. One does not get anything more damning than that in the early pages of a report.
The report also states that in the long run the exercise of non-existent authority, to quote the commentators, the surreptitious introduction of family assessment, the disregard for clear principles of law, the sustained proffering of incorrect advice, the reluctance to acknowledge mistakes, the tardiness in the Department's dealings with the Ombudsman's office can only undermine public confidence in Government and our democratic institutions. I call into question whether the present arrangements facilitate efficient, open and accountable government. From the point of view of the Houses of the Oireachtas to which this report is addressed, the issue is whether their intentions, as expressed in legislation, were honoured as befits their constitutional status.
Those two paragraphs sum up the report. While there are other considerations to be taken into account, the major consideration is that there was no control, monitoring or standard application of the rules across the health board system for those who needed the support of the State at a difficult time of their lives. That must be examined. Why did the Eastern Health Board not have prob lems? It came out of this report with no stain on its behaviour.
I am not here to defend the Eastern Health Board, of which I was honoured to be a member in the late 1980s and early 1990s. It was the largest health board at the time and there were more administrators between those receiving its largesse and the top decision makers. Other health boards are smaller and there is a more intimate relationship between the administrators and those in receipt of moneys. What happened to this special relationship? How could administrators deal with such vulnerable people in a heartless manner while the Eastern Health Board interpreted the rules in a more charitable and humane manner?
I do not wish to attack health boards and their officials. There was a breakdown somewhere along the line. A minuscule amount is involved in the context of the entire health Vote. Ultimately, the Ombudsman's report reveals there was a failure in the exercise of correct procedures; to recognise the correct relationship between the Legislature and Executive; to respect and act on legal advice; and to exercise the normal motives of humanity and charity in dealing with vulnerable people. It also displays that the poor law mentality is alive and well at certain levels of administration in our health system.
I am glad to have the opportunity to debate this important report. Senator Jackman referred to the debate on the nursing homes Bill in 1989 and 1990. There were contributions from all sides of the House because people were aware of the difficulties that existed. Nursing home standards were appalling. Both my parents suffered ill health and, fortunately, we were able to care for them at home for most of that time, but because of various practical problems both of them had to reside in nursing homes for relatively short periods, six to eight months. I recall doing the rounds of nursing homes and the smell of cabbage and the dark, dismal surroundings. I was depressed that my parents would have to reside in such conditions. Although circumstances have improved and regulations were introduced, nursing homes have staffing problems. This has implications for the care of old people who are left in bed far too long.
The Ombudsman referred to such human problems and the manner in which he laid out the report is excellent. When one reads the case studies, one realises this is a human problem and relates to elderly persons who cannot look after themselves and who need and deserve to be looked after. That is not charity, it is their right. That is the reason I feel strongly about this issue.
The Minister was a little defensive. He put his hands up and said mistakes were made, that we must learn from them and that it was everybody's fault and nobody's fault. All of us should bear responsibility for what happened. Given that questions were being asked, the time it took for this to come to light was extraordinary. If we do not learn from this, shame on us. Are all the health boards working together now? Are their actions being monitored? Will we be convinced that this cannot happen again?
Senator Fitzpatrick referred to the Eastern Health Board, which came out of the report better than any other health board. I will illustrate how awful the rest were. I had an old maiden aunt who lived at home. She worked as a post office clerk and, therefore, she received a minuscule pension. She fell into ill health when she retired. She sold the small family home and invested the money thinking that she would be able to look after herself. However, her money ran out three years ago. Nursing homes in Dublin cost £450 per week, not £150 per week as some say. The onus was on the nursing home to obtain a subvention for her. She knew that she was running out of money and did not believe that she should have to ask the extended family, who were already looking after elderly relatives, for help. She was not fit to go cap in hand to the health board for help. The nursing home and I had to seek the subvention for her.
Why did this lovely old person have to go through that? It was completely wrong. I thought elderly persons were in a better position because of the nursing home regulations and so on. What happened to her was wrong and one would swear one was asking for a king's ransom if one tried to obtain the maximum subvention. There were communication difficulties and niggardliness, but administrators responded well when one got through to the correct person who was trying to do his or her best. That is one example of how difficult it was for the nursing home, me and one or two relatives to look after this elderly woman. It was heartbreaking.
When one reads the cases in the report one realises how much more awful the situation was for others. The report is damning. The Minister stated:
However, more importantly for us as Members of the Oireachtas, it also considers the nature of the relationship between the Houses of the Oireachtas and the Executive and within the Executive and also the relationship between the political and administrative levels. As the Ombudsman states, in relation to his findings, "any attempt simply to apportion blame, without regard to the complexities of the framework within which Government in Ireland operates, runs the risk of the central message in this report being overlooked."
