Seanad Éireann debate -
Wednesday, 9 Nov 2016

Vol. 248 No. 4

Health (Amendment) (Professional Home Care) Bill 2016: Second Stage

Senator Colm Burke

I move: "That the Bill be now read a Second Time."

I welcome the Minister of State and her officials. I thank the Minister of State for the work she is doing in the area of elderly care.

In 2011, the Law Reform Commission published a report on the regulation of people who provide home care or who care for individuals in their own homes. The research relating to the report was carried out in 2010. As a result of that report, I have published the Health (Amendment) (Professional Home Care) Bill 2016. I originally brought the legislation forward during the lifetime of the previous Seanad but, unfortunately, it was not reached. I sincerely thank the Minister of State for taking the time to come to the House to deal with the matter today.

I hold strong views on this issue. I will outline the current position. If a person serves prison time for any offence, there is nothing preventing him or her from setting up, on the morning he or she is released from prison, a company that undertakes to provide professional home care to elderly people. What I am saying is not to be taken out of context. I am merely highlighting the fact that there is no strict regulation in respect of who can provide the type of service to which I refer.

The Law Reform Commission set out a number of recommendations in its 2011 report. A key recommendation was that the Health Information and Quality Authority, HIQA, should be empowered to regulate and monitor undertakings that provide professional home care, whether public sector, private sector, for-profit or not-for-profit. While the main beneficiaries of the proposed new HIQA regulations would most likely be those over 65 years of age, the proposed system should apply to professional home care provided to any adult over 18 years of age. This was another recommendation contained in the Law Reform Commission report. The HIQA national standards for professional home carers should be specifically tailored for the home-care setting. Obviously, the regulations for nursing homes would be different from those relating to home care. The recommendations build on the 2008 draft HSE home-care guidelines. That is how the HIQA standards were subsequently agreed in respect of nursing homes. Draft guidelines were published by the Health Service Executive in 2008.

The proposed standards should have regard to specific principles, including the right of a care recipient to independent living, privacy, dignity, quality of care and protection from abuse. There should be a specific register of professional home carers which would set out specific requirements in respect of the registration and monitoring. The terms and conditions of home-care arrangements should be agreed between professional home carers and recipients. This should be recorded in a care contract to ensure maximum protection for the care recipient. These are some of the recommendations contained in the 2011 report.

Almost six years have passed since the publication of the report and I believe we need to debate the issue. Significant change has occurred in demographics in Ireland. According to the 2006 census, 11% of the population was over 65 years of age. It is predicted that 15.4% of the population will be over 65 years of age by 2021. Another major change has taken place in the population over 85 years of age. My understanding is that the number of those over 85 years has increased by 20% the past six years alone. Things are changing a great deal. This is a great thing about our health service. I realise many people criticise it and some of those criticisms are justified. However, despite all the criticism, people are living longer and looking after themselves better and for longer. Moreover, there is more information with regard to how not to put one's health at risk.

Another figure is relevant. In 2002, a total of 114,000 people were living alone. The prediction for 2021 is that the corresponding figure will be 210,000. This is relevant for the older population. For example, let us consider the figures for our hospitals. Up to 51% of all hospital beds are occupied by those over 65 years of age. As our population continues to age, there is going to be more demand on our health services.

As our population ages, more demand will be placed on health services and on general practitioners. It is predicted in one report that consultations with general practitioners by members of that older age group will increase by 33% by 2021. In some European countries, there are four people retired for every two people working. The demographics in Ireland will also change. With regard to the current structure, if we consider the cost of the fair deal scheme and that more than 23,500 people are in private nursing homes and another 6,000 or 7,000 are living in community settings, that is not what everyone wants. An increasing number of people want to remain in their own homes. I recently attended the birthday party of a lady who is 100 years old and who lives alone. I am sure other Senators could cite similar examples. A relative of mine who is 95 years old and confined to a wheelchair is residing on her own but she can only do so because home care is being provided.

The Law Reform Commission report of 2011 refers to the fact that there is imbalance in the focus on residential care as opposed to home care. The position in this regard has not changed substantially in the past five years. We need to change the whole focus. There are certain categories of people who will require residential care. However, the number of people we should try to keep out of residential care will continue to rise and we need to ensure that we can continue to increase the number of home-help hours provided. I have the 2015 figures and I am sure the Minister of State has more up-to-date ones. Approximately 10.4 million hours of home care were provided to 47,915 people last year. We have major challenges ahead of us.

