Health (Nursing Homes) (Amendment) Bill 2006: Second Stage.

Question proposed: "That the Bill be now read a Second Time."

Minister of State at the Department of Health and Children (Mr. S. Power)

I am pleased to have the opportunity to introduce to the House today the Second Stage of the Health (Nursing Homes)(Amendment) Bill 2006. Government policy in relation to older people has long been to support them to live in dignity and independence in their own homes and communities for as long as possible and to support appropriate long-term care where this is no longer possible. It was for this reason that the nursing homes subvention scheme was introduced in 1993. The aim of this scheme is to provide financial assistance to older people towards the cost of maintenance in a private nursing home. The Bill is designed to ensure that the existing subvention scheme for private nursing home care is grounded in primary legislation, and it will also help the Health Service Executive to implement the scheme on a standardised basis across the country.

Before getting into the detail of the Bill, I want to outline some of the major developments that the Government is pursuing to improve services for older people. It has been the policy of successive Governments to endeavour to help older people maintain themselves in the community — while at the same time providing for appropriate residential care, where living in the community is no longer possible. The policy of this Government as regards the development and delivery of services for older people is to maintain them in dignity and independence at home for as long as possible, in accordance with their wishes.

The last two years have seen an increased focus on services for older people, particularly in relation to long term care, whether residential or community based. Additional funding for services for older people and palliative care amounting to €150 million was allocated by the Government in the 2006 budget — an additional €110 million for 2006 and €40 million for 2007. As part of the budget yesterday, additional full year funding of €170 million — €120 million is for allocation in 2007 with the rest for 2008 — was announced to improve services for older people and palliative care. This is the largest ever annual increase in funding for older people and clearly shows the Government's commitment to improving the quality of service provided to older citizens.

Approximately two-thirds of the money announced in 2006 was allocated to community support for older people. The announcement yesterday will continue this philosophy as the funding will provide for 2,000 additional home care packages, to benefit over 4,000 older people. The number of home help hours will be increased by 780,000 in 2007. An additional €3.5 million is being allocated to further increase day and respite care. This is in line with the focus on keeping people in their own homes, in independence and dignity, with proper health and social support systems in place in the form of home care packages, increased home help hours and increased day and respite care places.

Not every older person can, or wishes to, remain in his or her own home. Of the budget investment that I have outlined, €60 million has been allocated in 2007 towards the provision of additional long-stay care bed capacity, with a follow on cost of €22 million in 2008. This is a significant investment, ensuring that those who can no longer be cared for at home, for whatever reasons, have access to appropriate long-term care.

I now wish to briefly discuss the background to the subvention scheme. The nursing homes subvention scheme was introduced in 1993 on foot of the Health (Nursing Homes) Act 1990 and the subsequent Nursing Homes (Subvention) Regulations 1993, which were made under the 1990 Act. The purpose of the subvention scheme is to provide financial assistance to older people towards the cost of maintenance in a private nursing home. The scheme does not cover, and was never intended to cover, the full cost of private nursing home care. The 1993 regulations provide that a subvention can be paid to an applicant qualifying on both dependency and means grounds. Dependency is assessed according to an applicant's ability to carry out the tasks of daily living, such as washing and dressing. There are three levels of dependency set out in the regulations — maximum, high and medium, which are referred to in the Bill as categories I, II and III.

The maximum rate of subvention that may be payable to a person is determined in the first instance by his or her level of dependency, and the current maximum rates of subvention, as set out in the regulations, are €114.30 per week for a person of medium dependency, €152.40 per week for a person classed as high dependency, and €190.50 per week for a person at the maximum rate of dependency.

Once a person's rate of dependency has been determined, the HSE then carries out a financial assessment of the applicant which takes into account the value of his or her income and assets, subject to certain exclusions as outlined in the regulations. The appropriate level of subvention to be paid is then determined, based on the level of dependency and the outcome of the financial assessment of the applicant, and may result in the maximum level or a reduced level of subvention, as appropriate to that dependency level, being paid, or indeed no subvention being paid. Where a person is married or cohabiting, the means assessment is based on half of the combined means of the couple.

The Health Service Executive has the discretion to pay an enhanced rate of subvention, over and above the rates I have just outlined, in a case, for example, where personal funds are exhausted. This discretion regarding individual cases is a matter for the HSE. The average rate of subvention paid by the HSE generally exceeds the current approved basic rates.

As previously stated, the subvention scheme is provided for in the Nursing Homes (Subvention) Regulations 1993 at present. These regulations, which are made under section 7 of the Health (Nursing Homes) Act 1990, outline the scheme in detail, including such matters as how an application should be made or determined, how to appeal a decision made under the scheme and so on. Legal advice received from the Attorney General has indicated that new primary legislation is needed to underpin sufficiently the principles and policies of the scheme.

Sections 6 and 7 of the Health (Nursing Homes) Act 1990 were amended by section 3 of the Health (Miscellaneous Provisions) Act 2001. The purpose of this amendment was to incorporate principles and policies into the 1990 Act that would facilitate the making of new subvention regulations under the Act. However, the available legal advice indicates that section 3 of the 2001 Act does not adequately provide for the making of regulations under that Act. Consequently, section 3 of the 2001 Act has not been commenced and this section will fall on the enactment of this Bill.

The Ministers for Health and Children and Social and Family Affairs established last year an interdepartmental group to examine the entire subject of long-term care for older people. The group included senior officials from the Departments of the Taoiseach, Health and Children, Social and Family Affairs and Finance and was chaired by the Department of the Taoiseach. The group had a number of reports available to it, including the Mercer report on the future financing of long-term care in Ireland, which was commissioned by the Department of Social and Family Affairs. The group also considered Professor Eamon O'Shea's report, Review of the Nursing Home Subvention Scheme, commissioned by the Department of Health and Children. Both reports were published in 2003.

The group reported to the Government earlier this year and, consequently, the Government is considering policies on long-term care for older people. Several principles underlying this policy were agreed with the social partners in Towards 2016. For example, these principles specify there should be a single standardised national needs assessment for older people who need care. Moreover, the use of community and home-based care should be maximised. When required, residential care should be of a high quality and there should be appropriate and equitable levels of co-payment by care recipients based on a national standardised financial assessment. The level of support for residential care should be indifferent as to whether such care is provided in a public or private facility. The financial model to support any new arrangements must also be financially sustainable.

Consultation has taken place with the Departments of Finance and Social and Family Affairs, the Office of the Attorney General, the Office of the Taoiseach and the Health Service Executive in respect of the provisions contained in the Bill. There will be ongoing discussions with the relevant Departments regarding any developments or changes made in the area of services for older people, including any regulations to be made under this Bill. Naturally, discussions have taken place throughout the drafting of the Bill with the Health Service Executive, which has responsibility for the implementation of the subvention scheme.

The purpose of this Bill is solely to put the existing subvention arrangements on a sound legal footing and to underpin sufficiently the principles and policies of the current subvention scheme. I now propose to outline briefly the main provisions of the Bill.

Section 1 contains a minor drafting provision and simply will insert a heading into the Health (Nursing Homes) Act 1990. Section 2 of the Bill will amend section 2 of the Health (Nursing Homes) Act 1990 to specify that subvention shall only be paid to a person maintained in premises in which a majority of its residents are members of a religious order or priests of any religion if the premises are a registered nursing home.

Section 3 is the main section of the Bill. It will replace section 7 of the Health (Nursing Homes) Act 1990 by inserting the provisions of the 1993 Nursing Homes (Subvention) Regulations into primary legislation, after which those regulations will be revoked in the Bill. Given the length and amount of detail contained in this section, I propose to go through it subsection by subsection.

The new section 7 will define the various terms used in the Bill. Subsection 7A specifies that all dependent persons may make an application to the Health Service Executive, HSE, for a subvention. It specifies that making an application to the HSE is required and outlines the manner in which it must be made. It also provides for an offence in which false or misleading material is provided in a subvention application.

Subsection 7B provides that once the HSE receives an application for subvention, it shall arrange for an assessment to be carried out regarding the degree of dependency and the means of the applicant. The assessment to be carried out in this regard will be based on the applicant's ability to carry out the activities of daily living, such as walking and dressing. Other factors affecting an applicant's ability to care for himself or herself will also be taken into account, such as the receipt of medical services and family support.

The subsection provides that the person carrying out the assessment must be suitably qualified to do so in the opinion of the HSE and may or may not be an employee of the HSE. This will allow the HSE to arrange for suitable medically-qualified professionals, such as, for example, physiotherapists who are not employed directly by the HSE, to carry out such assessments. An amendment will be tabled on Committee Stage to reflect the change of names of the social welfare payments mentioned in this section.

Subsection 7B also provides that the HSE shall arrange for the means of an applicant to be assessed, either by an employee of the HSE or a person nominated in writing by the HSE. It provides that the financial assessment shall take into account all of the applicant's assets and sources of income, such as, salary, pension, savings, etc. It also provides that certain assets and income shall not be taken into account, including the applicant's principal private residence, where occupied by certain relatives as prescribed in the subsection, as well as the first €11,000 of the applicant's assets. When an applicant is married or cohabiting, the means assessment will be based on half of the combined means of the couple.