The central message is that the most vulnerable in society must be looked after in an open, non-oppressive way. People must not be put in a position where they are of the view that they are mendicants in society when they have borne the brunt of all the bad times in our history. There are messages for politicians and administrators within the system. The primary, fundamental message is that we must care for vulnerable persons, particularly the elderly who are unable to look after themselves.
I welcome the Minister of State and I listened with great interest to his speech. I approach this with some degree of schizophrenia because for part of my life I was an ombudsman and in another incarnation I was secretary in the Department of Health. I have a rough notion of what happens on both sides of this counter. This is a model ombudsman's report. Any ombudsman anywhere would be proud to have produced it. I will discuss three aspects of it; the mechanics, the relationship between the different parts of Government and the Administration and the policy.
I congratulate the Minister of State on his response today. It is characteristic of him that he does not try to defend the indefensible and when in a hole he stops digging. Much of what he told us today goes a considerable way towards addressing some of the points I would have made had he not spoken. I am glad he takes the equitable view, and does not hide behind legal advice, in extending compensation to all concerned. The important thing about an ombudsman's report is that it takes the individual case, looks at how the administration handled it and then seeks to have it put right.
It is important that the people who are disadvantaged in any degree by maladministration or poor administration are compensated to the extent that they can be. I do not think anybody can express compensation for the agony, grief, worry and annoyance they had. We also need to look at how the system works to see where it went wrong and what we need to do to improve it. A matter addressed by implication, rather than directly by the Ombudsman is the policies and the extent the activities of the various agencies show that the policies are either incomplete, imprecise, outdated or wrong.
One thing we must recognise coming through in the report which is moderate and neutral in tone, is a certain degree of impatience. It can be seen that as far as the Ombudsman was concerned, dealing with the Department was like drawing teeth. That is not good enough. An ombudsman, who is a servant and officer of the Oireachtas, should not have to go through that sort of thing. There must be machinery which enables replies to be obtained more quickly and we must require Departments and their boards to take ombudsmen inquiries seriously. This must be done out of respect for the Ombudsman and more importantly out of respect for the people who have been disadvantaged.
The Ombudsman asks us not to forget the central message and I agree with Senator Keogh that the central message is how people are treated in society. People are entitled to be treated with dignity and not be required to become suppliants or mendicants. One thing we take from it is that it is agreed that it is not a matter of looking for scapegoats. We must ensure that a system seen to be fallible is corrected and made to work better. I have some sympathy for Ministers in a case like this because the umbrella of ministerial responsibility tends to cover all and a Minister cannot be held to account for everything that goes on in a Department. The genesis of the office of ombudsman in Ireland was the Devlin Report which said policy, which is the Minister's business, could be separated from the Executive. It was because of that separation, which it was held would produce greater efficiency and managerial control, that the Ombudsman was seen to be necessary. The Ombudsman's function is to see that the machinery is working. We should look more often at ombudsmen's reports and I suggest we have a committee on the Ombudsman which would receive reports from him periodically on all Departments. The Ombudsman then could come to the committee in cases where he perceived obstruction or dalliance.
One important note in the report relates to the danger of Departments and their agencies changing or attempting to change the law as laid down by the Oireachtas. That brings in the question of defining or narrowing things by secondary legislation or even by departmental circular. We must protect the public and the Oireachtas against that. The Ombudsman suggests the extension of the process of affirmative resolution which might actually have the effect of gumming up the works. In some other legislatures I was involved with they did have a person called the Examiner of Statutory Rules. His job was to examine these matters and report annually, pointing out where Departments had enacted rules which were rather ultra vires or which distorted the intent or were beyond their own powers. Now that we have an independent legal adviser for the Oireachtas it may be a role for that person.
Another problem the Ombudsman underlines is that if through the law we give people statutory entitlements then those should be their entitlements. The implication should be that the Oireachtas as well as willing the end also wills the means and provides the money. The whole question of tracking money through Departments and health boards is difficult and complex but must be tackled. It seemed odd to me that some health boards even when they were given money by the Department to pay compensation, used the money for something else. It should not be a lottery. Entitlements should not depend on where one lives, or under which health board's regime one comes. We need consistency. These are issues the committee would look at but I would like it also to look at the policy implications of what the Ombudsman's report discloses. He says he is neutral on policy which is the classic position of ombudsmen. I am not sure that he is or that he should be. If you read the report carefully, it is quite clear that there are deficiencies in policy.