I will briefly go through the detail of the Bill, which sets out the amendments to the various sections of the 2007 Act. It defines what constitutes a designated centre and states that professional home care "means services which are required to ensure that an adult person, that is, a person aged 18 years and over, can continue to live independently in their own home and includes, but not limit it to the services of nurses, homes care attendants, home help, various therapies and personal care and palliative care". It also sets out the amendment to section 8 of the Act of 2007, which deals with the standards of professional home care. The Bill further sets out the various changes we need to bring about in order to put a proper regulatory structure in place. In fairness to the people delivering services, be it through the HSE or private contractors, they are providing very good services right across the country. I hope the 10.4 million home-care hours currently being provided could be increased to a major degree because this would ensure that we could assist many more people and that there would not be the same pressures on nursing homes and hospitals.

Another relevant issue relates to hospital discharges. I dealt with a case recently of an elderly person living alone who was discharged from hospital. I am not clear about the connection between the hospitals and the people working in the community. No home care provision was set up for the person in question. Therefore, they were very much reliance on their family members who live 50 to 60 miles away. Much more co-ordination is required in that area. Our hospital service also needs to have contact with the people who are contracted to provide the support to people in the community.

The Bill sets out in great detail what is needed but it also makes adequate provision for the Department to bring forward the necessary regulation. It would have to examine it and deal with the regulation that needs to be brought in to provide supervision and so on. When a Law Reform Commission report is brought forward, it is important that it is not simply left on a shelf and that we proactively examine what is the best way forward. We cannot afford to leave this sector totally unregulated. Unfortunately, in the case of many care facilities down through the years, we relied on the skills and judgment of those we thought were properly managing them but now we find that report after report has to be compiled. That is not the way we should allow this area to be managed. We should set up a regulatory structure. The Bill deals with this issue and I know it is not written in stone. I would like to hear the Minister of State's comments on it. I would also like the Department to be very proactively involved in developing the legislation and the level of regulation required in this area. I thank the Minister for taking the time to be with us this afternoon.

Senator Maura Hopkins

I thank the Minister of State for attending. I also thank Deputy Colm Burke who has done a great deal of work in this area in recent years. This is a very important debate around ensuring that people who receive care in their homes across the country are being provided with the best possible care and that we have appropriate structures and regulation in place to deal with the difficulties that continue to arise. We know, as Senator Colm Burke mentioned, that carers do very important work. In the vast majority of cases, professional carers and family cares are doing the very best for the people for whom they care. However, we know of situations where standards have not been at the level at which they should have been.

In 2010, a "Prime Time Investigates" programme highlighted appalling standards of care that are just not acceptable. However, since that time there has been a void in terms of dealing with this matter and putting in place regulatory standards to ensure that those people who are vulnerable and need care are supported in the best possible way. HIQA said that it has received complaints about home-care provision but that it does not have any legal powers to investigate them. That is a major issue. HIQA can inspect community nursing home facilities but our main focus should be on supporting people in their homes. We have seen increases in the number of home help hours and in the number of home care packages provided but we need to ensure that the care delivered in people's homes - which is where most people want to be if they have the right support - is to the highest possible standard. We need to protect those individuals. I urge the Minister and the Department to progress the work in this area in order to ensure that there is proper regulation to deal with cases where the standards we would all expect are not being reached.

I very much support my colleague, Senator Colm Burke, in respect of the Bill he has brought forward. I look forward to working with him and ensuring that progress is made in this area in terms of better regulation of professional home-care provision.

Senator Keith Swanick

Fianna Fáil is happy to support this legislation, which stems from a Law Reform Commission report published five years ago. The legislation provides for a regulatory framework and legal standards to be put in place for professional home carers engaged in the provision of care to people in their own homes. Similar legislation based on the Law Reform Commission report was published by Deputy Billy Kelleher in 2012.

As Senator Colm Burke stated, it is recommend that HIQA should be given additional regulatory and inspection powers to ensure that appropriate legal standards are in place for undertakings that provide professional home care.

The report did not propose that the HIQA regulatory and inspection system would apply to informal carers such as family members. That is important in so far as it has allayed fears among people in the community. I heard that at first hand in the practice. The report made 29 recommendations for reform of the law and also included a draft health Bill to implement them, which is the one before the Seanad today. The LRC pointed out that it is well known that the proportion of people living in Ireland who are aged over 65 has been increasing in recent years and is projected to increase at an even greater rate in the coming decades.