As for an applicant's property, where an applicant's principal residence is not continuously occupied by a relative as prescribed in the subsection, such as a relative whose sole income is the old age pension or a spouse, the HSE shall exclude 95% of the estimated market value of the principal residence from the financial assessment of the applicant. This means that an imputed income of 5% of the market value of the principal residence shall be taken into account.

The subsection further provides that the principal residence of the applicant will not be taken into account if that could give rise to destitution or homelessness of a person with a close connection to the applicant. This provision is to allow for exceptional circumstances and will generally apply in the case of a relative who does not fall into the categories prescribed in the subsection.

Subsection 7C outlines the basis on which the HSE will determine subvention applications, the amount of subvention payable and the grounds on which it may refuse to pay a subvention. This subsection also provides that the HSE may pay an enhanced rate of subvention, referred to in the Bill as an alternative subvention, when a person cannot meet the costs of care without undue hardship, the amount of alternative subvention having been decided after taking available resources into account.

The section also provides the HSE with discretion to refuse to pay a subvention if the value of the applicant's assets exceeds a certain threshold, or the applicant's principal residence exceeds a certain threshold and his or her income is above a certain level. Such thresholds were recently increased by way of the Health (Nursing Home)(Amendment) Regulations 2005 and the following thresholds apply at present. The threshold for assets to be disregarded for the purposes of subvention assessment is €11,000, the asset threshold above which subvention may be refused is €36,000 and the income threshold above which a subvention may be refused is €36,000. The threshold of principal residence value above which subvention may be refused is €500,000 or more when the residence is located in the Dublin area or €300,000 or more when the residence is located outside the Dublin area, when the income of the applicant is above the threshold of €9,000. The Dublin area is defined as Dublin city and county.

Members should note that while the threshold regarding income was not included in previous regulations, it has been added to this Bill for consistency. This section also provides that the HSE can, at its discretion, pay a subvention to the proprietor of the nursing home in question instead of directly to the applicant himself or herself.

Under subsection 7D, the HSE can arrange for a review to be carried out on the degree of dependency or means of a person who is in receipt of a subvention. When the HSE is satisfied the person no longer qualifies for subvention or qualifies for a different rate of subvention, it can arrange for the payment to stop or be altered appropriately and for notice of same to be sent to the applicant and the nursing home proprietor, if appropriate. When a person's subvention payment is being stopped or decreased, the HSE will not implement this decision for 60 days to give the person time to get his or her affairs in order.

Subsection 7E allows for an appeals mechanism against decisions made by the HSE in respect of an application not being considered because some condition of the application has not been met, the level of subvention to be paid, or a decision to pay a different level of subvention following a review.

The HSE must appoint a person to consider the appeal who may be, but is not necessarily, an employee of the HSE. The person must consider the appeal based on guidelines issued by the HSE. He or she must make his or her decision as soon as is reasonably possible and must send a copy of that decision in writing, together with the reasons for the decision, to the person making the appeal. A further appeal is also possible regarding the decision of the High Court, whose decision is final, except where a further appeal is made to the Supreme Court on a specific point of law.

Subsection 7F states that a nursing home owner must inform the HSE in writing of the death, discharge or permanent departure of a resident within 48 hours. This is to ensure that subventions do not continue to be paid in respect of persons no longer in the home. When a nursing home proposes to discharge a person, its proprietor must inform the HSE in writing 14 days in advance and must outline the reasons for so doing. The Bill provides for an offence where a nursing home proprietor does not fulfil his or her obligations in either of these situations. This subsection also provides that where a person in a nursing home starts or ceases to be paid a subvention, the Health Service Executive will inform that nursing home proprietor of this fact as soon as possible.

The new section 7G provides that the HSE may recover all or part of any payment or overpayment if the HSE is satisfied that an overpayment occurred or that the payment was procured through fraud or misrepresentation. The new section 7H allows the Minister to make regulations, with the consent of the Minister for Finance, on the rates of subvention payable, the amount of assets to be disregarded when assessing a person for subvention, the thresholds above which subvention may be refused, the percentage of the family home to be disregarded and the percentage of the spousal income to be assessed, as required. It provides that, when making regulations, the Minister will take into account the cost of living and nursing home care in the State and the rate of inflation, as appropriate.

The rates of subvention payable relative to a person's degree of dependency are also laid out in this section. This section provides that the Minister will only make regulations on the rates of subvention after taking into account available resources and the prevailing cost of nursing home care for persons falling under the various dependency categories. It also provides that the maximum rate of subvention that may be payable to a person, based on his or her level of dependency, is reduced by the amount by which the person's means exceed the weekly rate of the old age non-contributory pension, or State pension as it is now known, payable at the time of assessment. This represents no change from current practice. This section outlines the basis on which it is decided whether a person falls under one of the categories of dependency — category I, II and III of dependency, otherwise known as maximum, high and medium dependency — based on such factors as the person's degree of mobility and the extent to which he or she is confused or disturbed.

The new section 7I provides that where a person is in receipt of subvention immediately before the passing of this Bill, he or she will continue to receive a level of subvention equivalent to what he or she received prior to its enactment. However, the HSE may still carry out a review of the degree of dependency and means of any person in receipt of subvention at any time and may discontinue paying subvention or pay a different level of subvention if the review shows that he or she is not being paid the correct level of subvention. The new section 7J provides for guidelines to be issued by the HSE to provide practical guidance in respect of the provisions of the Bill and how the subvention scheme will work, for example, the process to be followed to decide the amount of subvention to be paid to an applicant.

Sections 4 and 5, like section 1, are minor technical provisions which insert a heading into the Health (Nursing Homes) Act 1990. Section 6 replaces section 14 of the Health (Nursing Homes) Act 1990 with a new section, which provides that regulations will only be made after a resolution approving the regulations has been passed by both Houses of the Oireachtas. At present, regulations are made before being laid before both Houses of the Oireachtas, which can subsequently annul them.

Sections 7 to 10 also contain minor drafting and technical provisions. Section 7 repeals section 3 of the Health (Miscellaneous Provisions) Act 2001. Section 8 amends Schedule 7 of the Health Act 2004 by deleting item 6 in Part 4, as this item updates a section of the 1990 Act that is being replaced under section 3 of this Bill. Section 9 revokes the 1993 Nursing Homes (Subvention) Regulations, as the provisions contained in those regulations are now contained in the Bill. Section 10 amends section 2 of the Health (Repayment Scheme) Act by replacing section 3(10)(c) with section 3(10) in the definition of “spouse”. This is a technical provision. Section 10 also contains a provision relating to commencement. Section 11 cites the Short Title of the Bill and cites the Health Acts of 1947 to 2006 collectively as the Health Acts 1947 to 2006.

At this stage, I want to speak briefly about the Health (Nursing Homes)(Amendment) Bill in the context of other developments and legislation ongoing at this time which are related to services for older people. The Health (Repayment Scheme) Act 2006 came into effect on 30 June 2006. The repayment scheme was launched publicly by the Health Service Executive, HSE, and the scheme administrator, KPMG/McCann Fitzgerald, on 14 August 2006. A national advertising campaign and a helpline also commenced on this date.

The HSE has informed the Department that more than 22,000 forms have been submitted to the scheme administrator applying for repayments and these applications are being processed at present. The timeframe for payment is predicated primarily on whether the applicant is alive or whether the application is being made by a family member or the estate of a deceased person. Priority is being given to pay those who are still alive, of whom it is estimated there are 15,000. The HSE has advised that the first payments have now commenced. It is expected that the bulk of payments to estates will commence in the spring of 2007. Provision has been made for applications to be received up to 1 January 2008.

The Health Bill 2006 will establish the Health Information and Quality Authority, HIQA, and will put the social services inspectorate, SSI, on a statutory basis within the HIQA. The intention is that the SSI will be required to monitor residential services provided to older persons against standards adopted or set by the HIQA. This is in accordance with the commitment in the health strategy, Quality and Fairness — A Health System for You, to extend the remit of the social services inspectorate to other social services, including residential services for older people. As previously stated, my Department is in discussion with the interim HIQA on standards for residential care for older people.

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

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

The Minister established a working group last year to produce draft standards for all long-term residential settings — public, private and voluntary — in conjunction with the relevant bodies. My Department is in discussion with the interim HIQA on a consultation process on these draft standards. The standards are based on legislation, research findings and best practice. While broad in scope, the standards acknowledge the unique and complex needs of the individual person at the centre of care and the additional specific knowledge, skills and facilities needed for service providers to deliver a person-centred and comprehensive service that promotes health, well-being and quality of life.

The standards are set out in two parts. The first part focuses on the standards concerning the resident as an individual, and includes personal identity, social connectedness, rights, and health care. The second part focuses on the organisational aspects of the residential care setting and includes management, staffing, care environment, and health and safety.

The Department is also preparing legislation to update and clarify the current legislation on eligibility for services. The main aim is to make the system clearer and to bring it up to date with developments in service delivery and technology that have occurred since the Health Act 1970. The legislation will define specific health and personal services more clearly, define who should be eligible for what services, set out clear eligibility criteria, including for older people, and establish when and in what circumstances charges may be made. It will also deal with an appeals framework.

I reiterate that this Government has made services for older people a priority by supporting older people to live in dignity and independence in their own homes and communities for as long as possible and, where that is no longer possible, by supporting the provision of quality long-term care. The significant progress that has been made in terms of the growth in funding available for this sector in recent years and, in particular, the investment package put in place in the 2006 budget is indicative of the Government's commitment to the ongoing development of health-funded services for older people.