The Department and others could be faulted for maintaining and continuing to develop policies which are clearly out of kilter with social and demographic movements. It is based on a late-Victorian concept of the family, on a society where the average life expectancy was probably about 60 years instead of in the 70s as is the case now. It ignores the extent to which elderly people, thank God, are living longer. Two cases are particularly pathetic. One concerns a person of 95 years and the other a person of 89 years. In both cases, the health boards were looking for subventions from the adult sons and daughters. What age do you imagine the sons and daughters were?
We have an enormous problem of elderly people being cared for by those who are themselves elderly. We have maintained a care system through exploitation of the children of the elderly. In particular, we have exploited the female children of the elderly. One can see the number of elderly ladies who have dedicated their whole lives to looking after parents because no one else in the family would do it. Our policies as enunciated do not take sufficient account of social mobility, changing habits and social mores.
In the economic sense, there is a very strong argument for making nursing home care for the elderly as freely available as possible and as free as possible. If this is not done, elderly people will simply become more infirm and ill and will need hospital care, and hospital beds will be used in a much more inefficient and expensive manner.
Behind all this is the message of how this society values people who have made a contribution to it in many ways. These are people who have built this society by paying their taxes and they are entitled to be treated with dignity, care and compassion. Sadly, as shown in the Ombudsman's report, this is not so in every case, but we should find ways of making it so.
I am glad my colleagues have placed this matter in a human context and put on the record their own family experiences. My closest relative was an aunt who died six months ago in her one hundred and third year. I moved into her house for five years to keep an eye on her. We had a very happy relationship but, eventually, she started to fall and that was very dangerous. I would come home and find that she had been on the floor for an hour. She was a ruthlessly practical person and she said that she wanted to go into a home. The very phrase " a home" sends a shudder down any person who loves an elderly parent or aunt. We were very lucky to find the Alexandra Guild House, of which I cannot speak highly enough. It was initiated by the old girls of Alexandra College and run by a committee. It had a matron and properly trained staff who did their own baking. It was an intensely human situation.
There were difficulties at first in obtaining a place for my aunt but I wrote to the home and asked if this was because she was too old – some homes will not take in people on the basis that they are perceived to be too old. What happens to people in that case? I wrote and asked them to reconsider because my aunt was very upset. I offered to be of assistance to them at any time. My aunt had stayed there for periods when I was abroad. Two letters were written back, one to my aunt offering her a place and the other inviting me to meet the board. The home was in difficulty and was on the point of closing down and I was able to use the resources of the Oireachtas to help them.
I wish to make the point that programme managers have been attacked from time to time. The programme manager for the Department of Health at the time was Anne Byrne, and she and the staff of the Department of Health were absolutely marvellous. The salvation mechanism for the home was triggered and a wonderful resource was saved, with the result that 30 elderly ladies were allowed to live out their lives in dignity in a really human environment.
I have seen some of the other homes, which were dark, miserable and cramped. We should encourage better conditions. Homes like the Alexandra Guild House are better than State-run institutions because they have an ethos and motivation. It is in the economic interests of the State to support them.
I wish to make one comment about the Minister's speech. Senator Keogh said that she admired the Minister for coming out with his hands up, but he did not. The hands up were of every other Fine Gael or Labour Minister for Health that he could find, and they were the ones named in the report.
The report is very significant in a number of areas. Broadly speaking, two questions were considered: first, whether there was an entitlement to assess the means not just of the person seeking this care, but of their immediate family and, second, was the question of pocket money. We should be careful about our use of language. How demeaning it is to even say "pocket money". These are people who have worked and raised families and are in their 70s, 80s and 90s. I would hate to be getting pocket money at that age. I am 55 years of age and it is a long time since I got pocket money. I would not be grateful to anybody for patronising me by offering me pocket money.
What concerns me, and it should concern this House, is not alone those particular issues, which have been superbly addressed in the Ombudsman's report, but that clearly the unambiguously expressed wish of the Oireachtas was deliberately and knowingly frustrated by agents of the State. That worries me because that is an attack upon democracy. It was not done unknowingly, it was done in the light of repeated advice which had been sought by the health boards and the Department. They knew exactly what they were doing. They were robbing the most vulnerable people in the State. That must not be allowed happen again.