I wish to highlight a few welcome provisions in the Bill, but I will not go through them all. It provides that palliative care be included in the definition of professional home care. That is very important, as it is a basic human dignity that people can spend their final days in their own home, surrounded by their loved ones - friends and family. The assessment must include an assessment of companionship, which is also very important. As a rural GP I am very well aware of how mental illness affects the elderly population. Those elderly people are often without a voice. Companionship needs may include preparing snacks and monitoring diet and eating. Malnutrition is rife in this country and we do not realise it, especially among the elderly population who have chronic diseases such as chronic obstructive airways disease. Other elements of companionship include arranging appointments, reminders for medication, which is also important because it is estimated that half of all medications are taken incorrectly in this country. In turn, that would prevent admissions to secondary care.

In developing a Bill such as the one before the House it is important that it is matched with investment in primary care. By that I do not necessarily mean primary care centres, although they are important in certain locations. I am referring to the provision of care in terms of bodies on the ground - the provision of nurses and GPs. It is about the activity that happens within the primary care centre more so than the bricks and mortar of the centres. If the Bill is to work we need investment in the carers who provide the front-line services in communities.

In terms of making home care packages a statutory right, that was the aim behind a Fianna Fáil Bill introduced by Deputy Willie O'Dea in the Dáil prior to the recess. If passed, the Bill would be an enormous step forward in helping to empower older people. It would enshrine in legislation their right to services to allow them to stay in their own homes and communities for as long as possible, which would not only benefit the individuals concerned and their families but also the State due to less demand being placed on long-term residential care services. It is time we gave older people a greater choice in determining the care they receive.

Senator Máire Devine

I thank Senator Colm Burke for bringing this Bill before the House. I wish to respond to a comment made about discharges from hospitals. How callous is the national director of acute hospitals in trying to persuade nurses to forcibly remove patients from their beds, but sin scéal eile for another day?

Sinn Féin will support this important legislation which will safeguard and protect older people. Those people have made Ireland what it is today. They are the backbone of the country. The issue is extremely important in this ever-changing world where the background of technology has changed as well as societal behaviours and there is more widespread use of both private and public sectors in the provision of essential care. In order to support people in their later years it is important that a proper regulatory framework is put in place which will give older people and their families the comfort and confidence of knowing their physical, mental, emotional and-or financial well-being will be safeguarded by regulatory legal powers.

The provision of private home care has grown enormously and advertisements are constantly on television for it. Several workers in the sector contacted me as they knew I had previous nursing experience to check out what was going on as they thought certain things were wrong. They were very concerned and their response was really humane. They were like whistleblowers. Many of the companies just ignore elderly people lying in bed with incontinence difficulties and leave them there for a long time. They do not want to put in the extra hours or the extra work as they are overwhelmed. The area needs to be regulated, which is the reason the Bill is so important. The experience of some home care staff has left them aghast at some of the practices. The Bill is a very practical and much-needed step.

Home care is the care that the vast majority of older people and their families seek, as opposed to residential care. Many feel imprisoned when they go into a nursing home. It suits some but not all, but often there is no choice available to people. I note the progress of the Assisted Decision-Making (Capacity) Bill. There will be much more demand on the resources and we must build up the provision of home care and community care and keep people where they belong and feel comfortable. That is what they deserve rather than being made to feel they are a burden on society and must be locked away or sent to prison.

The basis of the Bill is built around the principles of independent living, privacy and dignity for people requiring home care, quality of care and most important, protection for people who receive care. We agree with and fundamentally support those principles and have no hesitation in supporting the Bill. We also welcome the proposed introduction of a register of all home carers and the introduction of an assessment of need, which are essential in moving towards the principles outlined.

We have a concern about how the measures contained in the Bill will be implemented and adhered to. Ultimately, the responsibility for adherence to standards will fall to HIQA. I know HIQA and I commend its work. As previous speakers said, it is a success story for a relatively new authority but the demand for its services is growing. The added responsibility of regulating home care providers would stretch HIQA at a time when it is already stretched to the limit. More supports and resources will have to be provided to HIQA to give the Bill any teeth.

The Bill specifically deals with professional home care. I acknowledge the care that is provided by thousands of family carers all over the country. A significant amount of care provided to older people is done by unpaid family or friends in people's own homes. Perhaps that angle could be examined on another occasion because Age Action and ALONE have raised cases of abuse, mostly of a financial nature. I am conscious that it does not relate to the Bill before the House.