This Bill will ensure that the existing subvention scheme for private nursing home care is grounded in primary legislation and will also go a long way towards helping the Health Service Executive to implement the scheme on a standardised basis throughout the country. Further announcements about the subvention scheme will be made shortly. These will have implications for the Bill and I intend bringing forward amendments at a later stage.

I commend the Bill to the House.

Mr. Browne

I welcome the Minister of State and his officials to the House. If the House agrees, I wish to share my time with Senator Finucane.

An Cathaoirleach

Is that agreed? Agreed.

Mr. Browne

The one political issue about which I have changed my mind is the need to plan ahead. Care for the elderly is an integral part of that concept. When I worked as a teacher, I took for granted the fact that I would have a nice pension on retirement. Many older people find themselves in nursing homes and, consequently, under severe financial hardship. The Bill is designed to place the current regulations in a legislative framework. Fine Gael's concern, however, is that it will make it more difficult to obtain basic or enhanced subventions. The Minister of State spoke of standardising subvention rates throughout the country but it remains to be seen how that will work in practice. The current system is far from perfect but at least there is some scope for appealing and making representations on individual cases. Will that scope be removed in the standardised approach? Will it be a black and white situation with someone being either under or over the limit?

I am puzzled by the provision whereby 5% of the value of a person's home is taken into account when calculating subvention rates. We will all die some day but we never know when and therein lies the difficulty. An elderly person could spend three weeks, six months or ten years in a nursing home. Due to advances in medicine, patients are now living longer. I am sure Members of the House have made representations to their local geriatric hospitals to get people admitted, but the answer is always that all the beds are occupied and there is no regular turnover of patients. That is a particular problem in the case of women in nursing homes who tend to live there for two to three years on average. The lifespan of patients in nursing homes has increased, which has put great pressure on those involved. People seeking to have their elderly relatives accommodated in nursing homes must often seek places in private nursing homes.

The 5% rule is unfair in some cases. I was approached by a couple whose relative was in a nursing home. The man was single and in calculating the equation they were going to take into account 5% of the value of his house. He would not sign over the house at the time, however, so the couple were left in an impossible situation. Some days he was for signing over the house, while on other occasions he was against doing it.

There is an onus on everyone to plan ahead. Has the Minister of State considered the idea of encouraging people to set aside money in case they have to go into a nursing home? Could he discuss with the VHI a possible expansion of its scheme to give people that option? If they wished to pay extra money into the VHI, it might cover them for future nursing home charges. We should examine this matter and encourage people to plan ahead. None of us knows whether we will end up in a nursing home. My own grandfather had a peaceful death in his 80s. He got up one morning, did not feel well and so lay back in his own bed and died a few minutes later. It is a lovely way to go but others who are unwell may spend years in a nursing home. I am thinking of patients with Alzheimer's disease in particular. They are physically well but unfortunately their minds are not.

The Minister of State should negotiate with the health insurance companies or establish a scheme, similar to the SSIAs, whereby people could set aside money to cover the cost of nursing homes in later life. The population is living longer and the number of 65 year olds is set to treble in the coming years. That statistic represents a timebomb waiting to explode.

The Government's record on the elderly is not good and the Minister of State knows that. It took the Fine Gael Party to highlight the issue of medical cards and overcharging for nursing home care. As we have seen, the repayments are not coming on line as quickly as they should be. In addition, nursing home patients are still being charged for clothing and social outings. Recently, I received representations from a lady whose brother was in an institution for people with mental disability. She claims that he is being charged for clothing and social outings, including a trip to Lourdes. She is concerned about the interpretation of the regulations. Perhaps the Minister of State could re-examine whether it is appropriate to charge for such facilities?

Last year, the Minister for Health and Children, Deputy Harney, promised a better home-care package, yet there is great ambiguity over the increased number of home-care hours. In his speech, the Minister of State referred to additional hours. In the Dáil, Deputy Twomey said that home-care hours had been cut, a claim never conclusively refuted by the Minister.

Mr. S. Power

We provided 1.75 million extra hours this year. In yesterday's budget, that was increased by a further 780,000 home-help hours.

Mr. Browne

I raised this question because during the Kildare by-election I was taken to task on the doorstep by a lady involved in home care. I promised to check it out for her and the reply I received said that everything was perfect. However, that lady, who was involved in providing the home-care service, was adamant that the hours had been cut. I am confused about that point. Deputy Twomey took up the matter subsequently in the Dáil.

According to the Minister of State's speech, there seems to have been no consultation with outside groups concerning this Bill. The Department of the Taoiseach, the Department of Social and Family Affairs, and the Department of Health and Children were involved in the process, but no input appears to have been sought from outside bodies. No Opposition amendments were accepted in the Dáil debate, although the Minister of State referred to tabling amendments on Committee Stage.

As the Bill adopts a standardised approach, there is a danger that it will tie the hands of officials who hitherto had some discretion in awarding nursing home subventions. It remains to be seen what limits will be put in place. I plead with the Minister of State to seriously examine my suggestion to have some scheme in place so people can plan for the future. In that way, they would avoid the financial pressures of nursing home care in later life. The public would be happy to take that route. Half the population has private health insurance, while others choose not to avail of such schemes. Major costs are involved in nursing home care and much heartache could be prevented by establishing a scheme to provide for such future costs. Some elderly people can find themselves in difficult financial circumstances. This is also the case for relatives of single persons because 5% of the value of their property is taken into account. That is where difficulties can emerge.

Mr. Finucane

I hoped the Minister of State's speech would include some changes in nursing home subvention rates, although I understand he will table amendments later in order to revise those rates. I remind the Minister of State that those subvention rates have been in place since 2001, despite the changes that have occurred since then, including the increased cost of private nursing home care. In the past, when one applied for private nursing home care, family members were taken into consideration in factoring whether or not one was entitled to subvention. Even though that provision was removed subsequently, it happened in a surreptitious way. If one takes the maximum subvention level of €192 and the new pension rate of €200, that makes a total of €392. That means that a person attending a nursing home must find an extra €300 or more to cover the required costs. That is what is causing these problems.

While the provision involving family members may have been dropped from the application form, the same thing is now happening by stealth. In many cases, when an elderly person faces financial difficulty in paying nursing home costs, his or her family members will make up the differential. The Government should recognise what is happening and increase the subvention rates so they will be compatible with current costs. Over the years, the Administration has gradually, by stealth, reduced the number of beds in public nursing homes. By definition, all incentives are going towards private nursing homes. Private nursing homes operate to make profit, which is one of the main reasons some of the inherent difficulties encountered in Leas Cross and other nursing homes occurred. In my constituency public nursing home beds are not available to many of those aged 70 years and over who hold a medical card and are, therefore, entitled to one. The case assessment unit will assess people for public beds but finding a place for them is as difficult as getting a camel through the eye of a needle.

I take issue with the practice of imputing a value of 5% of a person's house. The house of an elderly person living in a rural location was recently valued at €95,000. While this may not seem a great deal of money, is it fair that the 5% imputation, which amounts to almost €5,000 in this case, will reduce the low level of subvention available to the gentleman in question by as much as €90?

The Government has received many plaudits for increasing pensions above the €200 figure. I remind Senators of the much vaunted fact that Ireland is one of the wealthiest countries in the world. The new pension rate is equivalent to 40% of the average weekly income. This is in sharp contrast to the figures in many European countries, specifically the Nordic countries where pensions are 70% of average weekly income. Let us not get carried away with the increase in pensions.

I am annoyed by the layers of bureaucracy attached to dealing with elderly people. It is understandable that the adjudication process for determining eligibility for home care requires an assessment to be carried out by a home help organiser. However, the process also requires that a financial evaluation of eligibility be carried out and a determination made of the number of home help hours the person will receive. If a person is unable to look after himself or herself and moves to a private nursing home, another layer of bureaucracy applies. A further means test, financial determination and an assessment of medical capacity are carried out to determine the level of subvention. Given that the home help organiser will be familiar with the person in question, it must be possible to short circuit much of this work and remove many layers of bureaucracy and administration.

What do officials in the Department of Health and Children do? Every time Members query a decision taken in any area of the health service we are told to refer to the Health Service Executive. The HSE has created layers of administration and tiers of management all over the place. The greatest cause of frustration is the inability to find out who in the HSE is responsible for what areas. I am aware the Government is trying to address this matter by establishing a parliamentary affairs division in the HSE.

Elderly people have major concerns. I hope the package to which the Minister of State referred, including an additional 780,000 home help hours per annum, materialises because most elderly people like to live at home. My mother is 90 years of age and lives at home, thank God. I hope her good health prevails and she will be able to continue to do so. This is not an option for many elderly people who do not have someone to look after them.

The Minister of State, in his 30 minute speech, referred to a series of new regulations which will tighten up matters. I share Senator Browne's concern that the new regulations will give administrators even more power to tighten up rather than relax criteria. It is extremely difficult to receive enhanced nursing home subvention from the Health Service Executive.