The report addresses this matter. It states that when the Oireachtas delegates to a Minister or to some other authority the power to make regulations, the delegation given is very specific – what is being delegated is the authority to fill in the details where the main lines have already been spelled out. Such regulations should not contain anything that is not clearly envisaged in the parent Act. In that sense, regulation-making, or setting a regulation as it is sometimes known, is an exercise in realising the intentions of the Oireachtas. It is not an exercise in realising the intentions of the Minister or other authorities to which the delegated powers have been given. Anything in a regulation which is not demonstrably in line with the intentions of the Oireachtas is likely to result in the regulation being deemed ultra vires and struck down in the event of a legal challenge in the High Court. The various agencies involved, therefore, were repeatedly advised. That worries me because it is an attack on democracy.
Let us look at the specific complaints. An enormous number seems to have been generated in the past ten years because of alterations. The question of the equation of in-patient services and residential care in nursing homes was raised. Very clear legal guidance is available. I refer to the decision of Henchy, J. in 1976, in the matter of Maude McInerney, a ward of court. The judge held that there was a specific, clear and absolute equivalence. This has been known since 1976, yet since 1990 an increasing number of complaints have been generated. There were financial constraints which need to be considered.
During discussions with the Ombudsman, the Department indicated that it would need to amend section 51 of the Health Act, 1970, which defines in-patient services, to exclude nursing home care from entitlement. Pending an amendment of the Act by the Oireachtas, the Department said it would look seriously at the possibility of amending section 51 by way of regulation. Ombudsman staff pointed out that any such attempt to restrict an existing entitlement by way of regulation would most likely be invalid ultra vires the Act. Nothing could be clearer. Senator Maurice Hayes, who was once an ombudsman, made an excellent contribution in paying tribute to the report. He used the phrase “late Victorian versions of the family”. There is something Dickensian about the atmosphere here, and I do not mean that in a complimentary or flattering light.
In ideal circumstances, families would support their elderly relatives. My aunt decided it was not in her interest to stay with me – we do not have an extended family – but I visited her every day. I would have been happy to contribute, which is not true of everybody. A parent would be humiliated to hear an outside body saying that their son or daughter ought to be paying for them. It would insult the parental role. The parent may already feel humiliated by the fact that their child is not paying. There is a moral responsibility to look after one's parents in such circumstances, but there is no legal responsibility whatever.
Page 25 of the reports states:
Despite numerous reminders, Mrs. T..'s son J.. failed to provide the information needed to ascertain his disposable income, and we were obliged to base our assessment on best local information. He runs a business. J.. was assessed as having a minimum disposable income of £32.41 per week. If, of course, J.. does provide the necessary information we would review the case again.
It is none of their business. What is this best local information? Does it mean that they applied to the neighbours to find out how much money they had? That is simply appalling. Children ought to help to support their parents if they are capable of doing so, but we cannot have big brother poking his nose in. The Eastern Regional Health Authority, through the agency of the very effective advocate, Maureen Browne, supplied me with three examples to show that it behaved in a more decent and humane way in a number of instances, although it is not entirely immune.
It is important to say what the conclusions of the report were. The Health (Nursing Homes) Act, 1990, does not make children legally responsible for parents' hospital or nursing home costs. There is nothing in the Act to suggest that any such liability was contemplated by the Oireachtas. Regulations cannot impose a liability on adult children which is not explicitly provided for in the 1990 Act. The definition of 'circumstances' as originally provided in the regulations is likely to have been invalid as it cannot be said that it was authorised by the Oireachtas in the 1990 Act. The practice of determining and assessing a level of contribution which an adult's son or daughter should be capable of making towards a parent's nursing home costs was invalid, even where such an adult son or daughter is willing to make some level of contribution. The approach to the regulations in regard to family assessment was fundamentally misconceived.
The report's analysis is entirely neutral as to whether it is desirable that an adult son or daughter should be liable for a parent's hospital or nursing home costs. This is a question of public policy which should be dealt with by the Oireachtas. It is an open question, according to the report. I think it remains a moral obligation which many decent people would fulfil. It is obviously not legally enforceable.
Regarding the issue of moneys allowed to be retained by elderly people, the report states that the Ombudsman does not accept that Article 8.2, in its original wording, was unclear in its meaning or its intended application. This article was amended with effect from 1 January 1999, osten sibly to clarify whatever was allegedly unclear in the original version. The amended version, provided for by statutory instrument 498 of 1998, is as follows:
A health board, in assessing the means of a person in respect of whom a subvention is being sought under these regulations, and in calculating the amount of subvention to be paid in accordance with the regulations, shall ensure that income equivalent to one-fifth of the weekly rate of the old age non-contributory pension payable at the time is disregarded for the purposes of such assessment. Such sum is to be retained by the person for his or her use.