The current State policy of care for older people is based on two pillars: first, financial support for nursing home residences, which has been the priority and we must move away from that being the sole focus; and, second, the provision of home help, home care and day care for older people. Despite the fact that most care is provided for people living in their own homes, the vast bulk of State funding is spent on nursing home care. The policy is a failed one as nursing home care demands huge resources. Nursing home care is needed for some citizens obviously but there are many people who do not need it but end up in a nursing home. Insufficient resources are directed towards the provision of home care compared with other countries, especially Scandinavian countries. That is an evident policy failure on the part of the State. In Sinn Féin's alternative budget, we proposed an additional €32.4 million in supports for older people. The funding was intended to increase home help hours, which would cost €20 million and an increase in home care packages by 10% which would cost €12.4 million.

We are committed to the provision of health care services and social care services with equal access for all, based on need and to the greatest extent that resources allow. That right is especially relevant for older people. We are all aware that Ireland’s population is ageing and our current services will not sustain our population into the future.

I welcome the Bill and congratulate Senator Colm Burke. The Bill is progressive and it will implement safeguards for older citizens whom we respect and treasure. New politics should not be just piece-meal. It is an opportunity for progressive change. My party's alternative budget is consistently dismissed as fairytale economics. We all know it is not bonkers economics. It is costed and it gives value for money. People should open their eyes and their hearts to it and get some idea of what it contains.

It contains a vision to deliver a fairer society, in particular, for what could be considered a very vulnerable group in the community.

An Cathaoirleach

The Minister of State has indicated she might wish to speak. She may come in now or at 4.45 p.m., whichever.

Minister of State at the Department of Health (Deputy Helen McEntee)

Of course.

An Cathaoirleach

It is a Government speaker next. I call Senator O'Mahony.

Senator John O'Mahony

I will be brief. I simply want to support this Bill and commend Senator Colm Burke for sticking with it along the way, following it and ensuring that it has been brought before the House. Its contains commonsense provisions. There is a commonsense approach. Its provisions are there to protect, not only the person who is being cared for but the excellent carers who are out there as well. As for its effect, this will protect all sides and eliminate the need for any of those who should not be involved in caring. That is an important point.

I would not be an expert in this area. I would have assumed, maybe naively, that these regulations were already there for the carers in the home. I am referring, for instance, to section 6 that provides that an assessment of needs of care of the recipient must be carried out in advance, and that the dignity, independence and needs of the person who is cared for have to be taken care of. As Senator Colm Burke pointed out, the number of elderly people is increasing. People are living longer. It is more economic to care for them in the home.

I do not usually listen to "Liveline" because it is continually a moan, but I heard it last week. An elderly lady who rang in to Joe Duffy was not criticising the nursing home that she was in but wanted to get home. There may have been an issue with the family or whatever, but a Bill like this can only further eliminate any of the loopholes, abuses or whatever in the system.

It is vital that the provisions of this Bill are brought forward by the Department at the earliest opportunity. It can only be a good result for everybody.

Senator Colette Kelleher

I strongly support the Health (Amendment) (Professional Home Care) Bill 2016, as presented by my fellow Senators, Senators Hopkins, Richmond and Colm Burke, during Private Members' time.

Home care enables people who have a disability, people living with a chronic condition, people with dementia, people who are frail or elderly. Home care enables people to live well with their disability, condition or frailty. It enables people to live independently and continue to be active participants in their own homes, among their families - citizens in their own community and country. Home care enables people to live where they wish to be, and often supports people with the most intimate and most personal care in familiar surroundings - familiarity being so important, for example, for a person with dementia or those caring for him or her. Home care enables people to even die in the comfort of their own homes, supporting the person with end of life palliative care which is referenced in the Bill. Therefore, home care is a really important part of the web of support that we all wish to rely on for those we know - people we love and for ourselves, the web of support that we would all wish to rely on when we no longer can fully look after ourselves.

This Bill acknowledges that home care can be provided, though not exclusively, by "nurses, home care attendants, home helps", and includes various therapies and personal care, including, as Senator Swanick mentioned, companionship which is often forgotten. Loneliness often really affects people. The Bill covers all of the aspects, from eating food that is digestible to personal care, to palliative care and to companionship.

