I welcome the Minister of State, Deputy Áine Brady, to the House.
Nursing Homes Support Scheme Bill 2008: Committee Stage.
Sections 1 and 2 agreed to.
SECTION 3.
Amendments Nos. 1 and 2 in the names of Senators Mullen and Norris, respectively, are deemed to be out of order because of a potential charge on the Revenue.
Amendments Nos. 1 and 2 not moved.
Section 3 agreed to.
SECTION 4.
Amendment No. 3 in the names of Senators Fitzgerald and Norris is deemed to be out of order because of a potential charge on the Revenue.
These are cases in which the Leas-Chathaoirleach's ruling is clear, but I appealed a previous decision to the Committee on Procedure and Privileges. Will the Leas-Chathaoirleach use his office to ensure that there is a meeting of the Committee on Procedure and Privileges soon to tease out this matter of the ruling out of amendments on economic grounds? Perhaps we can also look at the fact that it is idiotic that the Seanad is prohibited from making important amendments on this ground. I understand there is a constitutional prohibition but I want to raise that protest.
That is a matter for the Cathaoirleach, and Senator Norris has a representative on the committee to which he referred.
I wrote to him but he keeps telling me that no meetings take place of the Committee on Procedure and Privileges.
Amendment No. 3 not moved.
Section 4 agreed to.
SECTION 5.
I move amendment No. 4:
In page 12, between lines 12 and 13, to insert the following subsection:
"(6) The Minister shall provide a report to the Houses of the Oireachtas on the funds made available for the Nursing Home State Support Scheme.".
This issue of how the elderly will get support if they need residential care is one of the critical issues we in society must face at present. As the House will be aware, it is very inequitable, it is arbitrary and the criteria are far from clear. This legislation is an attempt to move in a direction that provides some clarity and a mechanism to bring fairness into the equation.
The critical question is: what resources will be made available to allow this to happen and what resource capping will there be as we move towards implementing this important legislation? I am concerned that we would arrive at a situation where, for example, there would be a care assessment, it would be agreed by everybody that it was necessary that a residential placement should be provided but, because of resource shortages, it would not be available.
This is the position at present. If one takes the number of people who are in hospital beds whose care has effectively been assessed as needing residential care and who are high dependency, there are large numbers of individuals living in hospitals around the country who should be in residential care.
The question of what resources will be made available to implement this legislation is critical and it is not an easy one. Obviously, we are in an extremely difficult financial situation. It is not an easy question for the Minister to respond to or to give guarantees on, but the point of this legislation is to make places available to those who need them and to provide a funding mechanism for families, who are unclear on the matter and who are finding it very difficult to manage. Many people are paying a great deal of money. Some of them are getting subvention while some are not and it is not clear why that is the case. It is a major concern for families and individuals.
My simple amendment states that the Minister shall on an ongoing basis — I expect on a yearly basis — provide a report to the Seanad and the Dáil on the funds made available for the nursing home State support scheme.
Section 5 of the Bill stipulates that the fair deal scheme is resource capped. Obviously, that will lead to waiting lists for support under the scheme and it is possible that family members will be called upon to fund the difference. At the same time in recent budgets the tax relief on nursing home care has been reduced to the standard rate.
This amendment brings some accountability to the Houses of the Oireachtas for the funds being made available to the scheme. It is an opportunity to look at how adequate is the provision being made by Government at any particular time for funding for the scheme. There are questions. If the scheme is to be resource capped, which I understand, there will inevitably be waiting lists, but how will the waiting lists be dealt with? Will family members continue to be expected to pay up while we wait for some funds to be freed up by places becoming available, perhaps through death?
Under the existing system, people received some contribution to the cost of their care, even if it had to be supplemented by the person's family. Under the new scheme, is it possible that an older person could be left with nothing and no certainty about how funding might become available? We are in a situation where the need for high dependency beds is great. Many high dependency people are in unsuitable placements in hospitals, which is creating major problems within hospitals and for individuals and their families. I look forward to hearing what the Minister of State has to say about the resource issue because it is critical.
I do not know how much she can say on the matter today, given the financial situation, but at the least this amendment would ensure there is some ongoing monitoring of how the scheme is evolving and developing, what funds are being made available, what priority it is getting from Government, how many places are being made available on an ongoing basis, how many are being funded, what the waiting lists are and what the need is. It would bring some useful democratic accountability into the process. I ask the Minister of State to accept the amendment.
I support the thoughtful amendment tabled by Senator Fitzgerald because she used the correct word when she mentioned accountability. For the Houses of the Oireachtas to operate effectively it is important we have access to all the information on a factual basis.
Senator Fitzgerald expressed some hesitation and did not seem completely sure the amendment would be accepted and would not be ruled out of order because it could have been as I have no doubt it creates a charge on the Exchequer. It must do so because one would have to prepare, print, publish and issue a report. A number of amendments have been knocked out because they would cause a charge on the Exchequer. This amendment plainly does but for some reason, perhaps because it is an interesting subject to discuss, it has been accepted.
I mention this because the amendments that have been ruled out of order were important, for example, the one on couples. I would have welcomed the opportunity to again say to the Minister of State, Deputy Brady, that I welcome the interesting development of accepting same sex couples and so on. It would have been useful for me because in this House I have been accused of being sectarian and not accepting the views of the Roman Catholic Church. It has made a strong case for the acceptance of people outside marital relationships of various kinds, such as siblings who are living together. This kind of thing exists all over the country, where elderly people, such as two brothers or sisters, are living on an old farm up on the hill in Kerry, Leitrim or wherever. I have no difficulty whatsoever in saying such people should be covered, but I would protect and ring-fence the radical change here, which is the redefinition of "couple" to include same sex couples. I did not have the opportunity to say that because of the prohibition on this amendment.