That is reasonable. I cannot find the figures, but I think the discretionary amount was about £2.50 per week. Such an amount for adults, many of whom raised families and worked for 40 or 50 years, would not buy a packet of cigarettes. In many city centre pubs it would not buy a pint of stout. They are allowed one seventh of a pint of stout, or one cigarette per day, as pocket money. Any parent who attempts to inflict £2.50 as pocket money on a teenager would have it rapidly flung back in their face. The elderly deserve better.
I have made criticisms, but they should not be personalised. We should not persecute people in the Department of Health, with whom I have had good experience. We would not have a report on this sensitive issue without the co-operation of personnel in the Department. The report deals with a particular kind of nursing home, which seemed to prefer genteel people from a nice background. They were probably terrified they would have nonagenarian heroin addicts. The matter was extremely sensibly handled and I am grateful for that, but for the sake of elderly people, we should take on board the recommendations of this report. We should recognise people's humanity and needs rather than dealing with them by administrative regulation. If we are lucky, we may attain the status of old age. A civilised society treats its vulnerable people with sensitivity.
I pay tribute to the journalists who, with the Ombudsman, exposed this matter. I first came across this in a Sunday Independent article. It was followed up by an article by Fintan O'Toole, who can be very good but sometimes irritates me. We owe them a debt for bringing this into the public light.
I would like to refer to an article in the Irish Social Worker by journalist Ann O'Loughlin in which she says there should be no doubt that elderly people in need of long-term care are among the most vulnerable to confront any social worker advising people about the subvention form. More recently, the daily grind of many social workers has included writing begging letters seeking extra money to meet the ever widening gap between private care costs and what elderly people can afford.
I hope the debate raises the profile of this vulnerable group and ensures that we never again treat them in this niggardly way. We must never again allow a situation where agencies of the State treat the clearly expressed will of the Oireachtas with the degree of contempt that was expressed towards its legislation on this matter.
I have not had the chance to read the Minister's address because only nine or ten copies were produced. We should ensure all Members addressing the House have a copy prior to their remarks. The Minister has a duty in that. I am not sure if the Minister came out with his hands up, or if he came out with every other Minister's hands up, and in what manner he responded to the report.
This document makes pretty pathetic reading. We have waited 11 years since the passage of the nursing homes subvention legislation in 1990 to get a report and a true picture of the total inadequacy of the service provided, the demeaning and illegal way in which elderly people who were cared for within this service, and their families, have been treated, and the lack of accountability and transparency. It has required the intervention of the Ombudsman, who must be thanked for this report, to bring our attention to how dire the situation is.
The opening words of the report deal with the payment by health boards of subsidies or subventions to patients in private nursing homes as provided for in the Public Hospitals (Amendment) Bill, 1990, and says that the majority of these patients are elderly people, by definition unable to care for themselves or to be cared for at home by their families.
This is the vulnerable category of people we are talking about and it is sad that so many regulations and so much bureaucracy surrounded the operation of these nursing homes. It is a euphemism to call them homes, because people gained admission with great difficulty, they were allowed to remain on with difficulty, and their families had to make a substantial financial contribution, as the health boards were able to elicit.
Recently, a client in my constituency visited me concerning an 85 year old family member resident in private care in Beaumont nursing home. This patient was admitted to the home five and a half years ago with a subvention of £220. Costs have escalated since then, but the health board has refused to increase the subvention by one penny despite the pension of the senior citizen going toward their contribution. With inflation and the rising cost of living, the cost to the family has almost doubled over that five and a half year period. The reason given for the increase to the family was that that this patient owned her own home which is considered an asset. The family have had to let her home, earning £600 per month. That sum, in addition to the patient's pension, goes toward the cost of the nursing home and the family contribute the rest. The total cost has now gone up by £370 per month.
That is the type of story which informs this report. Under the State system a person is entitled to be dealt with by the health board, yet this entitlement has been treated as a privilege by health boards, and responsibility in terms of remuneration and costing has been passed over substantially to family members, who in many cases are unable to contribute. The health boards, including what is now the Eastern Regional Health Authority, are not ogres, so why are they doing this?
The ERHA has circulated most Members with documentation claiming that they are not as bad as some other health boards of whom the Ombudsman was more critical, but there is no doubt that they were in breach of regulations. When it was brought to the board's attention that family members had complained at inclusion in assessment for the subvention, it then declined to enforce payment for that assessment. That is hardly a wonderful concession on the health board's part, as it did not have the entitlement to look for that money in the first place.