Access to the right kind of home care, and at the right time, can literally transform the lives of both the person needing some support and his or her family, and this view is not new. The excellent Law Reform Commission report, published in 2011, highlighted in unequivocal terms the case for home care dating as far back as 1968 with the Care of the Aged report, the 1970 Health Act, The Years Ahead report of 1988 and the 1997 impact of The Years Ahead report. In fact, home care has been official Government policy and strategy since the 1990s and one wonders why home care, such an important plank of modern, dignified living for citizens, can be so neglected and unregulated for so long.

More recently, the preference, benefit and cost effectiveness of home care was, once again, affirmed in the report of a joint study published in July this years by UCD, Age Action, the Alzheimer Society of Ireland and the Irish Association of Social Work, IASW, entitled, Meeting Older People's Preference for Care, where people's clear preference was for home care rather than residential care.

This preference for home care was, once again, reflected in the support for the Alzheimer Society of Ireland's petition for expanded home care in its submission for the 2017 budget which was signed by 25,000 people. I have the submission here. It runs to three volumes, and is from people in all parts of the country. That is something that we should be paying attention to and taking note of. One can see what can happen when the citizen is ignored in countries such as the USA. When people go to the bother of signing a petition, we should take note of what is in it and pay attention to it.

In spite of warm words, photo opportunities by Ministers and politicians eager to be seen at pre-budget events, this preference for home care and the petition for it was only very modestly responded to, with a most modest increase in the home care budget for 2017. It is a baby step in the right direction which, of course, I welcomed in place of the recent cuts we have all seen. I welcome the additional funding but sometimes it is hard to see. Official information about home care is hard to find and maybe the civil servants here can help us out with the language because sometimes one gets a letter in response and one is not sure whether the funding is more or less. That would be important.

It is also important that additional funding for home care, if it is allocated, actually gets through. The most recent information I have on the modest - that word again - investment in home care through the national dementia strategy, co-funded by Atlantic Philanthropies, is that funding for the 500 intensive home-care packages has only reached 72 of the estimated 55,000 people with dementia in Ireland - a drop in the ocean. Not only is the case and preference for home care proven, it is also cost effective and often cheaper than residential alternatives. The availability of home care enables the health care system to work effectively for patients' timely and appropriate discharges, freeing up much-needed acute hospital beds.

This is an important Bill as it addresses home care specifically. Although home care is provided in its different guises to an estimated 50,000 people in Ireland for charge and often for profit, and funded by the taxpayer, shockingly, home care is not regulated. Given its nature of home care workers working on their own providing the most intimate of care to vulnerable people, shockingly, home care remains an area that regulation does not reach. The work is difficult and is usually carried out by the kindest and most compassionate of people, but some people are just not cut out for this kind of work which is sometimes badly paid. From scandals of the past, we know that work like this can also attract the unscrupulous and the abusive - people in it for the wrong reasons with vulnerable people at their mercy. The unregulated home-care sector makes it easy for such people to be up close and personal with people who are vulnerable, people we know, people we love and care about, people like ourselves one day. The kind and decent home care worker will welcome regulation and oversight and will have nothing to worry about. The other kind might just be put off and be denied easy access to prey on vulnerable people.

This Bill provides for the extension of the powers of HIQA to regulate professional, not family-provided, home care, building on and avoiding duplication of HIQA's expertise in its regulation of nursing homes and residential care for people with disability. The Bill provides for HIQA to set out national standards. These are already in draft form by the HSE.

The Bill provides for the setting of training requirements for those providing this most sensitive and intimate of care and manual handling. It also provides for the establishment of a registry of all professional home carers.

I urge the Minister to take on this Bill, or do we wish as politicians to abdicate our responsibilities to "Prime Time Investigates" as in the case of Leas Cross or Áras Attracta? Shall we just wait for the scandal, the abuse or even the death of a vulnerable person in receipt of home care? Must we wait for Joe Duffy or the hidden camera before we act? If that is the case, perhaps those who voted to abolish the Seanad might have been right. Today, we have an opportunity to prove the worth of the Seanad. I urge support for this Bill. It will improve the lives of people with disabilities, older people, people with chronic conditions and people such as ourselves in time. We have a duty as legislators to put people first and to put protections in place. There will be arguments about money, but money can be suddenly found to bail out banks or to fund pay deals. It is important that we find the money to provide this regulation and to act before we see something horrible on our screens. I urge the Minister of State to take up legislation on behalf of people with dementia or disabilities and older people who may not always be able to speak out for themselves.