I again highlight the fact that sometimes these decisions are absurdly exclusionary or inclusionary, but I welcome the inclusion of this amendment although I have no doubt there is a charge, small though it may be. Technically, this amendment could have been ruled out of order. I am very glad it was not and I compliment Senator Fitzgerald.
It has been judged by the Cathaoirleach that this report could be carried out from existing resources.
It still creates a charge.
I understand Senators are concerned that there should be transparency regarding the level of funding committed to the scheme in each financial year. A dedicated subhead has been established within the overall HSE Vote for the purposes of the scheme. Subhead B16 would then be part of Vote 40. As such, the funding made available for the scheme will always be ring-fenced and will be clearly identifiable within the Revised Estimates of public expenditure. The funding within the subhead will be subject to careful monitoring and the Department of Health and Children has already agreed a set of reporting requirements in this regard.
Furthermore, under section 31 of the Health Act 2004, the HSE has to prepare and submit a service plan. The Minister has stipulated that the service plan must report on the numbers of people provided with support under the scheme and the current plan already reflects this within its performance activity targets for services for older people. In addition, the HSE will also have to include in its annual report any information that may be specified by the Minister for Health and Children.
I do not propose to accept amendment No. 4 due to the range of reporting and monitoring mechanisms already in place and I hope the measures I have outlined will address the concerns of the Senators.
I thank the Minister of State, but her response does not reassure me and I will tell her why. In the past year mental health funding was supposed to be ring-fenced but it has disappeared into a black hole and has not been used for mental health. There is a number of other examples. The idea that there is a subhead where this money should be spent is not enough. The fact that it is in the service plan that would come from the HSE is not enough.
It is one thing to introduce this Bill to the House, but it is quite another to ensure the spirit of the Bill is maintained and it is put effectively into practice. If we are to bring back democratic accountability to this House, we ought to have reports before the House outlining how the scheme is being run, what the effects of the legislation are, how much money is being spent on it and what the balance is between the demand for the service and what is actually being delivered.
The people we are discussing are the most vulnerable in society, namely, the elderly who are high dependency and need these places. A report ought to be provided to the Oireachtas on a yearly basis. I am not happy to leave it with the HSE, given the critiques there have been of it in recent times and the lack of ring-fencing of money — I gave the area of mental health as an example. This amendment would mean bringing actual detail on what was happening regarding the Bill to the floors of the Dáil, Seanad and committees. It is about time we started doing more of that in this House and stopped hiving off responsibility to unaccountable bodies or bodies which are not directly accountable to Members of this House.
I would like to register my delight at the Leas-Chathaoirleach's wonderfully Jesuitical justification. I shall remember it because it applies to every single amendment that has been excluded previously. In other words, as long as it comes within the global budget, no matter what it dislodges, it is not a charge on the Exchequer. I am extremely grateful for his instruction. I shall improve and I shall certainly use this justification when I am arguing for the retention of these kinds of amendments in the future.
In response to Senator Fitzgerald, mental health funding was not put into a single dedicated subhead and because the fair deal funding is within a single dedicated subhead it cannot be moved elsewhere without notification to the Oireachtas. The HSE makes monthly returns to the Department regarding expenditure on each subhead, including B16, and this will be carefully monitored. Allocation of resources to this and all other health expenditure is a matter for Government and is kept constantly under review.
Is amendment No. 4 being pressed?
Amendment put.
The Seanad divided: Tá, 16; Níl, 22.
Tá
- Bacik, Ivana.
- Bradford, Paul.
- Burke, Paddy.
- Buttimer, Jerry.
- Coffey, Paudie.
- Cummins, Maurice.
- Donohoe, Paschal.
- Fitzgerald, Frances.
- Hannigan, Dominic.
- McCarthy, Michael.
- McFadden, Nicky.
- Mullen, Rónán.
- Norris, David.
- O’Reilly, Joe.
- Ryan, Brendan.
- White, Alex.
Níl
- Brady, Martin.
- Butler, Larry.
- Carty, John.
- Cassidy, Donie.
- Corrigan, Maria.
- Daly, Mark.
- Feeney, Geraldine.
- Hanafin, John.
- Keaveney, Cecilia.
- Leyden, Terry.
- MacSharry, Marc.
- Ó Domhnaill, Brian.
- Ó Murchú, Labhrás.
- O’Brien, Francis.
- O’Donovan, Denis.
- O’Malley, Fiona.
- O’Sullivan, Ned.
- Ormonde, Ann.
- Phelan, Kieran.
- Walsh, Jim.
- White, Mary M.
- Wilson, Diarmuid.
Tellers: Tá, Senators Jerry Buttimer and Maurice Cummins; Níl, Senators Labhrás Ó Murchú and Diarmuid Wilson.
Amendment declared lost.
Section 5 agreed to.
I propose that the House suspends until 2.45 p.m.
Is that agreed? Agreed.
Sitting suspended at 1.40 p.m. and resumed at 2.45 p.m.
Section 6 agreed to.
SECTION 7.
I move amendment No. 5:
In page 13, subsection (4), line 2, after "possible," to insert "not to exceed a period of six weeks".
This amendment is about the assessment. The Bill accepts there should be a care assessment. Section 7(4) states: "Upon receipt of an application for a care needs assessment, the Executive shall, as soon as reasonably possible . . . .". Instead of "as soon as is reasonably possible" we propose the assessment should be done within six weeks. That is to ensure it is done when it is needed and that there is a timeframe for it. We propose giving six weeks to have this assessment done because if a timeframe is not put on it, the process could go on and on. It is also difficult for hospitals because they do not know when the care needs assessment will be done. A patient's acute phase of care might be over, the assessment would still not be done and the patient would be waiting to get it done. There is a priority about making the assessment for high dependency patients in terms of getting suitable placement. The way to do that is to have a care needs assessment, as outlined in the Bill, but we suggest it should be done within six weeks.