The EHRA has sought to reduce their culpability by presenting Members with some response to the document, and I would like to see a response from the other regional authorities also. The health boards are not ogres and do not try to harm people or remove their dignity in an organised fashion, though that might be thought from the number of regulations. The response by the health board focuses on funding constraints and inadequacies. A short piece from that response, entitled "The failure of responsiveness and accountability", says that in all its contacts with the Ombudsman's office from 1992 onwards, the Department made it clear that the health board's capacity to meet its obligations to people in need of nursing home type care was severely curtailed by the inadequate finances available.
That is the nub of the problem. The health boards have tailored their finances to get the maximum number of bed-places in nursing homes and have tried to enforce additional costs on family members of patients, causing an enormous burden. A similar burden has been created by the practice of retaining much of the so-called pocket-money that individual elderly patients should be entitled to.
The report has an effective acknowledgement by the Department of Health and Children that it is failing in its obligations to people in need of long-stay care. It recognised that the subvention scheme was a cheaper option than that of meeting people's statutory entitlement to long-term care. Notions of entitlement and legal propriety were not in evidence on either side of this dialogue. Entitlement and legal propriety were left out. This is the Department of Health and Children's reply to the Ombudsman: the State is currently unable to meet the demand for long-stay places. This is an indictment of the State's contribution to dealing with the elderly. If the nursing home legislation became unworkable, the State would have to pick up the pieces by means of huge capital investment for the provision of new long-stay accommodation for elderly people. The capital cost alone would be well over £200 million.
Since the Act commenced on 31 December 1996, 10,106 people have been approved for a subvention. Of this number 5,639 people are being paid subventions at a cost of £17,124,000. According to the Department's reply, the State could not support that many people in health board long-stay units, assuming those units existed for £17 million per year. That is the value that the State and the Department of Health and Children have put on the elderly. All it has contributed in subvention since 1992 is £17 million and it would have needed an extra capital cost of £220 million, presumably to provide the premises for the nursing homes, if it had not availed of the private subvention system. Is it not incredible that it says there is no way the State could have provided it? It is less than £2 million per year to cover subvention for the 10,000 people listed there. The capital cost would not all have been provided at the same time.
Clearly this report is extremely damning. It is a failure most of all to provide funding to take care of the elderly and without the funding we get the Dickensian system that the Senators have been describing. The system has demeaned the people being care of and their families. It has not provided a service that is in any way adequate. We should not have to wait this long to deal with the suffering of so many vulnerable people. If the accountability mechanisms were in place, then we would not have a crisis showing up in a report such as this. There would be no need for the Ombudsman's report if accountability and the finances existed. Arising from this report we must decide how to deal with the growing number of elderly people. We must look beyond just the nursing homes response. We have to look at the family response within the community and what support mechanisms can be put in place to assist the family.
In 99% of cases, the person will not end up in a nursing home unless the family is unable to take care of that person. Normally the family would make provision in the community and in the family home if the facilities were there and if the funding were available in a different, more supportive fashion. The carer's scheme has always been a penny pinching. It has always been very difficult to have that scheme extended to assist the family members in dealing with the elderly.
We are airing our concerns on nursing homes but the response rests with the Department of Health and Children, the Government and the Minister for Finance. We must ensure we are not beset by concocted regulations with no standing in law simply because health boards tried to get as many bed places as possible with totally inadequate finance.
I join with others in welcoming Minister of State at the Department of Health and Children, Deputy Moffatt, to the House. We all agree that it is a very damning report. The health boards, both systematically and quite unlawfully it would appear, have taken money from the families of elderly people who had the basic need to be cared for in old age. We all hope that, when we reach that stage, the services will be there to look after us. For once, I agree with quite a lot that Senator Costello says. However, when this scheme was introduced £4 million was provided for the subvention and this year £53 million is expected to be spent on it. While there are many criticisms of the subvention scheme, it is important to note that efforts are being made. I welcome what the Minister has said on paying back the arrears, the pocket money and so on. I welcome the increase in the subvention in April 2001 because we all recognise that nursing home costs have increased considerably in the last couple of years but the subvention has not.
Often a dictionary is needed to understand a report but, in this case, I commend the Ombudsman for such a straightforward report. I do not mean that in a condescending or patronising manner. Unfortunately it is quite damning and makes dreadful reading in parts but it is easily understandable. It is clear what we need to do to improve the system. There are individual cases in the report of elderly people, some suffering from Alzheimer's disease, who could be put out of the nursing home within a week because they cannot continue to pay. There are other cases where a person's spouse dies before they get paid back by the health board. It is very sad that the service has dropped to that level.