Senator Gerald Nash

I am pleased to have an opportunity to contribute to the debate and to make a few points that, I hope, are relevant to the House's consideration of the important matters before us. I congratulate Senator Burke on his far sightedness in introducing this important legislation, which my party supports. It is clear to everybody that a form of regulation is required in this sector and for home care provision in general. We should use every lever at our disposal to make sure those who wish to be cared for at home, whether they are older or are chronically ill, have that option, and that it is viable and supported by the State. We know from experience that long-term nursing home care is expensive and it is not in all cases the preferred option for a significant number of people. Most wish to stay at home as long as they can to be cared by their loved ones and, indeed, by professionals. While I acknowledge the demographic and economic challenges the country faces, we need to prepare and plan better for our future. As most of my colleagues have said, most older people would like to retain their independence and autonomy in their homes and they should be supported in doing so.

The home care sector has evolved organically over the years and there is a complete absence of regulation in the sector, which is surprising to some. A regulatory framework, therefore, is absolutely essential both for those who are being cared for and those who are operating in the sector. The Bill recognises this but if we are serious about enabling people to remain in their own homes as long as possible, we need to do much more than merely regulate the sector and those who work in it. Senator Swanick mentioned the need for investment in those who deliver the service, which is crucially important because the sector is characterised by low pay, limited protections, low hour contracts and it is open to exploitation not just in respect of those who are being cared for, but also in respect of those who work in the sector. It is one of the great conundrums facing our society that those who do some of the most important jobs - it is not just a phenomenon unique to Ireland - such as those who deliver early years education and those who look after our older people, whether that is at home or in nursing homes, are treated extremely poorly in terms of pay and terms and conditions.

Section 2(h) of the legislation provides for the development of what might be described as a "contract" for the provision of care services, fee arrangements and so on. It is important and it should be front and centre of any new legislation governing this area but the Bill is silent on the need to address the pay and working conditions of those who deliver services on the front line, day in, day out, in this exposed sector. It does not recognise that the norms in the sector in the context of pay and terms and conditions need to be drastically altered, improved and enhanced. We will never, for example, have a decent high quality and affordable child care sector or a decent, accessible, quality home care sector if that reality is not addressed. I would like more effort to be made by this Administration to do that.

I fully support the principle that those who work in the sector and companies in the sector should be properly regulated, and progressive people in the sector believe that as well, but the Bill and the Government's approach in general to this area could be improved immeasurably - indeed, the message the Bill sends would be better understood - if a real and sincere effort was made to address those shortcomings in a sector that is extremely exposed. I look forward to hearing the views of the Minister of State and Senator Burke on how those issues can be satisfactorily addressed by Government because we will not have a decent quality system unless we reward and support those who work in it.

Minister of State at the Department of Health (Deputy Helen McEntee)

I thank Senator Burke for highlighting this important issue. Nobody would question the work the Senator has done to date in this area. He has been working on the Bill for some time. Home care is an increasingly important part of the supports that we offer to older people, and will continue to increase in importance into the future. In that context, it behoves us to consider how home care should be provided and regulated. The Senator has mentioned a number of the issues dealt with in the Law Reform Commission report. This 2011 report highlighted the imbalance between residential and home care. The number of people aged over 65 will double in the coming years while the number of people aged over 80 will treble. Currently, 11 people a day are being diagnosed with dementia and that figure will only increase. We need to continue to focus on the fact that getting older should never be seen as a burden on society and we need to continue to address the imbalance.

It has long been Government policy to help older people and others to stay in their homes and communities for as long as possible, with long-term nursing care being seen as a last resort only after home care and other community-based supports have been fully utilised. Under the Government, that emphasis is being strengthened. People want to stay at home with the environment, possessions and friends built up over a lifetime and that are most familiar to them, and this is entirely understandable. I also attended a party last year for a lady who was 100 years young and still living on her own and I want that to continue to happen. Accordingly, the programme for partnership Government includes commitments to increase funding for home support services, to improve these supports, to introduce a uniform home care service so all recipients can receive a quality support, seven days per week, where possible, and to review the management, operation and funding of national home-help services.