I would be interested to hear what the Minister of State has to say in terms of whether that is feasible. What does she expect will happen under the Bill? What sort of timeframe are the Health Service Executive and the Department working within currently in terms of the care needs assessment? Does the Minister of State intend to put anything into regulations as to when it should be carried out? The Minister of State might inform the House on the way she intends dealing with this issue because rather than leaving it open-ended, there might be the possibility of its being done reasonably quickly. Six weeks is a fairly short time but we are talking about high dependency patients.
I support Senator Fitzgerald's amendment because sometimes it can be critical to have these assessments done quickly. As she said, many of these patients are highly dependent. There may be an urgency about it. Speaking professionally as a member of the NUJ, I worked as a journalist for a mass circulation newspaper for three and a half years and I found the fact that I had a deadline of lunchtime on Thursday focused the mind wonderfully. I am what Sean O'Casey would have called a prognosticator and a prevaricator and I believe things can be very easily put off to the next day or whenever. This kind of thing concentrates the mind. I strongly support the principle but I am not sure about the six weeks timeframe. While I do not mean I withdraw my support because of this, I am not sure how appropriate that timeframe is. It may be that a shorter or longer term might be necessary in some circumstances. I would be interested to hear the Minister of State's views on this but the idea of a target date and a time limit is good in ensuring efficiency.
I understand from where Senator Fitzgerald is coming in regard to the time period to which Senator Norris referred. In the whole area of care assessment needs, to which several sections of the Bill refer, the real issue I have come across is the consultation process in regard to the assessment and the discussion with the individual and the family. There is currently a bit of passing of the ball from the social worker to the medical person to the GP, and from one set of suggestions to another, before people begin considering long-stay options.
Other areas of the Bill will also deal with this issue. I am not sure we can insert an assessment period because if a person is in assessment, the authorities may need to continue the assessment over a period of weeks as the person progresses either to a better or worse state of well-being, and assessment in such a situation might not work. There is room for improvement, however, and I am interested to hear what the Minister of State has to say. The one change I would like to see is more involvement on a case conference basis which involves the family with all the other participants in the care assessment to ensure there is full and clear understanding by and co-operation between those associated with the person under assessment and those who should be involved in assessing that individual.
I support Senator Fitzgerald's amendment. It is very easy to include in legislation phrases such as "as soon as is reasonably possible" when what we want to promote in all aspects of care, in particular care of older persons in our society, is a culture of excellence, dispatch and thoroughness. I support the amendment on that basis. There should be minimal delay in this regard. Only if we set out clearly in legislation what we require will we get to the stage where matters are handled with appropriate dispatch given the importance of the decisions involved.
The amendment proposes to impose a timeframe for the commencement of care needs assessments. I appreciate the policy intention of this amendment. It is envisaged that care needs assessments would be undertaken quickly. However, it is considered imperative that the legislation should be flexible on this point. This is particularly pertinent having regard to the fact that the legislation will establish a scheme that will have to accommodate the needs of a rapidly growing demographic.
In drafting the Bill, careful consideration was given to the Disability Act 2005 which provides that assessments must be commenced within three months of the date of application. Assessments of need require a considerable level of resources, particularly dedicated input by health care professionals. As such, the stipulation of a timeframe for commencing assessments within the Disability Act has necessitated that a phased approach be taken to the roll-out of needs assessments. However, even with a phased approach, the HSE service plan 2009 reports that only 79% of assessments commenced within the timeframe.
In summary, given, first, the variable length and potentially time and resource consuming nature of the assessment, second, the rapidly growing demographic to which it relates and, third, the experience gleaned from the roll-out of assessments under the Disability Act, it would be unwise to immediately implement a statutory timeframe in respect of care needs assessment. For these reasons, I cannot accept the amendment. I will, however, offer the Senators a commitment that the issue will be addressed by way of published guidelines, approved by the Minister for Health and Children. Furthermore, the issue will be tabled for consideration in the review of the scheme which will take place three years after its introduction.
I welcome the fact that the Minister intends to publish guidelines, which will be helpful. I take it they will be published shortly.
Yes.
That will be helpful. I ask the Minister of State to bear in mind the difficulties that will arise if those guidelines are not rigorous and detailed in regard to when this assessment should be done, again bearing in mind the high dependency people we are in general talking about.
The Minister of State used the statistic of 79%. Almost 80% is not a bad statistic with regard to the completion of assessments in this roll-out in regard to disability. In a way, that is nearly an argument for accepting this amendment, given that the Department was almost in a position to move to an 80% review. While we of course all want 100%, in terms of the roll-out of any new assessment of needs, close to 80% is certainly moving in the right direction. We have achieved lower target figures in other areas previously.
I ask the Minister of State to seriously consider including in the published guidelines as much detail as possible in regard to the expectation concerning when the care assessment should be done. It could be the case that a person is left in a situation where there are not enough resources to carry out the assessment, although that person is still in a totally unsuitable placement and nobody knows when the necessary resources will be available.
I will withdraw the amendment. Perhaps the Minister of State will come back on Report Stage to give us more detail on the guidelines it is intended to publish and to inform the House in more detail of how she sees those guidelines developing, which would be helpful.
I appreciate the Senator's point in regard to the 79% figure but this means the law is being broken in regard to over 20% of cases. It has taken us five years to reach 79%. I will get further information on the guidelines for the Senator.
Amendment, by leave, withdrawn.
Amendments Nos. 6 to 14, inclusive, are related and may be discussed together. Within this grouping, some amendments are alternatives to others.
I move amendment No. 6:
In page 13, subsection (5), lines 5 to 7, to delete all words from and including "shall" in line 5 down to and including "Executive)" in line 7 and substitute the following:
"shall be carried out by a multidisciplinary team (who may be employees of the Executive)".