If a person is deemed eligible for subvention, by definition he or she will be entitled to a home care package if he or she chooses to remain at home. Is the value of the home care package equal to the maximum amount of nursing home subvention? For example, if the nursing home subvention is €192, will fairness dictate that the person will receive the maximum number of hours of home care? I am concerned that this is not the case and that a person who has been determined eligible to receive the maximum level of nursing home subvention will not receive home care hours of an equivalent value. I ask the Minister of State to investigate this matter. His officials should examine whether equity and fairness apply when a person decides to remain at home. I care about this subject because, like all public representatives, I encounter it on the ground.

A fortune has been spent on an extensive advertising campaign encouraging victims of abuse in long-term residential institutions to claim compensation. How many compensation claims have been paid out? Will there be a sudden rush in April or May next year to pay compensation with a view to impressing people before they go out to vote? The same incentive was used last year when child benefit payments were deliberately delayed and paid in one instalment the week before elections were held. This was done to ensure people voted for Fianna Fáil. I hope the Government is not deliberately withholding compensation payments to people who spent time in residential institutions. Shame on it if that is the case.

Mr. S. Power

It is not the case. There is no need for the Senator to get so excited.

Mr. Finucane

The scheme has been operated and advertised for long enough. People should be compensated but I have met people who have encountered bureaucracy.

Mr. S. Power

The Senator is talking nonsense.

Mr. Finucane

It is not nonsense. How many compensation claims have been paid out? The figure is small and I can guarantee there will be a rush to pay the others before next May. I know how the Government behaves and the tactics it adopts in these kinds of circumstances. It should not play with the elderly.

Mr. Glynn

Cuirim fáilte roimh an Aire go dtí an Teach. This is an important Bill which reflects in practice the Government's interest in the elderly. As has been proven, elderly people are a core priority for the Government. It is one thing to talk and another to act but this Government does what it says. It is committed to developing a comprehensive range of services for older people and wants to ensure they can live in dignity and, where necessary, receive care at home. In so far as practicable, it is the objective of the Government to maintain older people in dignity and independence at home in accordance with their wishes. It also wants to restore independence at home to those older people who become ill or dependent. As the Minister for Finance, Deputy Cowen, pointed out in his Budget Statement yesterday, the Government is investing to improve the level and quality of services for older people.

Those with knowledge of care of the elderly will be aware that elderly people perform best in their own homes. Many people in the early stages of Alzheimer's disease become confused when moved to the unfamiliar surroundings of a new care setting. For this reason, it is vital they are cared for in their own homes, subject to the availability of appropriate supports.

People are living longer with the result that the number of those in what are considered older age categories is increasing. People aged 70 years are no longer considered to be very old, while those aged 80 years could be described as "getting there" and those who hit 90 years are a good bit up the road. Not too far from my home, a person aged more than 100 years still drives a car and enjoys a little shot of whiskey.

Mr. S. Power

I hope it is Powers.

Mr. Glynn

More power to the person's elbow regardless of whether it is Powers.

The Bill gives effect to the concept that people should be cared for in their own homes. This should be applied where possible. Statistics show that people are living longer and a greater percentage of the population is aged. This must be addressed by means of the recruitment of more consultant physicians with an interest in old age. I am pleased to note that my own hospital, St. Loman's, has a very good department dealing with the psychiatry of later life. I exhort An Bord Altranais to ensure more nurses are trained in geriatric nursing care. I applaud the role of religious orders in the care of the elderly. While it is argued that the religious orders have outlived their role in the care of the elderly and in other care situations, I do not agree. In my view, they were never more needed.

Last year the Government allocated €150 million for service improvement in this area and next year an additional €255 million will be allocated to augment the enhanced spend. The measures include 2,000 more home care packages providing a total of more than 5,000 packages. Further increases in home help hours have been outlined by the Minister of State and there will be an increase in the number of day and respite places. Home helps provide a very important service. I have a family relative who is fast coming to the stage when they will require ongoing care. The home help service is providing an excellent service which ensures this person can live in the dignity of their own home and look after themselves to the degree their illness allows.

The Bill provides that the agency can arrange for a review to be carried out of the degree of dependency or means of a person in receipt of a subvention. Where the HSE is satisfied that the person no longer qualifies for subvention or qualifies for a different rate of subvention, it can arrange for the payment to stop or be altered appropriately and for a notice of same to be sent to the applicant and the nursing home proprietor, if appropriate. Where a person's subvention payment is being increased or decreased, the HSE will not implement this decision for 60 days to give the person time to put their affairs in order. This is a de facto acceptance that geriatric medicine works and that people who must be placed in care situations can often recover sufficiently to be discharged. A person while in care may require additional care such as total nursing care instead of partial nursing care. This would require a higher level of subvention.

The appeals mechanism is provided for in the new section 7E inserted by the Bill. The new section 7F is of particular importance with reference to what happened in a certain nursing home and where people died. It provides that a nursing home must inform the HSE in writing of the death, discharge or permanent departure of a resident within 48 hours. This is to ensure that subventions do not continue to be paid in respect of persons who are no longer in a home as this is what happened in some cases. Additional residential places should be required for the reasons I have stated in my contribution because people are living longer.

I ask the Minister of State and my colleague on the Independent benches, Deputy Henry, how much use is made of the new drug for the treatment of Alzheimer's. There is controversy in Britain where it was proposed that addicts in prison would be given heroin whereas those with Alzheimer's cannot receive treatment. To what degree is the new treatment for Alzheimer's being used?

Since my time in the nursing service I have been aware of the lack of visits made to those in long-term care. I ask the Minister of State to consider making a provision in this legislation that it would be mandatory, within reason, for people in both short-term and long-term care to receive visits. I have many times seen where weeks, months and years come and go and there is not a sign of a relative. This may not be to the liking of some people but the truth hurts.

It is the case that some older people will require nursing home care. To help with this, the Government provided additional funding of €20 million for the nursing home subvention scheme in 2006. The new funding brought the budget for the nursing home subvention scheme to €160 million. This is a far cry from the €5 million that obtained in 1993 when the scheme was first introduced. The additional €20 million is to support more basic nursing home subventions and reduce waiting lists for enhanced subventions. It is also designed to bring more consistency to subvention support throughout the country.

To ensure the existing subvention scheme for private nursing home care is grounded in law and to implement the improved scheme on a standardised basis, the Government has introduced the Health (Nursing Homes) (Amendment) Bill 2006. I look forward to considering the proposals which the Minister of State will bring forward by way of amendments on Committee Stage. It is an important Bill which is badly needed. We all know what happened in the past. There has been criticism from certain quarters in the House about the charging of medical card patients in hospital but as I have already said, it was the worst kept secret in the history of the State and it obtained under successive Governments. However, it is never too late to do the right thing and this Bill is a further step in the right direction.

Dr. Henry

I welcome the Minister of State to the House. The legislation has been brought forward because we have legal advice once again that primary legislation is required to give these provisions a statutory basis.

I support the Government's aim to keep people within the community and in their homes as they grow older, and this is what most people want. However, I have not found in practice that there is as much support as people need. I commend those voluntary organisations which give social support to so many people as they grow older, some of which, such as Action Age, have been specifically set up to help older people. I also commend the ICA in rural areas which plays a very caring role in ensuring that those who live on their own do not become isolated. Senator Glynn is correct when he refers to the lack of visits received by people in residential institutions. It is frequently the case that older people receive fewer visitors to their home. As a doctor I frequently heard people say that what they missed most was people calling to see them, especially in winter.

The situation regarding keeping people in their homes is lamentable. The money may be available but I have frequently found the supports, which are supposed to in place, are not. I will give an example of the type of complaint I have received. Changes can be made to people's houses if they have difficulty using baths, taps, etc., but before they can get a grant to have work done they must be visited by an occupational therapist. A person could be on the waiting list to see an occupational therapist in the public service for years. Even if a person employs a private occupational therapist to carry out an assessment at considerable expense — perhaps €180 or €200 — there is a considerable delay. This is counterproductive because people may be able to stay in their own homes if they were in a position to use the facilities in them in a better manner. I have seen what can be done following one of these assessments by an occupational therapist. It is remarkable and has transformed people's lives. While money may be provided, the organisation on the ground sometimes leaves much to be desired.

The Oireachtas Joint Committee on Health and Children discussed older people with chronic illnesses at this morning's meeting. We discussed, in particular, the lack of neurological services. In the past, we discussed the lack of rheumatological services. These are two areas in which older people, in particular, may need to see a rheumatologist or a neurologist having been referred by their general practitioners because of the development of arthritis, Parkinson's disease, Alzheimer's, as was mentioned by Senator Glynn, or any of these chronic conditions for which there are huge improvements in treatment. However, people need to get this treatment early on. We do not want to see them wait for four or five years for it, as is happening, because they will be so much more disabled. Although we are putting money into this area, we will not be in a position to keep these people at home. We should not only look at the person's situation in the home and at bringing in a home help, which would be useful, but we should also deal with whatever medical problems associated with ageing he or she has.

Many HSE staff are extraordinarily helpful to older people, including community nurses, public health nurses and mental health nurses, and are very conscientious about what they do. However, they are very thinly stretched in many places and they do not have the back-up teams they need in some areas. The postman is even an important person for many older people. There was a huge campaign years ago in regard to door to door postal deliveries. One forgets how important postmen are to older people.