I have criticisms of health boards, and my own one in particular, but we are all accountable. In my short time in politics, I have had many cases where individuals have been put through the wringer trying to provide statistics, data and income details to show that their parents should be entitled to subvention in a nursing home. The Ombudsman's report states that health boards were using local knowledge to determine if people had means other than they claimed. We all know neighbours who, we think, are millionaires and wonder how they made their money. Local knowledge is one thing but we need to take a more humanitarian view of these people.
I like my colleagues have made numerous representations to health boards on behalf of individuals. However, if people are refused subvention and I have gone as far as I can go, all I can do is apologise. This report makes me aware that the regulations were flouted. We all have criticism of our own handling of cases. I take no credit for what I have done. I told people that they are not entitled to subvention and nothing further could be done. It may appear callous but that is what I believed.
I welcome this report. We can improve the situation. The report highlights many damning points. It highlights the relationship between the legislators, State agencies and the people who implement the laws. We discussed underage drinking this morning and it was stated that laws are not being enforced in that area. Right across society, laws are ignored and unenforced. It is a feature of our society that laws are made to be ignored. The fundamental issues regarding homes for the elderly are what are the laws, how are they implemented and how much accountability is there.
The greatest scandal is the failure of the health boards to alter practice after getting legal advice that it was wrong. There was an attitude of "get away with it if you can". The Minister allocated £4 million in 1998 to pay the health boards' arrears. Six out of the eight health boards diverted the funds, we are told, to other aspects of care of the elderly, but they ought to have used the money as it was intended.
We are accountable to those who elected us. This is an age of openness, accountability and transparency, but health boards appear to be able to operate to suit themselves. I know from my own health board that despite promises or obligations, it can do what it wants. Health boards and other agencies empowered by the Oireachtas to provide services must be accountable. The problem is how to achieve this.
Senator Costello talked of the lack of resources in the 1990s but the health service's resources have more than doubled in recent years. Speaking of my health board, of which I am somewhat critical, I wonder is there increased accountability. The public, particularly in Cavan and Monaghan, feels that the more resources there are, the less accountability, and that more staff are appointed to administer the funds. This must be addressed. It is like pouring water into the sea. The Department of Health and Children, we as legislators and the agencies we have empowered must be more accountable. Greater resources make it more difficult to keep account of money, but the administrative staff in health boards must be accountable.
The Minister in his speech addressed standards in residential homes. The number of people over 65 will increase from 400,000 now to more that 750,000 by 2020. Within that age group there will be people living beyond each age cohort. The number of citizens dependent on the State and in private nursing homes will double. This will make an impact on the Exchequer. It is proper that we debate what should happen in future.
There is no national inspectorate to examine standards in residential homes. Each health board designates people who also have responsibilities enforcing environmental legislation, looking after children's needs etc. We need a full-time professional inspectorate separate from the health boards under the Department of Health and Chil dren. The same standards must apply everywhere. Random visits should be conducted by a team of professionals – a doctor, nurse, dietician, engineer and others. Every aspect of nursing homes should be inspected. They are not inspected twice a year as required by law because the health boards do not have the staff.
We would not have this debate were it not for the Ombudsman's report, which I welcome. We need an ombudsman for senior citizens. In New Jersey, USA, the staff of the ombudsman for senior citizens visit nursing homes and talk to the residents. They discuss issues relevant to them and deal directly with the management. Here, we give the subvention and, apart from the occasional visit, do not participate. We only know what is happening from reports of inspections of nursing homes. The majority of homes are excellent but a minority are not. These reports should be readily available. They can now be obtained on request. If someone is considering placing a relative in a home, the report on that home should be accessible on a website. Reports should be on display in the nursing home and residents and relatives should receive copies of each report. We require transparency and honesty in this area, but that is not always the case.
I understand a report received yesterday states that while Ireland has a mild winter compared to the rest of Europe, the numbers of senior citizen deaths are significantly higher than the European average. I understand research indicates that the critical factor is internal temperature within the home or, in this case, the nursing home. Is it reasonable to expect patients in a private nursing home to be in a room with a temperature of 11.9 degrees or 12.5 degrees instead of 18 degrees, the minimum permitted? Is it fair that following the inspection of a nursing home, which I will not name, in the North Eastern Health Board on 8 December, the report of the visiting doctor stated that the temperature in 50% of the bedrooms and day areas was below the minimum permitted? The nursing home in question was in breach of the Act from last May until 21 January this year. That is unacceptable.