This deals with the multidisciplinary aspect of the assessment group, and assessment is at the core of this section of the Bill. The amendment refers to section 7(5) which states: "The assessment referred to in subsection (4) shall be carried out by [the following is a description of the composition of the team] a person or persons (who may be an employee or employees of the Executive) who, in the opinion of the Executive, are suitably qualified to make that assessment and prepare a report in relation to the assessment.” This is general and vague in that “a person or persons may be suitably qualified”. In this area, we have a particular tradition and particular advice from within the professional bodies, which is also endorsed by the HSE. I want to replace that very loose definition with the simple phrase “shall be carried out by a multidisciplinary team (who may be employees of the Executive)”. This is the first and most important amendment.
The second important amendment is No. 13, which seeks to tighten up subsection (7), which currently states: "A care needs assessment may include an examination of the person concerned by, as appropriate, a registered medical practitioner, a registered nurse, an occupational therapist or a chartered physiotherapist, or any combination thereof." However, that combination is an internal reference. It does not expand or allow for expansion but it constrains by numbering off these elements. It allows for a combination of this entire group, but it does not make reference to any other groups such as therapists, social workers and so on. In assessing family and community support one really needs the input of professionals, adequately and properly trained, to review and assess social variables. A document has been produced by the Nursing and Midwifery Council this very year entitled Guidance for the Care of Older People and I wish to quote a sentence from it. It states, "You need to recognise your limitations in the scope of your practice and refer to a colleague, for example older people's nurse specialists, psychiatric and palliative care nurses or other members of the multidisciplinary team, to ensure that the most appropriate care is provided". I accept that section 7(5) states the assessment should be carried out by persons suitably qualified to make the assessment and that section 7(6) goes much further in explicitly setting out professions whose service will be guaranteed in care needs assessment, but social workers are not included, which is a concern.
I refer the Minister of State to the HSE's 2009 code of practice for integrated discharge planning, which argued strongly for patient assessment that is thorough, that covers pathological, physiological, psychological, social and cultural needs with a multidisciplinary and multiagency approach. It is useful to put on the record the professional definition of a multidisciplinary approach as understood generally within the service. Multidisciplinary teams are groups of professionals from different disciplines who work together to provide comprehensive patient assessment and treatment. The team usually consists of medical staff, a consultant registrar, a nursing team, a discharge co-ordinator, community services, a discharge liaison officer, a dietitian, physiotherapists, occupational therapists, speech and language therapists, pharmacists, social workers, a public health liaison nurse, a chaplain and a spiritual adviser. This definition is from the HSE itself and yet a constriction or narrowing is applied. Either it should have been left vaguer to allow for these additional inputs, which are very valuable, or it should have been specified in the way I suggested. One reason is that the type of vulnerable patients involved very often have a complex background and medical situation. It may well be necessary to draw on the resources and professional capacity of people who have a specialised interest or capacity in this area.
I have been briefed by Age Action Ireland and I refer to its position. It believes assessments ought to be made by a multidisciplinary team because of the proven benefits in making appropriate and timely referrals. It quotes several academic papers published in this area including O'Dell, 2006; Wilson, 1998; BMA, British Medical Association, 2000; and Paul et al, 2000. Multidisciplinary teams are advantageous in reducing the likelihood of mistakes and also subjectivity. In other words, there is a group or variety of specialists all of whom bring expertise to bear. Otherwise things may be missed, especially if people are suffering from strokes. There may be an apparent incapacity but someone with a particular skill may unlock a capacity on the part of that person. Multidisciplinary teams are advantageous in resolving the likelihood of mistakes and also subjectivity from the decision making process. In addition, because the assessment is used to determine what health or personal social services may be appropriate for the person, correct assessment is fundamental for people going into care and the nature and extent of services they will be deemed to need.
In 2006 the HSE itself advised that assessment of need for residential care would be carried out throughout the country by multidisciplinary teams of health care professionals in the course of that coming year. It used the phrase "multidisciplinary teams" again. We know what it means and we know also that certain elements are excluded from the operation of the Bill as it stands. I refer again to the complex needs of patients. The benefits of such co-operative working include timely and effective patient discharge, increased patient confidence, continuity of quality care, enhanced communication, partnership regarding resources management and so on.
My final argument, for the moment at least, in support of the amendment is to quote the Minister of State on the subject. On 26 May 2009 the Minister of State at the Department of Health and Children, Deputy Áine Brady, stated: "By maintaining the function of undertaking care needs assessments within the HSE, the legislation ensures that the applicant has access to a multidisciplinary team of health care professionals located close to his or her place of residence". The belief generally is this is not comprehensively catered for in the wording of the Bill before the House and that a guarantee of access to such teamwork and professional expertise needs to be written into the Bill on this Stage. For this reason I put my amendments before the House and I believe the same applies for my colleagues who have placed either similar or related amendments.
I support the amendment. A multidisciplinary team is the only way to proceed. Each individual is different and, therefore, has different needs. This is especially the case for elderly men in rural areas, for example, who need support from a professional such as a social worker and this position has been argued by my colleague in the Dáil. I believe it is necessary to have a service from doctors, nurses and occupational therapists but the service should also involve social workers. No two people are the same and there should be a care package designed to suit every individual. There must be professionals such as social workers available to support the best possible care package for the individual.
I support the statements of my colleagues. We may try to take different ways up the mountain but we all agree there should be more than one person involved in an assessment and that the various needs of a person subject to an assessment should be spotted. In this regard I thank Age Action Ireland and Nursing Homes Ireland for their briefings. Mr. Tadhg Daly of Nursing Homes Ireland is present today.
My approach in amendment No. 7 is to suggest the deletion in page 13, subsection (5), line 6, of "a person or" to move towards what Senator Norris referred to as a multidisciplinary, multiperson approach and that more than one person should be involved. This is the very minimum one would expect and there should be no question of the term "a person or". The fact the legislation is so worded suggests the Government is a good way off realising the complex and multidisciplinary nature of what is required.