The home help service is very good and I am delighted to see more money is being put into it and that the hours are to be extended. It is essential to do so because there are more older people each year given the better survival rate. I have had several complaints about the fact that when the very good and industrious home help goes on her — it is usually her — well entitled break of two weeks, it is not possible to find a locum to look after the person. I asked Mr. Aidan Browne of the HSE at a meeting of the Joint Committee on Health and Children if people were entitled to a locum. The answer was that they were if a locum was available. However, if the person is severely limited from a mobility point of view, that is not a very helpful reply. We must ensure there is someone available to take over the work of the home help for those two weeks. The money may be provided but we must ensure the structures are in place.

When Professor Desmond O'Neill, who wrote the report on the Leas Cross nursing home, appeared before the Joint Committee on Health and Children, we discussed nursing homes in general. He was asked what type of advice he would give to people who had an older relative or someone who was disabled whom they wanted to put into a nursing home. He said the first type of nursing home he would advise was one run by a voluntary organisation. These are the not-for-profit nursing homes, many of which have a background in a denominational or religious organisation which would have set them up years ago. Thankfully, they continue to operate and from what Professor O'Neill said, they seem to be well run. The next type of nursing home he would advise is the public one. Senator Finucane mentioned the large drop in the number of beds in the public nursing home service. The Minister of State said he would put another €22 million into bringing forward long-stay beds. I hope these beds are in the public service.

Mr. S. Power

It is approximately half and half.

Dr. Henry

While I do not have a problem philosophically with public-private partnerships or with private nursing homes being set up, we must note that these are being set up to make a profit and that they are businesses. The people who received the tax breaks to set them up have set up businesses and it is a hard business in which to make a profit. Some nursing homes charge as little as €650 per week. If a person progresses to being a high dependency patient, that would not cover anything. One would have to pay someone nursing such a patient €10 per hour, although they will not be a qualified nurse. It would cost €80 for someone working an eight hour day. One is talking about huge money for staff, not to mention money borrowed or the extra facilities one might have to provide. The cost of these nursing homes varies from €650 to €1,300 per week. There is almost certainly a huge difference in the amount of care being given. I am concerned about that as people become more dependent. The maximum subvention is €190.50 and while I know it is to be increased, it would go nowhere towards helping with the cost of a nursing home.

Many of these private nursing homes have been set up in the country because it is much cheaper to buy land there. That is the reason there are people from Dublin in nursing homes in Galway. The number of visits they will get from their relations from Clontarf and Rathfarnham will be strictly limited. We must ensure the public service gets back to what it was. One cannot blame people who have set up a business and find themselves in a loss-making position, no matter how compassionate they are, wondering how they will deal with the situation.

People are always suffering so I visit accident and emergency departments now and again, particularly in the evenings, to see how they are getting on. One sees very distressed older people who are frequently disorientated and who have come from nursing homes. Perhaps the people who have come with them are trying to get them admitted because they are too ill for them to deal with.

I am glad the Minister of State is to introduce standards in these homes because they are very much needed and that there will be a reassessment of people while they are in care. It is good that assessments on the degree of a person's dependence will be done by medically qualified people. I do not mind whether they are employed by the HSE or whether they are private practitioners hired by the HSE to do the work. However, it is essential they have some type of medical background, whether in nursing, physiotherapy, etc., because it is not fair — complaints have been made to me — to have clerical officers ask people in fairly public situations if they are incontinent. Such questions do not respect the dignity of the person. I am glad that the person who complained to me about this resisted answering strongly and said she would only take such questions from someone entitled to ask about such a personal matter.

I wish to refer to the situation regarding the value of people's houses and the intention to recoup 5% of their value if a person's house is valued over €500,000. Many of us, especially in Dublin, have through no skill of our own ended up with houses worth more than €500,000. I hope my children will not try to get me to downsize rapidly in case their inheritance is removed or diluted. I do not know what problems lie ahead as a result of the significant increase in property values in this country, even for people in fairly modest houses. I do not think a house can be bought in the Dublin area for under €400,000. Therefore, virtually everyone will be within the grasp of this provision.

I wish there was not within the Bill such a feeling of dependency on the private sector because private nursing homes are set up as businesses. People going into such businesses are not necessarily uncaring, but they frequently find the profits they expect are not forthcoming.

While subvention rates are not very high, in some psycho-geriatric institutions, the HSE pays in full for people in high-dependency units. I am glad this is recognised in the Bill because some people can go nowhere else. The problem with Leas Cross occurred in this context, but in that case the HSE tried to empty a long-term psychiatric institution into an unsuitable institution. The owner of Leas Cross had a contract or business arrangement with the health board and if he had not taken the patients he was sent, he would possibly have lost his contract. We must examine this sort of situation. As a colleague of mine, Dr. Mick Molloy, wrote in a recent article, acute beds might be quite a cheap way of keeping elderly patients if it were not for the fact that this blocks getting elective work done within acute hospitals.

Ms White

I welcome the Minister of State at the Department of Health and Children, Deputy Seán Power, to the House. Yesterday, I spoke in Donegal town at the regional meeting of the active retirement group about the research conducted for my document, A New Approach to Ageing and Ageism. The people attending the meeting represented active retirement groups from Donegal, Sligo and Leitrim.

At the meeting I spelled out the fact that we all live longer now owing to better and warmer home conditions and better food and medication. The 2002 census found we had 436,000 people over the age of 65. By 2016, that figure will have increased by 50%. Therefore we will have more older people who will all live longer, have a better quality of life and have greater expectations for that life. The people I addressed were group leaders from the different counties so I told them to go back and encourage the people in their active retirement groups, in Stranorlar, Tubbercurry or wherever, not to accept the ageism prevalent in society. The chart on page 7 of my document demonstrates that before the age of 65, people are considered an asset to the State, but that after the age of 65, they are considered a liability. I tried to encourage the representatives of the active retirement groups to be proactive, lobby for their needs and not just accept what doctors, nurses or even the Government put forward.

There is no question that the 5% subvention charge is controversial. One of the gentlemen attending yesterday's meeting, Mr. Butler from Strandhill, said 23,000 members of active retirement groups would march and lobby against this. I said to him I was unable to discuss the issue yesterday because I was not 100% au fait with the provision, but that I would get back to him about it. I would like the opportunity to speak to somebody in the Department on that issue.

I am optimistic and positive for the future. I spoke for one and a half hours on ageing and ageism yesterday and was optimistic about the quality of life older people can expect. Last year €150 million extra was provided for home care for the elderly and yesterday provision was made for full-year funding of €170 million. This is what it should be about. This is the largest ever annual increase in funding for older people and it clearly demonstrates the Government's commitment to improving the quality of service provided to our older citizens. I was happy that yesterday's budget dealt with the issue of ageing. Not everything can be covered in each budget and this year was the year for the elderly. I have also issued a child care document which is there as a platform for the future.

My document on ageing also covers the current situation with nursing homes and institutional long-stay care. It states:

While the preferred option is to keep older people in their homes and communities for as long as possible, approximately 5% of older people [I was amazed it was only 5%] require long-stay residential nursing home care. The principal reasons for admission include chronic illness, mental infirmity, physical disability and social reasons.

Despite perceptions:

87% of those in nursing home care are there for less than 1 year.

77% for less than 3 months.

63% of those in institutional care go back into community.

It is because 63% go back into the community that it is so important we have home care facilities, speech therapists, physiotherapists and chiropodists in place and maintained at an optimal level for people in their homes. The fact that most older people leave residential care after a short period means that much of the reason they had to avail of residential care was that the supports were not available to help them remain at home. The extra funding provided in the budget will assist greatly in helping people remain in their homes.

At the Oireachtas Joint Committee on Health and Children last week, Professor Des O'Neill spoke about the voluntary sector. We all live in fear that we may have to go into a private nursing home. I do not know what economic model is used for running these residential homes, but there seems to be something radically wrong as they must constantly cut corners with regard to care. Most of us, if we had to go into care, would now aspire to a public hospital where there are many more nurses to each patient. There is something radically wrong in this regard.

I am supportive of the Minister of State in his brief as the Minister with special responsibility for the elderly. I wish him continued success in his work. As a Fianna Fáil Senator, I am on a mission with regard to a new approach to child care, aging and ageism.

Mr. Ryan

Much of what has been said on this side of the House represents my views, although I would perhaps take a more radical view. I am intrigued about the way we put certain aspects of our society into boxes. While I may use the term "society", I should say "the present regime" because after ten years of the present Government, one must accept, regrettably, that perhaps it has an insight into the thinking of Irish society currently, which those on this side of the House will have to change.

With regard to the Bill, there is no point in anybody telling me that this is what was there before. This is not the Ireland that was there before. It is a classic case. At the end of the 1980s this was a country that had in preceding years come close to going the route of some of the countries of Latin America. It is always worth remembering that Argentina was a rich country by European standards 60 years ago but ended up in a Third World condition.

That is what this country had to deal with in the 1980s. A considerable amount of stress was involved, as well as debate and discussion about an agreed solution — I still believe many changes decided then were extraordinarily unfair. Nevertheless, that was the situation. It happened in the context of extraordinarily limited resources, added to the fact, about which nobody seems to talk any longer, that Germany's Bundesbank was continuously looking over our shoulder to try to keep us out of the European monetary system. Therefore, our finances had to be not only on the right side of the Maastricht conditions but vigorously and substantially so. Otherwise, we would have provided a very convenient way for the Bundesbank to assert itself. The Germans had to get a little humble later when their finances when out of control, but that was the view at the time. They wanted to use us as the proxy to get at Italy.