How does one enforce the regulations? They are not rigidly enforced because there is no proper inspectorate. I would condemn any regime, whether operated by a health board or privately, where, when issues such as significantly reduced temperatures are brought to the attention of the statutory and nursing home authorities, a minimum period of, say, two weeks is not given to put the matter right. If it is not put right, there should be an immediate prosecution and the health board should take over the running of the nursing home until it is put right. It is shameful and disgraceful that that has happened. It both shocks and concerns me. It is unacceptable to find, as I did at 4.30 p.m. on 17 December, a subvented patient in a private nursing home wearing two jumpers and day clothes in bed to keep warm. That is an indication of how low standards can be in places.
In many nursing homes standards are very high. It is incumbent on the Minister not just to ensure minimum standards, but best practice, to which every nursing home should aspire and which people have a right to expect. Unfortunately, the situation in the case mentioned is unhelpful. The regulations and rules are worth nothing when such practices are allowed to continue month after month.
It is shameful the way our senior citizens are being treated. We are, effectively, walking away from the issue by ignoring the plight of our senior citizens. There must be a vigilant and positive interaction between the health boards and both private nursing homes and State-run geriatric institutions.
The following questions must be asked about private nursing homes. What level of care is available? What physiotherapy and occupational therapy services are available? Who is looking after the chiropody service? Is there any investment in these services? There is a need for a root and branch reform of what is on offer to senior citizens not only in private nursing homes, but public nursing homes.
If senior citizens are dying because of a lack of heat in their homes, why does the Minister not change the regulations applicable to the disabled person's grant? A sum of £14,000 is available to disabled persons, including those who suffer from arthritis. With such a sum one could build an extension to a three bedroomed house in which a senior citizen is living alone. Why can the Minister not provide a grant of between £2,000 and £3,000 to install central heating in such homes? The senior citizens concerned do not want a big extension. They want to have their shower and toilet located downstairs, but first they need to install central heating. While money is available, it is not being used in the right way.
I am not solely blaming the Government. While we all have a part to play, we are not doing our best. The report is a wake-up call to the State and the nation. We must do a great deal more for our senior citizens, but we are not concentrating on the issue. Apart from young children, those most at risk and who have most to lose, most of all their lives, are our senior citizens. We need to take a hard look at the issue.
I thank the Chair for giving me latitude. I hope we will have a comprehensive debate on services for our senior citizens. This debate is confined to nursing home subventions. In a modern state in the new millennium, our services are disgraceful and unacceptable.
I thank the Senators who participated in the debate and, like the Minister before me, take this opportunity to express my apologies for the adverse effects caused to familes by nursing home subvention.
The Ombudsman does not issue too many reports, but when he does we are obliged to look carefully at what he has to say. Each Member of the Oireachtas since 1993 must accept some responsibility for his findings. While there were mitigating circumstances in the late 1980s and early 1990s regarding funding for nursing home subvention, despite what has been said recently, great strides have been made, particularly in the past three years, in the provision of services for the elderly.
We introduced a statutory instrument on 1 January 1999 which deals with two of the issues involved, that of pocket money and the assessment of family income, which has now been taken out of the reckoning. I accept that we must make moneys available to make up, retrospectively, for what happened. We expect the scheme, which initially cost £4 million per year, will cost £52 million this year. We have also put in place a capital programme under which £200 million will be spent over the course of the national development plan on services for the elderly.
Our main aim is to treat the elderly in their homes where we would like them to remain in appropriate settings for as long as they can. That will require a great deal of expenditure on community care, a matter at which the Government has already looked. For every pound spent on hospital care one pound will be spent in the community under the national development plan.
We are encountering difficulties in providing physiotherapy, occupational therapy and speech therapy services. While we have catered for those who look after elderly persons in their own homes, a great deal more remains to be done.
The Ombudsman questioned severely our analysis and how we look at primary legislation, whether it is scrutinised properly in the context of the regulations made thereunder. Even though provision is made for such regulations to be laid before both Houses within 21 days and everybody should have an opportunity to make their views known, this has not been happening in practice. I am glad that the report is being referred to the Joint Committee on Health and Children, where it will be teased out further.
An assessment of the subventions payable is being conducted by Dr. O'Shea in Galway, the findings of which we expect to receive shortly. We also are looking at the matter of elder abuse, on which we will also receive a report. It is not true to say, therefore, that we are not making progress on care of the elderly. While we are providing a great deal of money, money will not solve all the problems. There are many issues about which we can learn.
I thank the Senators who participated in the debate. It is through debates such as this that we will learn more and take due cognisance of what an independent person such as the Ombudsman has to say about such matters as care of the elderly.
When is it proposed to sit again?
At 2.30 p.m. on Tuesday next.