Amendment No. 9 proposes the insertion of wording after the word "Executive". The assessment referred to in subsection (5) should be carried out by persons who may be employees of the executive with experience in caring for older persons and this is the nub of the issue. I do not intend to press any of my amendments today but I call on the Minister of State to give consideration to the question of whether we should go even further. I may go further myself on Report Stage. It is not just an option but it should be a requirement that a geriatrician or a psychiatrist specialising in old age should be involved in the care assessment. My reason for this suggestion is that when decisions are being made by, for and to the benefit of a person who may need long-stay residential care, there may be a number of competing interests and sometimes those competing interests may be unconscious on the part of the people who hold them. I refer to an example suggested to me by a geriatrician who has great expertise in this area. He suggested that a younger person who is worried about Mammy or Daddy and feels they may need to go into a nursing home, has the best interests of their loved one at heart and there is no doubt about that. However, they also want their own peace of mind. I will put it bluntly that Mammy or Daddy, on the other hand, might prefer to contemplate falling down the stairs and even being on the floor overnight rather than losing their independence. It may well be that a person who has experience, such as a geriatrician or a psychiatrist who is a specialist in old age, who would see that older person in a consultation, might well be able to tease out some of the issues causing concern to the older person in question. It seems to me that geriatricians and psychiatrists have the kind of experience of dealing with cases that makes their participation not something to be considered as a desirable inclusion if possible but as something that should be mandatory. I ask the Minister of State to give consideration to this proposal.
Amendment No. 10 was earlier ruled out of order on the basis of the usual excuse that it might involve a charge on the Exchequer. I fully support what Senator Norris said in that regard. It is very important for us to be able to consider legislation properly. For example, in the case of amendment No. 10, I was suggesting that it would not be a matter of "may" but rather of "will". My proposal was that a care assessment will include an examination of the person concerned. It seems to me that it should be a mandatory situation that it would be required that there would be a registered medical practitioner or a registered nurse, an occupational therapist or a chartered physiotherapist or any combination thereof and, as I have added, a geriatrician or an old-age psychiatrist. It seems to be very lame to exclude my proposal on such a technical ground when I am proposing that it should be mandatory rather than optional to include such expertise. This goes to the heart of this legislation. To exclude such a proposed amendment on a technical ground shows up the inadequacy of our procedures as they stand.
Amendment No. 12 proposes:
In page 13, subsection (7), lines 34 to 36, to delete all words from and including ", as" in line 34 down to and including "thereof" in line 36 and substitute the following:
"a registered medical practitioner and/or a nurse with an occupational therapist or chartered physiotherapist."
Senators Norris and McFadden have spoken to these proposals adequately and I submit that between all of us, we are making clear the need for full and thorough assessment as distinct from something that is partial or that could be done just by one person. On that basis I will conclude my comments.
Two issues are dealt with in this series of amendments Nos. 6 to 14. I ask the Minister of State to consider the possibility of including social workers in the multidisciplinary team. The legislation is not making their inclusion mandatory but is proposing that professionals are to be used as appropriate. There would be occasions where it would be appropriate that a social worker would be the professional involved. It would seem to me to be very reasonable to include this provision. Given the role of social workers in doing this type of assessment and their familiarity with such assessments and care plans and meeting families where care is needed, to exclude the social work profession from this group of professions is inappropriate and I ask the Minister of State to return on Report Stage and respond to that point.
There are two issues in the care needs assessment where I would see the social work assessment as being critical. The legislation states that the family and community supports available to the person should be assessed and the personal social services that are available to the person should be assessed. It would seem unreasonable to exclude the profession of social work and I ask the Minister of State to consider this proposal.
The independence of the care needs assessment is addressed in amendment No. 8. There is an inherent problem with the HSE being the provider of the service and the body that establishes whether the person is entitled to receive the service. There could be a real conflict of interest and there could be an under-reporting of need, simply because the resources are not in place. The same body would be doing the assessment and recommendations and supplying the service. I refer to a number of groups with an interest in this area. I compliment Age Action Ireland and the Nursing Homes Association of Ireland for the interest they have taken in this Bill and I am sure the Minister of State is also looking at their submissions.
Assessments of need for those with autism carried out in the UK found that very low prevalence rates were found that were completely inconsistent with the national average. The belief was that this under-reporting happened because the services were not in place so there was a tendency not to identify the need. For example, if the HSE is coping with shortages of services which will be the case while at the same time it is being asked to do the assessments, if one is operating within the same service, the tendency might be to minimise the needs of the person. To avoid any under-reporting, we propose that the assessment of needs should be conducted by a multidisciplinary team of health care professionals who are independent from the HSE and the Department of Health and Children. I look forward to the Minister of State's response.
I support the points made by the two previous speakers about the type of examination which is required to ensure the correct result is obtained for the elderly person who would be the subject of the application. It is very important to ask what this legislation provides. We must be determined that this legislation is for looking after the interests of the elderly people in a holistic fashion and who may need nursing home accommodation. The legislation should not be about making the State feel good about the fact it is providing in some fashion a clean bed in a clean nursing home. It should not be about simply reassuring families that their loved one is looked after; it must be about what is best for the elderly person who may be placed in a residential nursing home. As part of the assessment of that person's application and more important as part of the decision as to whether a nursing home solution is either the best or the only option, we must consider all the aspects, not simply the financial aspect, not from the perspective of whether a family member is available to care for them in their own home or community, not whether neighbours or friends can help out; it must be a case of considering what is the best for the person concerned. This is the reason it is so important that all strands of examination from a social worker to the physiotherapist and the GP is part of that equation.