I say all this because this was the context in which the Government of the time was constrained with regard to public expenditure. Some of that period was led by a Fianna Fáil-Progressive Democrats Government and some by a Government in which Fianna Fáil and the Labour Party were involved — there was a variety of Governments. However, the fundamental values that arose at that time were wrong, and they are wrong today.

Section 7, which goes to the core of this issue, outlines the level of evaluation of an old person that must take place before he or she gets any subvention. The Bill does not specify that the person carrying out the evaluation must have a qualification but must be any person "who, in the opinion of the Executive, is suitably qualified to make that assessment". The Bill does not state the person should be a nurse, doctor or physiotherapist or otherwise, and we have no guarantee that it will not be bureaucrats who do this work. The capacity of the Health Service Executive bureaucracy to believe it can make decisions that professionals should make is remarkable, as any doctor or nurse in the service will know.

The Bill contains a long list of qualifications necessary for a person to be even classified as being at a level of dependency. There is also a long list of conditions with regard to income assessment. Why pick on the elderly in this way? This is what I mean by compartmentalisation. Imagine we did this with regard to primary education. Imagine we went through this level of evaluation of people's incomes before their children could attend free primary education. What is the difference? Why is it good to provide universal, free primary education? With all its limitations, it is undisputed that we have an extraordinarily good primary school system, with good teachers.

Ms White

I agree.

Mr. Ryan

The same is true of free second level education. When Donogh O'Malley introduced free second level education, he did not go through a rigmarole of means tests and cross-checking. He decided it would be free. While it is not entirely free, that is a separate issue. Ms Niamh Breathnach introduced the abolition of fees——

Ms White

That was not a good idea.

Mr. Ryan

——a decision which was entirely correct but which has simply been diverted by the universities, which have managed to cream off the snobs of the fee-paying schools.

Members should consider the composition of those attending the institutes of technology and they will see the difference. They are not the children of the very poor but of middle income earners. Members should ask those in the bracket above the grant scheme threshold but below affluence what difference it makes not to have to fork out €5,000 to €10,000 a year for four or five years as their children go through college. In any case, we introduced the change. The same holds for medical cards, for which, although the income level is stingy and ought to be changed, the basic principle is simple. It holds for every other area. However, when one approaches the area of the elderly, this rigmarole is required just to give people a maximum subvention of €190 per week. Am I wrong?

Mr. S. Power

The Senator is wrong. There is enhanced subvention.

Mr. Bradford

I can do sums. I know what percentages are.

Acting Chairman (Mr. Dardis)

My sums indicate that the Senator's time is up.

Mr. Ryan

I appreciate that. The Acting Chairman is also very good at sums.

Mr. S. Power

Senator Ryan's number is up.

Mr. Ryan

I have outlined my fundamental view. Other issues of detail will need to be considered. The fundamental value system that underlines this legislation is antiquated, outdated and ungenerous.

Mr. Leyden

I welcome the Minister of State, Deputy Seán Power, and his officials from the Department of Health and Children to the House. I am pleased to have an opportunity to speak on the Bill relating to the care of the elderly, a topical issue. I do not intend to revisit the Leas Cross issue which has been discussed in the House previously. I would like to ask the Minister of State a few questions and hope he will respond to them later in the debate.

What is the current position on the repayment of nursing home charges which were illegally imposed? How many people have been repaid? Are many repayments outstanding? I understand that a considerable sum of money — approximately €300 million — is involved. Most of those who have received refunds are pleased with the service provided for them. That is history because the Government has acted appropriately on foot of the decision of the courts. Some estates have not received moneys because decisions have not yet been taken in those cases.

It has been brought to my attention that residents of psychiatric nursing homes are not catered for in this legislation. I would like the Minister of State and his officials to indicate whether my information is correct. I have received a query about the matter. I understand the allowances due to people in long-stay psychiatric hospitals were taken from them and lodged for them in banks.

I would like to speak about nursing homes in general. I accept that many of the concerns about the Bill relate to the question of the primary family home. When the legislation and regulations were first introduced, I was still a member of the former Western Health Board. At the time the family means test was introduced, which meant that sons and daughters were contacted to find out how much they could contribute. That system was not working. It was impossible to operate. The family member who inherited the land or the house, rather than the family member who had left 20 years earlier and become wealthy and successful, was deemed to be liable for meeting the costs of the upkeep of the parent in the nursing home. That system collapsed and was withdrawn. Under the new system that has been introduced, the person in the nursing home is assessed. I think the family home should be excluded from the assessment. If a person in a nursing home sells his or her family home, he or she is deemed to be a permanent resident of the nursing home. Such a person is not able to retain the aspiration of returning to the family home. I am sure the Minister of State will ensure the HSE takes a humanitarian approach to this matter. The Bill provides for every circumstance to be taken into account.

As I have said previously, it is ludicrous that the staff who assess and process medical cards are required to undertake a review every year. It is the most time-consuming and cost-ineffective method of assessing a person's right to a medical card. A person's circumstances do not change very much in a single year. Even though medical cards are renewed in most cases, each medical card holder has to contact the local community welfare officer who has to fill in a form which then has to be processed. The officer may have to travel to the medical card holder's home to see him or her. At the end of this process, it is usually decided that the medical card can be renewed. All that work is unnecessary. Random checks, perhaps one in ten, could be done or it could be done every three or five years. The staff could be gainfully employed because the community welfare officers are used to carrying out assessments. I appeal to the Minister to streamline the application system and the speed with which decisions are made.

I have no complaints on my books about the western region. I may create a demand from people who say they have a case but I speak as a long-serving Oireachtas Member from County Roscommon. I welcome representations and, like every other public representative, I am available to people.

I heard the debate in the Dáil which may have been somewhat over the top. The Bill is before us at a bad time in terms of yesterday's very good budget because it created a certain reaction and the possibility of people picking holes in this Bill. I appeal to anyone listening to this debate, which is broadcast on the Internet worldwide, that if they have an issue regarding a nursing home subvention in my area, I would be delighted to take up their case. To date, however, I have not received any complaints. Complaints in general have decreased compared to previous years. Even the enhanced subvention system has been handled extremely well.

In the last case I dealt with, the person died before the final decision was made. She had a very good teacher's pension which meant she did not qualify but covered the cost of the nursing home. Her house would have been taken into consideration in the process but, unfortunately, she went to her reward. She was very well cared for in a private nursing home.

On the overall regulation of nursing homes, there is a tax incentive for the building of nursing homes but there should be a certification of the need for a private nursing home in an area. There is no justification for adding additional nursing homes to the list when there is adequate space in the area. We have three major nursing homes in County Roscommon. The Sacred Heart Hospital, which I had renamed from the Sacred Heart Home because it is more of a step-down facility close to the county hospital in Roscommon, provides a full geriatric service. A geriatrician attends the facility and it has a medical officer in attendance full time also. It now has an Alzheimer's ward. I hope the Minister will give a major capital grant to refurbish one of the wards for another Alzheimer's unit or to build a new unit, which is in order. We also have the Plunkett Home in Boyle and Aras Mathair Pol in Castlerea, two well-run nursing homes about which I never get complaints. The private nursing homes in County Roscommon are very effective and a number were established recently.

I emphasise that the decision-making process to provide private nursing homes should not be tax led. Nursing homes should be provided because the State requires them in certain areas and where a need has been identified in certain areas, a certification should be given that they will be subvented. If a person wants to build a nursing home on the basis that he or she will not get subvention for the patients, that is his or her own business but that aspect should be considered.

I want to mention one nursing home in the public sector with which I am very impressed. It is located in Achill Sound and is one of the most beautiful nursing homes in the country. It was built beside the sea. It has its own oratory and is near the House of Prayer, although it is not connected to it. Every room in that nursing home displays the name of the person resident in the room on the door. When I visited I thought these were consultant rooms because every room had a nameplate on the door.

Ms White

That is very personal.

Mr. Leyden

Those persons were empowered by that. Every staff member had his or her name displayed. It is a beautifully managed nursing home. Entertainment is provided two or three times a day including people singing with accordions, others telling folk tales and so on. That is what I like to see in a nursing home. I hope the Minister has an opportunity, when he visits the west, to see a public nursing home being run the way I believe is required. It is also well designed.

I said recently there should be nursing home committees in public nursing homes. There are many active people who would be prepared to join a small committee to run these homes. That would empower those older people.

I commend Senator White on producing the report, A New Approach to Ageing and Ageism, and the effort she put into it. Everything in the section regarding residential care is included in that report. I ask the Minister and her officials to read it. The report will be presented to the Fianna Fáil Parliamentary Party and that section is very much in keeping with what is required. I understand the Minister has already commended Senator White on her work. I wish the Minister well in getting the Bill passed in the House.

Mr. Bradford

I welcome the opportunity to contribute to the debate on this legislation. The contributions of previous speakers were very interesting. In particular, those of Senators White and Ryan provided much food for thought, on which we must reflect strongly.

Some of the Minister's colleagues at both senior and junior ministerial level are contemplating the possibility of a constitutional amendment dealing with the rights and protection of children, something I look forward to dealing with and will support. What would be the political ramifications if our Constitution contained a clause on the protection of the elderly, guaranteeing their rights and ensuring their entitlements and comfort? If we had such a constitutional provision to provide for services, entitlements and all the other needs of the elderly, much of the legislation with which we have dealt here from the Minister's Department, including the legislation before us, probably would be deemed unconstitutional. We must seriously reflect on where we are going and what we are trying to do from a policy perspective regarding the elderly.

Yesterday, the Minister for Finance made his Budget Statement. The Minister had responsibility to spend a huge amount of money, which is welcome not only from the Government's point of view but also from that of every citizen. The country is now officially very wealthy, with tens of billions of euro available to him to be distributed yesterday by way of the budget. In the context of our relatively new-found but abundant wealth we must put in place the services and financial commitments we are setting aside for the elderly in our community.

Senator White spoke of the relatively small percentage of the elderly or the ageing community who will rely on nursing home care at some stage. This Bill is about nursing home care and deals with approximately 6% or 7% of the population. I am somewhat concerned that when we debate ageing and services for the elderly in this House and elsewhere we concentrate too much on the nursing home aspect and do not consider the bigger picture. As I said last week when we discussed Leas Cross, along with all Members I want to ensure people in nursing homes have all their entitlements, that the home is of the highest standard, the accommodation is of the highest quality and that the supervision, medical assistance and inspectorate procedures are of top quality. Much needs to be done in that regard but that is only one side of the equation. The majority of our elderly and ageing population wish to remain in their homes in their communities. We must also examine services for those people.

Yesterday's budget gave the annual increase in the carer's allowance, which I welcome, but I raised last week during the nursing homes debate and earlier this year during the various social welfare debates with the Minister, Deputy Brennan, the possibility of removing the means test for the carer's allowance. The Minister presented the House with his estimate of the cost of doing this. I do not remember the figure but it was a modest sum. It is like the analysis put forward by Senator Ryan on the question of universal care for the elderly. The cost of removing the means test for the carer's allowance and of ensuring all people in need of full-time care receive it would be modest.

Provision in this respect should take account of the societal aspect and of giving people a choice of where they want live in their senior years — I do not like the phrase "in their final years". It is great that people are now living longer. We debated the concept of removing the title "old age pension" during the debate on the Social Welfare Bill last year in this House, a matter for which I take some credit. People aged 65 and over are not old. In fairness, the Minister, Deputy Brennan, reflected on that and introduced the phrase "State pension" rather than "old age pension". It is not a question of people in their final years but people who have aged who require the maximum possible support and services from the State to enable them to remain, where possible, in their homes and communities.

Senator Henry spoke about the issue of applications for disabled persons' grants in Cork. I gather from what she said that apparently we should almost be thankful that the waiting list for an occupational therapist report at Cork County Council level is 26 weeks, but that is 26 weeks too long. Where a person requires the provision of a bathroom, shower or some other lifestyle improvements, such a delay should not be countenanced. It adds not only to the misery of the person who must endure the inferior facilities but by the time the application is made, the grant processed, the occupational therapist report completed and the engineer has called out three or four times, it is probably 12 months from the date the application was submitted. By the time the application is approved the cost of carrying out the work has increased. Such delay costs the taxpayer and the applicant more and it causes much misery in the meantime. We need to ensure that small issues, which can be resolved easily, are dealt with. In this respect, councils should have sufficient staff to complete these reports, sufficient engineers to assess such jobs and the applications should be processed quickly. That should be easy to do in our new wealthy Ireland.

I welcome the slight improvement in the level of respite grants announced yesterday, but much more progress could be made in this area. The issue of stamp duty was discussed in the other House yesterday and we debated it in this House last week. A suggestion made, which is generally supported across the political spectrum, is that stamp duty exemption should be provided where elderly people wish to trade down, in other words, sell a large house and move to a smaller house. That issue needs to be re-examined.

One of the tax reliefs announced by the Minister during the Budget Statement yesterday is pathetically insulting to the elderly. I refer to the adult dependent allowance, which amounts not to thousands but to only hundreds of euro for an incapacitated relative. I am not referring to the allowance for employing a person to look after an elderly relative but the tax allowance or tax relief which a person receives for looking after an incapacitated relative in his or her house. It amounts to only a few euro per week. That is highly insulting and the allowance should be reviewed. While these issues are slightly removed from this Bill, they need to be reflected on in the broader debate on services for elderly.

When the nursing home subvention scheme 1993 was introduced by the then Minister, Deputy Howlin, in the then Fianna Fáil-Labour Government it appeared to be a forward-looking proposal. However, a subvention of €190 per week or thereabouts, which is the figure before an enhanced subvention might be given, does not go far towards paying for the cost of weekly care in an average private nursing home. The subvention is a modest amount and the bureaucracy, red tape and regulation surrounding the application for it is pathetic.

The political challenge facing us, particularly Members on this side of the House, was set down by Senator Ryan when he spoke strongly about what we do with the financial choices available to us. He asked us to reflect on the fact as we have decided that young people, be they at primary, secondary or third level, have universal entitlement to education and should elderly people not also have universal entitlement to care? If we had a constitutional amendment and constitutional protection for the entitlements of the elderly, in terms of their entitlement to care, security and accommodation, it would throw a lot of present regulations, legislation and rules out the window.

I hope that the Bill — which the Government will enact given its majority — when enacted and when other such debates on the elderly and our ageing population take place, we will show more vision and policy initiative towards using our unprecedented wealth and resources to give something real back to the people who built up this country, whether it be provision for the 5% of people who need nursing home care, referred to by Senator White, or for the 90% or 95% of people who live in their homes, with their families, in their communities or in community housing.

Much more needs to be done for these people. I hope we do not limit our ambitions for them. Budgetary increases in the old age pension, which I welcome and on which I commend the Minister of State and his colleagues, are not enough. A much greater level of service, provision and assistance is required. There is a huge political responsibility on all of us to have a broader vision of how we look after our ageing and elderly population. We all will aspire to reach that sector of society at some stage. We need to put much more resources and measures in place and we have a huge social, political and moral responsibility to do so.

Dr. Mansergh

I welcome the Minister of State to the House. I also welcome the measures for the elderly in yesterday's budget, namely, the social welfare increases, the income tax exemptions and the home packages for the elderly. I have seen many instances where caring for the elderly, the very sick or the disabled at home can work very well but we cannot feel as proud of our care of the elderly as we would often like to feel. We have had the Leas Cross Nursing Home scandal and there is probably an uneasy feeling that it may not be an entirely isolated instance. We have had the case of the illegal deductions from welfare payment, which has now been straightened out, but it was embarrassing for the entire political system. Undoubtedly, we need a legislative framework and that is being offered to us.

The core of the legislation is in two parts. The first is the assessment of the degree of dependency of applicants for health care, which seems to be reasonable. What I find more problematic, and it is not only confined to this area, is the exhaustive means testing of people who are old and sick. It is not a very dignified activity for people carrying it out or for those who must undergo it. The cases one encounters most often are people of relatively modest means but who are, nonetheless, above a certain threshold where after a year or two of care — sometimes people are in care for some time — the means become rapidly depleted and family members find themselves having to scramble around to provide funds to fill the gap.

There are major problems of public policy that affect every country. I was struck by what the British Health Secretary, Ms Patricia Hewitt, said when she claimed that increasing life expectancy and medical advances would lead to new pressures which would need to be reconciled with the public's expectations about taxation. She stated that in a frank manner that does not always happen here. It is often said that politics is the art of the possible, but I have come to the view that politics is the art of the impossible. It involves reconciling conflicting demands. We have heard from the other side of the House about universal nursing home care, and a good prima facie case can be made for that. At the same time, Ministers and former Ministers have suggested that we raise taxation in order to cope with the demands and reforms that are needed in the health service. My general impression is that those arguments do not go down very well with the public, especially when the Government is running a significant surplus.

I would like to put forward a third solution that is not based on either universal provision or means testing down to the last good and chattel. We do not know which of us will reach what Gore Vidal called the hospital stage of our life. Which of us will go into nursing homes and which of us will drop dead one fine day or after an illness of short duration? Even with increased life expectancy, the vast majority of us will probably not go into a nursing home at any stage of our life. If we become infirm, we may be cared for at home or go into a home for short periods. Given that we are talking about a small minority who go into nursing homes, it might be possible to have a specialised health insurance scheme. The risk would be borne by all of us, as distinct from the current situation whereby due to a turn of fate, some individuals and families are hit infinitely harder than others. If one were to encourage such an insurance scheme, it would avoid the costs of a universal system that need a rise in taxation, while at the same time it would not push families to the pin of their collar.

It is very often the people in difficulty who are subjected to means testing. I do not see such testing as part of a very humane society. While I support the Bill, I hope that we continue to look at alternative, more humane, methods to deal with this. Very few of us will be in a nursing home for four or five years. It might happen to the odd individual, but it will happen to very few. Surely it is something against which we can insure.

Ms O’Rourke

I was following this debate from my office and I was fascinated by some of it. I put a question informally to the Minister of State yesterday, which I want to repeat today in the Seanad. I have been getting a number of letters from people who I would respect very much, such as those who are involved in retired nursing associations. There is a very strong rumour currently doing the rounds that older people will have to sell their homes if they are to receive a subvention. I want the answer from the Minister of State, even though I know it myself. This may be a scourge of a Bill that will impose draconian measures on older people, such as forcing them to sell their homes in order to obtain a subvention.