Senator Mullen made an interesting and challenging observation as to what the person may wish for himself or herself. It may not be a clean bed in a clean nursing home and safety from robbery and vandalism. It may be a desire to spend his or her remaining years in the community. To arrive at that solution might require considerable questioning and probing. That is why it is important the examination be done by a multidisciplinary team, as is proposed.
I hope the Minister of State has, at the core of her thinking, what is right for those who are elderly today because that will be all of us tomorrow. The legislation is not about filling a gap, getting rid of the inconvenience of nursing home subventions and finding places for elderly people when there is no one to look after them. That would be a very sad philosophy on which to base legislation in the 21st century. Assessments must include the broadest possible physical, physiological and psychiatric services. The necessary teams must be in place. We must not seek easy answers but look at the question from all angles. I ask the Minister of State to consider these amendments. The Bill must not present the neat and easy solution of Shady Pines. We must be broad in our thinking and aspirations.
Subsection 7(6) states that a care needs assessment of a person shall comprise an evaluation of a list of several aspects of a person's needs. The list consists of physical needs. The subsection refers to the provision of "medical, health and personal social services" but I cannot see a mention of mental health. As my colleague has said, we must be concerned with the whole person and not merely with his or her physical needs. While I do not wish to be patronising, psychiatric illness among the elderly is a serious issue. Senator Mary White will agree that there has been a huge increase in suicide among the elderly. Psychiatric services should be part of the multidisciplinary approach.
These amendments all concern the issue of who may undertake the care needs assessments. Amendments Nos. 6 and 7 would require all assessments to be carried out by more than one person and by a multidisciplinary team. I can assure Senators that applicants will have access to assessment by a multidisciplinary team, as required. As stated previously, the care needs assessment is intended to be a flexible, person-centred process. It acknowledges the reality that some applicants will require a greater level of assessment by a wider range of health care professionals than others. The legislation mirrors this, enabling a person to be assessed by more than one professional, as necessary. This approach is appropriate as forcing applicants to be assessed by all professionals, regardless of their particular care needs, would detract from the flexible nature of the assessment, divert precious health care resources away from front-line services and into unnecessary assessments and could cause needless delays for persons requiring long-term residential care. In addition, the term "multidisciplinary team" is not defined in legislation and I would be concerned as to whether the term could be legally contentious. For these reasons, I do not propose to accept amendments Nos. 6 and 7.
Amendment No. 8 proposes that care needs assessments would be undertaken by a representative of the Health Information and Quality Authority, HIQA. The function of HIQA will be to register and inspect all designated centres, including public, private and voluntary nursing homes. The undertaking of care needs assessments would be outside HIQA's role and would distract from its critical role as a national regulatory authority. It would also represent an inefficient use of public resources. By maintaining the function of undertaking care needs assessment within the HSE, the legislation ensures the applicant has access to a multidisciplinary team of health care professionals located close to the applicant's place of residence. Such health care professionals will simultaneously be engaged in the provision of care, either within the acute sector as part of their primary care teams or in the community setting generally. The transfer of this function to HIQA would require significant dedicated resources to be provided, with a resulting drain on the provision of front-line health care staff from the HSE. The fact that HIQA is a centralised regulatory authority would also represent problems in terms of providing efficient and cost-effective assessments to applicants at local level. For these reasons, I do not propose to accept this amendment.
Amendment No. 9 seeks to stipulate expressly that the person carrying out the care needs assessment must have experience in caring for older persons. The legislation provides that such persons must be suitable, which is defined in section 3 to mean the person has the necessary qualifications, training or experience, or combination thereof, to perform that function. As such, the proposed amendment is superfluous. I do not propose to accept amendment No. 9.
Amendments Nos. 11 to 14, inclusive, all concern the issue of examinations conducted under section 7(7). This subsection is merely an enabling provision which relates to physical examinations under the care needs assessment only. The actual legal basis for undertaking care needs assessment is section 7(5) which states that care needs assessments shall be carried out by persons who, in the opinion of the HSE, are suitably qualified to make the assessment. The intent and purpose of subsection 7(5) is to ensure a multidisciplinary team may carry out assessments on a flexible basis, as required. As such, I can confirm that the section will enable assessment by social workers, as necessary.
On a related note, the parameters of the care needs assessment as set out in section 7(6) extend to social as well as medical and health issues. The assessment is, therefore, holistic in nature. I trust this clarification addresses the concerns of Senators. On this basis, I do not propose to accept amendments Nos. 11 to 14, inclusive.
The Minister of State, although of very pleasant demeanour, is not giving very much to the Seanad. There was a slight chink that indicated she might consider some aspect of the principle. I am a little disposed to calling a vote but I will relent and leave the matter to Report Stage if the Minister of State can indicate she will consider some of the substance of what was said. For example, I referred to the apparently exclusionary effect of having a list. In Bill after Bill we are told not to add items to lists because it would appear to exclude other categories. Section 7(7) includes a brief list followed by the phrase, "or any combination thereof". This suggests the addition of any other specialised expertise is not contemplated. It is noticeable there is no mention of social workers. Senator Fitzgerald and I have proposed the inclusion of references to social workers at different points in this section. Can the Minister of State reassure Members about this? Social work is a professional area which is very helpful in assessments.
If the Minister of State can give an assurance that she will look again, charitably, at what has been said by Senators and, perhaps, promise a further review on Report Stage, we may not be inclined to push for a vote. On the other hand, there is always that possibility. I do not suggest there will not be any votes. There may be some later on.
Like Senator Norris, I admire the Minister of State's demeanour while regretting her lack of flexibility. The word, "flexibility" is key. The Minister of State herself spoke of the need for flexibility. The word can be a euphemism when we think how the wheels of authority grind. The need for flexibility can permit an unhelpful vagueness about what is to be provided. We should focus not so much on flexibility as on accountability and excellence. That is the reason we are proposing a high degree of specificity about what is required when an assessment is being made.