I never met a person or a family who had to sell their home, so this may be a wicked rumour. However, I want to receive a definitive answer from the Minister of State. People in the community are scared because they have heard some of these stories. Most people want to stay in their own homes and the home care packages announced in the budget yesterday, and by the Minister for Health and Children this morning, will be very good for people. The home care packages enable people to receive care, whether through nursing hours, home help hours and hospice hours at a later stage.

When these measures are codified they will help elderly people in need of care, but we need to put a shape on it. When elderly people apply to the county council for necessary supports, there seems to be no co-ordination between them, the county council and the employee from the HSE who must validate the applications for supports, such as lifts on a stairs, downstairs bathroom, toilet and so on. I thought these should be part of the home care package. Perhaps the Minister of State might consider whether they could be part of the home care package, working with the county councils, because they are very important. I know of a person in Ballymore, a rural area, who cannot come out of the hospital in Mullingar because the works needed on his house have not been done. He could come out in the morning if the works, for which there is sanction from the county council, could be done. A home care package that does not include that aspect is a waste. Perhaps the Minister of State might deal with that issue in his reply.

I would be obliged, too, if the Minister of State would clarify the position about people having to sell their homes to pay for their stay in nursing homes. I welcome that there is no difference between public and private care because I heard the Minister for Health and Children, Deputy Harney, talking about this when she opened a private nursing home in Athlone. She said that if there were beds available in that nursing home and people needed care, the Health Service Executive would underpin this by funding. This is always a fraught issue. Everyone who watches a television documentary, reads a report in the newspaper or hears about it on the radio is aware that they will probably reach that age at some stage and they wonder whether they will be looked after and properly cared for. Is due regard given to the elderly in society?

We can hark back nostalgically and talk about what the norms were long ago, uair amháin in rural Ireland, where every family had grandparents at the hearth in the family home. They were well looked after and provided an interesting level of societal observation for young people. The children could see that there were stages in family lives, grandparents, their own parents and siblings in the same household. That seemed very natural, and in that way many old people came to die under their own roofs, all of which was entirely admirable. We can look back with nostalgia and sigh for the passing of that era. It is rare enough these days, except perhaps in parts of rural Ireland where one can find such an arrangement.

In the event, it is wonderful to see because the voice of sagacity and age is listened to when advice is needed. It is not that the older people are just condoned. They are loved for their own sake and have a valuable role to play in the family environment. However the complexities of life, combined with the fact that two parents may be out working, etc. does not add up to a quasi-nursing environment for the older person and means that type of arrangement is slipping away, which is a pity.

The Minister of State's speech listed all the changes to various clauses in earlier Acts, new legislation and so on, which are all indicators of change. Leas Cross arrested us all in our tracks when we saw what had happened there and the brutality exercised on older people. We talk about brutality and young people, but it is especially sad in the case of the elderly because they are not able to defend themselves. When the Minister of State does the House the honour of replying, I trust he will be able to answer my questions.

Mr. Norris

I have spoken on the issue of nursing homes on a number of occasions, but not on this Bill, of course. I am reluctant to regurgitate what I have said on the subject before. However, this is a very important area and it has been highlighted by the media, in particular the investigations by RTE and others into the tragic situation at Leas Cross.

From the outside, what a lovely place it looked. One would imagine everybody was comfortable and well cared for. Then we learned that the situation was not as it appeared once one was inside. I listened to a woman on radio the other day who told a tragic story about her father. He had been very active, went into Leas Cross, I believe, and had a series of illnesses complicated by minor strokes as well as lung infections.

The woman visited one day and her father was not well. The next day they said he was better. They wheeled him out in a type of pram with a rug around his legs, his spectacles stuck on his face and the newspaper on his lap. The man was dying, but this was all just cosmetic to persuade the relatives that he was improving. The relatives insisted on an ambulance being called and waited a considerable time, but nothing happened. Eventually the daughter said they would take the man to hospital in their own car because the nursing home people had first of all said, "There is no admission from here", which was a very strange phrase to use.

Ms O’Rourke

Where was "here"?

Mr. Norris

It was Leas Cross, I believe, and there was no admission. In other words, they did not want to send patients from Leas Cross. Again, when one considers the phrase, "bed blockers", it precisely fits the description of people such as this old man. People describe them as bed blockers. That has ramifications whereby people do not want them admitted to hospital. It is a dreadful phrase——

Mr. S. Power

It is terrible.

Mr. Norris

——but in any case, they found that the ambulance did not turn up. A real ambulance had not been called, rather a type of patient care vehicle. It was only when the family said they were taking him into hospital that an ambulance was produced. In the event, that ambulance was there in ten minutes, so sometimes the services exist, but are not properly being called on.

There is a growing problem for a variety of reasons. First of all, Ireland has changed in social terms. We do not have the extended family any longer. This is having major effects. I expressed concern yesterday on the Order of Business about the alleged extraordinary high levels of what was described as psychiatric illness among children. If it is true that one fifth of children suffer from serious psychiatric illness, then it is not just the children who should be examined but the whole organisation of society. Again it strikes me that the extended family norm no longer exists.

For a variety of reasons an increasing number of people make use of services of this type and in some cases this is not entirely appropriate. I heard a woman speak on this subject who said she had been running a nursing home for the past 30 years and that it had changed significantly because of the increased number of elderly people with severe Alzheimer's disease who needed one-to-one care virtually around the clock. She said nursing homes were not in a position to provide this care. It is wrong to blame nursing homes if there are people in them who are not appropriate candidates for this type of treatment. We must look very closely at the issue of Alzheimer's disease.

I am very concerned about the inspection of nursing homes. It seems to me that particularly since Leas Cross, private nursing homes are subject to inspection. I am much less happy about publicly funded nursing homes because we hear so little about what goes on in them. If, in the regime of nursing homes for which patients pay enormous amounts of money and relatives routinely visit, almost nothing is heard about the situation in State-funded and State-run homes, there is an urgent case for a proper inspection regime for such institutions and I do not believe this is happening.

By coincidence I have just left the restaurant where I spoke to somebody who is not a Member of the Oireachtas but is a crucial part of the parliamentary system, namely, Ms Anne Byrne, a programme manager to Deputy Howlin.

Mr. Norris

However, I take grave offence to the contribution from Senator Finucane, who made some outrageous allegations regarding the illegal charges and the manner in which they are being repaid. The repayment scheme was launched by the Health Service Executive on 14 August last. The Government had provided in the Estimates sufficient moneys for this year and will do so again for next year. Apart from issuing the instruction that it wished and would insist that people who are still living should be a priority, the Government has had no hand, act or part in the disbursement of the moneys. The Government will be quite happy to see the moneys paid over as quickly as possible. I mentioned that approximately 15,000 people who are still alive are entitled to be repaid and this money will be paid back. For the Senator to make such allegations was an abuse of his position in the House and was most regrettable. However, I thank the other Members for their contributions. While I might disagree with some aspects of them, in the main they were very helpful.

As Members have noted, the Bill is designed to ensure the existing subvention scheme for private nursing home care is firmly grounded in primary legislation. Once enacted, this Bill will replace the 1993 regulations. Significant changes are projected regarding older people, particularly in the medium to long term. It is estimated that this year, there are approximately 463,000 people aged 65 years or more in Ireland. The latest population projections suggest the figure will increase to more than 1.1 million by 2036 and consequently, the old age dependency ratio will rise from 18% to 39%. The number of people aged 85 or more is projected to increase from 46,700 to 155,000 in the same period. This trend is expected to continue until 2056, when the old age dependency ratio is projected to reach 60%.

I will finish on this. The subsection further provides that the principal residence of the applicant will not be taken into account if that could give rise to destitution or homelessness of a person with a close connection to the applicant. This provision is to allow for exceptional circumstances and will generally apply in the case of a relative who does not fall into the categories prescribed in the subsection.

The Seanad divided: Tá, 22; Níl, 16.

Tá

Brennan, Michael.
Daly, Brendan.
Dardis, John.
Feeney, Geraldine.
Fitzgerald, Liam.
Glynn, Camillus.
Hanafin, John.
Kett, Tony.
Kitt, Michael P.
Leyden, Terry.
Lydon, Donal J.
MacSharry, Marc.
Mansergh, Martin.
Morrissey, Tom.
Moylan, Pat.
O’Rourke, Mary.
O’Toole, Joe.
Ormonde, Ann.
Phelan, Kieran.
Scanlon, Eamon.
Walsh, Jim.
White, Mary M.

Níl

Bradford, Paul.
Browne, Fergal.
Burke, Ulick.
Coghlan, Paul.
Cummins, Maurice.
Finucane, Michael.
Hayes, Brian.
Henry, Mary.
McDowell, Derek.
Norris, David.
Phelan, John.
Quinn, Feargal.
Ross, Shane.
Ryan, Brendan.
Terry, Sheila.
Tuffy, Joanna.

Tellers: Tá, Senators Dardis and Moylan; Níl, Senators Cummins and Ryan.

Question declared carried.

Sitting suspended at 3.45 p.m. and resumed at 4 p.m.

Seanad Éireann debate - Thursday, 7 Dec 2006

Health (Nursing Homes) (Amendment) Bill 2006: Second Stage.

Tá

Níl

Seanad Éireann debate -
Thursday, 7 Dec 2006