I remind the Government that its record is not good in this regard. Should we depend on everything being fine because the language is sufficiently broad to include everything that might be required? Recall that although people have a constitutional right to State-funded nursing home care, less 80% of the non-contributory pension, the authorities have not wanted people to know about that. Health care professionals who advised people, who were thinking of opting for the relatively high cost subvention scheme of nursing home care for loved ones, of their right to State-funded nursing home care were regarded as going offside. When they said that if they were told the constitutional position is otherwise, they would advise people accordingly — I spelt this out on Second Stage — the HSE officials more or less said: "You know the score". This is the State's record. Recall, too, that in recent days we have been discussing the Ryan report and the failure of the apparatus of the State to treat people properly. It is happening in this area too, in a different way. People have not been encouraged to pursue their rights.
I would go further. Earlier, my amendment proposing the inclusion of the therapeutic needs of the person was ruled out of order. Under the guise of generosity and giving people peace of mind, what has really happened here is that the State has not wanted people to know their rights. Then it holds out the so-called fair deal as a type of manna from heaven. There is something wrong with that. There is also something wrong with the fact that in a system where the State proposes to take money from people in the form of a proportion of the value of their property after their death, which is unprecedented, the people who would avail of such provisions are not guaranteed, at least, all necessary therapeutic care. We are aware of the diversity of needs of people in long-stay residential care. What should be on offer from the State, which presumes to take some of their property after their death, is at least everything they might be able to get if they were on the top plan of the VHI. That would be cherishing all the children of the nation equally, including our older citizens.
Therapeutic care in nursing homes is important and should be front and centre of what the State proposes to provide. Consider a person who has a swallowing disorder or a condition that might require some form of speech therapy. Is that provided for or guaranteed under this legislation? I do not think so. However, it arose in the Leas Cross report, and calls for such care provision were included in the Irish national audit of stroke care. That was accepted. It is interesting to note that Appendix A in the HIQA nursing home regulations for standards in residential care refers to the need for a minimum data set for needs in nursing homes. I am talking about an all-encompassing assessment of the needs of people who go into long-term residential care, with their full range of needs being assessed and set down. It would be much more than the rather vague assessment in which merely one person might be involved, as proposed by the legislation for the care assessment.
Something more thorough is required and this is aspired to by HIQA in the appendix. Not only would this help to ensure that the various needs of the person going into long-stay residential care would be addressed but it would also ensure thorough data for assessing how our nursing homes are performing, data which could be compared with international experience. However, I do not believe that is forthcoming and I regret that very much. At least we should be considering a national computerised system that gives instant feedback on each person's needs as well as our ability to assess the quality of the response at any time.
That is the reason for our concern. When the Minister talks about flexibility, what she is really endorsing is an unhelpful vagueness that will, on occasions, not prevent the correct assessment from taking place but very likely on other occasions will provide cover for an inadequate response to the care needs of the individual.
I share the concerns of Senator Mullen, Senator Fitzgerald and the other Senators on this side of the House. The phrase "any combination thereof" must be outlined more clearly. This is about the person's mental state, their happiness and how they will live the rest of their lives. As Senator Mullen said, a contribution from the person's estate will pay for this service. This is not just about forgetting our elderly by putting them into horrible institutions, as we did in the past, but about creating a home for the elderly, our relatives and loved ones, where they can live complete lives. They should be able to garden, to live in villages for the elderly, to get their hair done and look after their other necessities.
Assessment by a psychiatrist is necessary and it should be included in the list of needs. The Minister has provided a very comprehensive and good list but there is no reference to the mental health of the individual. There have been appalling circumstances in the past and the Minister cannot blame us, as legislators, for not having confidence. The Minister must reassure us. The last phrase "any combination thereof" is too vague.
Senator Rónán Mullen and Senator Nicky McFadden have put the case extremely well. There is a real danger of minimalist standards, combined with the lack of an independent review. There is a striking lack throughout the Bill of provision for independence or independent reviews, or involvement by people other than the HSE. This can be linked to an earlier amendment I put down which was supported by my colleagues. That amendment provided for a report to the Houses about the amount of money. When the Minister responded to that proposal, she said that what I had said about mental health was not correct. It was correct; I have checked it. There was a special allocation for the implementation of A Vision for Change, but that money was hived off. What the Minister said was incorrect. The money was put aside for mental health but it was hived off and not spent in the area for which it was allocated but on general health. That is the reason for having the specifics built in and the Minister reporting back to the House. It happened previously and it could happen in this area as well. That is also the reason there must be provision for independence in the Bill, whether it is with regard to care assessments or other reviews, the nursing homes, disputes about fees or other issues. There must be provision for independent review but it is not included to the necessary degree in the Bill.
The other issue is the care assessment. It is assumed that we are discussing quite high dependency persons. High dependency generally means there is a range of needs that must be assessed. It is unlikely that one discipline would be able to do that. The Minister should name a social worker and a psychiatrist in the list of the potential people who should make assessments. In addition, she should go into more detail about the guidelines she intends to publish. Perhaps she will clarify whether this area of assessment will be addressed in the guidelines, how the multi-disciplinary assessment will be carried out and by whom. What is the standard of assessment?
Previously, when I worked as a social worker, I was involved in assessments and they can vary. Senator Callely said assessments often need to take place over time, and that is true. It is likely that a number of disciplines would be required and that there would be certain minimum standards. It would be necessary to examine the physical, psychological and mental health and the social care provisions. In most cases all these issues would have to be addressed so a proper final care assessment can be carried out. That should be spelt out. The specificity which Senator Mullen discussed is the key point because without it one is potentially dealing with low standards and lack of proper assessments. My other point relates to long-term residential care services. What exactly are we talking about here? This is not spelt out in the Bill and many people are concerned about it, including many providers of such care and people who work with the elderly. If a person is obliged to give up 15% of his or her home, to be taken from the family, exactly what will he or she get for it? What level of care and what services will people receive? Will physiotherapy and occupational therapy be included? What minimum and maximum standards are guaranteed in the legislation given what is proposed, namely, the financial intrusion and demands made and the precedents to be set in the taking of money from estates? This may well be necessary but what will people get for their 15%? Is this information outlined anywhere? Will the Minister of State address this matter?
Might there be a situation in which nursing home residents would not have the same entitlements to specialised equipment, therapies and access to allied health professionals they currently enjoy in the community? We know that community services are lacking for the elderly at present but I acknowledge there have been great improvements, for example, in access to occupational therapy. Occupational therapists call to elderly people in their homes, make assessments and provide the aids and equipment necessary and this has led to a qualitative improvement in people's lives in the community. However, is there a possibility that people might end up in nursing homes without such access, having had 80% of whatever money they might have, such as pensions, taken? They might not have access to money to be able to afford to get basic services they badly need. What will nursing homes do if they find themselves in this situation, without any clarity?
I intend to discuss section 11 of the Bill and I hope my colleagues will do so also, especially the lawyers in the House. I am intrigued by this section which states there is no obligation to provide for or arrange for the provision of any such services. I find that an extraordinary paragraph. Perhaps it is pro forma but it brings up the issue of an obligation to provide services. Where is that laid down? What is the obligation and what is the standard of such services, considering the 15% of money and estate that is to be taken?
I ask the Minister of State to return to this matter. Is one entitled only to one's health care, food and bed, or are other services such as physiotherapy, chiropody and occupational therapy included? How can we find out about this? How can we know what is included? Where is it specified in the legislation? Will it be included in any guidelines the Minister of State will publish? If not, there will be a very big gap with very serious financial consequences for individuals, nursing homes and the State. This is an issue we must discuss in the House and there must be clarity on it from the Minister of State, either now or on Report Stage.
I hope the Minister of State has been listening intently to what was said by previous speakers. One of the weaknesses in the way we treat legislation in this country is that a Bill is published and a great deal of debate follows but minimal changes may flow from it. It is disappointing that, although there were ongoing debates about the elderly and their care before the publication of this Bill, we did not have a level of substantive debate, either in the Houses of the Oireachtas or at the Joint Committee on Health and Children. We might have teased out the problems and put forward our ideas about possible solutions in advance of publication.
This is a very important political debate but is also important philosophically. It is a statements debate because it offers a statement about how we wish to see today's elderly being treated. All of us will be tomorrow's elderly. I am worried that what we are doing is a housekeeping rather than a homemaking exercise, if the pun may be forgiven. It is about fitting people into a slot where they will be neat and tidy but removed and no longer the source of controversy and debate.
Reference was made earlier to the Ryan report and to what we must do as a result of that dreadful report and other similar ones dealing with what we deem to be atrocities. There is talk of a referendum on children. I hope that will come to pass and that children will have strong constitutional and legal protection. In 1983 and on other occasions we introduced into the Constitution protection for our unborn and I am happy with that provision. On Second Stage I made the point that perhaps it is time we deemed necessary the possibility of having a referendum to provide protection in the Constitution to safeguard the rights of the elderly in our community. That may be the type of statement we should make as a society.
Unfortunately, there are people in this country today who are literally afraid to grow old because they have no idea what the future holds for them. This Bill is an attempt to resolve their worries and concerns but it is politically and philosophically wrong in the sense that we are trying to find a solution to remove the problem from our books rather than address the needs of tens of thousands of our citizens. I do not mean this as party political and I hope the Minister of State knows me well enough to realise that.
The debate, therefore, must be wide-ranging as must the examination of options. That is why it is so necessary the Minister of State should take on board what we are saying. Perhaps we will not divide on Committee Stage. We are all going down the same road and in some way will all be part of the consequences of this legislation. We must get it right. The debate has not been sufficient over the course of the past two or three years. We do not seem to have recognised fully the demographics of society or faced up to the challenge of what we know the population trends will produce. However, if this Bill, in its amended form, is to bring about the sort of place in our society which our elderly people can enjoy, with safeguards, security and other options, more must be done. This is only a small part of what we should be trying to do for our hundreds of thousands of elderly citizens. We will not debate again today the questions of carer's allowance and benefits, community care and housing associations etc. That is for another day. In so far as we are trying to provide long-stay residential care by means of this Bill, it is crucially important that we approach it from the widest possible remit and that the type of concerns my colleagues have outlined should be taken on board by the Minister of State.
This is a profound political opportunity for the Minister of State to make her mark. Since I had the privilege of joining the Oireachtas over 20 years ago I have to say, looking at all sides of the Houses and all political parties, there have been very few Ministers who could genuinely say they had made a difference when they walked out of Leinster House. One who made a difference, with regard to the elderly and their care, was the late Seamus Brennan. Most people simply pass through and finish their job without making any real difference to anybody. I hope the Minister of State will avail of this opportunity to put in place a scheme of care and support for our elderly which will make a difference. She should try to approach that in the right direction, philosophically speaking.
The Bill needs significant changes, particularly in the thinking that underlies it. We are asking for a very small step, namely, that there should be the broadest consultation, examination and level of analysis of each person's unique circumstances. Rightly and properly, we love to tell children and teenagers how unique they are and how many options lie before them. The world is their oyster. The thinking in the Bill says to people at the other end of the life cycle they are not unique but more or less the same and one solution will fit all. I certainly do not agree with that analysis and hope the Minister of State can bring about the changes that will make life not just bearable but better for the people who have built this country. Our paying so much lip service to the elderly and claiming they built the country, etc. is glib, self-satisfying and hypocritical unless we make real changes and make this Bill work. We must put people, including the elderly, at its centre and not regard them as parts of some economic equation.
Progress reported; Committee to sit again.