I am pleased that overall funding for services for older people will increase to €765 million in 2017, which is an increase of €82 million since the HSE's 2016 service plan. This has focused on additional funding for home care, in particular, and is aimed at allowing people to continue to live in their own homes and at facilitating discharge of older people from acute hospitals. During 2016, the number of home care packages will have increased by 1,000 from 15,450 to 16,450 and the HSE will provide more than 10.5 million home help hours. Home care funding has increased by €41 million over the initial 2016 provision, and this will be augmented in 2017 with a further €27 million. I will work hard to ensure we continue in this direction in future years. I understand it is not enough and it is not the figure we need but we need to build on it. The dementia home care packages, in particular, will need to be delivered throughout the lifetime of that programme but we need to reach a stage where there is proper regulation, a proper structure and a proper framework to provide support to people in their homes whether they have dementia, a disability, or simply need care.

It is estimated that approximately 20% of the over 65 population receives some form of community-based support service annually from the State. Traditionally, home care was viewed as providing a lower level of support than residential care, and not as an alternative to it. Increasingly, however, it is considered possible to support many people at home who would previously have gone into residential care. This requires an increase in the amount and intensity of home care, and more effective integration with other supports including nursing, therapies and other primary care services. We want and have to develop home care services to provide a more viable alternative to nursing home care for a greater number of people.

Home care services are provided on the basis of assessed health care need and there is no means testing or personal contribution towards the costs involved. Other HSE provided or HSE funded services include day care, meals-on-wheels and respite care. These are services we must protect. People are cared for at home under a wide variety of arrangements, both formal and informal. The HSE provides services directly and through service agreements with private and voluntary sector providers. Informal care provided by family and friends plays a significant and invaluable role in providing care to older people. Furthermore, many families choose to supplement the level of care provided by, or on behalf of, the HSE with additional privately procured home care. It is estimated that home care provided or funded by the HSE accounts for only around 30% of the total market, with the balance being privately procured and paid for by individuals and families. That is quite a low percentage.

Arrangements for home care provision have developed over the years with a significant local focus and while the HSE is incrementally developing a more consistent and coherent system, some legacy issues are still being worked through. Unlike the nursing homes support scheme, which is evenly applied across the country and is centrally managed in a unified way, there remains more variation than we would want to see in home care arrangements. For example, access to services can vary from place to place and at different times of the year. We have all experienced and had difficulties with that in our constituencies.

It is clear, therefore, that there are issues to be addressed and that there does seem to be a case for a more structured and perhaps schematic approach to home care than has applied up to now. Work to prepare for the development of a more formalised system is already in train, and the Department of Health has already asked the Health Research Board to carry out an evidence review of international approaches to the regulation and financing of home care services. This review will describe approaches to the regulation of home care services in other jurisdictions including the legislative framework, registration processes, inspection regime, staff assessment and training requirements, and national standards. It will examine the approach to financing of these services as well as eligibility requirements and entitlements for publically funded services, and who bears the cost of regulation. Finally, it will review evaluations and assessments of the international approaches in terms of their effectiveness and costing issues.

The review will be presented to the Department of Health before the end of December and will be used as a basis to develop policy proposals in 2017 for the regulation and funding of home care services. In terms of quality assurance in the home care sector, a significant step was taken in 2012 when the HSE introduced a single procurement framework for external providers. This included quality standards in terms of governance and accountability, person-centred care, complaints management, training and qualifications. Providers are monitored through service level agreements with the HSE and are required to provide a range of information on the services they provide. From 1 September 2016, all new home care packages approved by the HSE will be provided by organisations that have been approved by the HSE following a detailed tender process. The 32 approved providers appointed under this process meet a required level of quality based on consistent national standards. I agree with Senator Nash and others about the need for a clear professional pathway for carers. That would be an important step in ensuring the development of this profession and that those who provide the service feel valued and feel that their work is of worth. Most carers provide amazing care. The importance of regulating the sector, however, is not in dispute.

I share Senator Burke’s concerns about the potential risks involved in delivering services on a one-to-one basis in the homes of some of the most vulnerable people in our society. However, there are characteristics particular to home care which make its regulation less straightforward than residential care, and we need to think through the implications of any new system in a careful and measured way. Of its nature, home care is less uniform than residential care, and includes a wide variety of formal and informal arrangements. Unlike the residential sector, family carers are a very significant part of the home care landscape, and we need to ensure that any new system of regulation does not have unintended consequences for them or for other informal carers. Defining the margins between informal and formal service provision needs thorough assessment.

It is clear that there are considerable differences between the residential and home care contexts, and regulation needs to be designed for home care in a bespoke way that recognises its particular characteristics. Regulation is necessary, and we are all agreed on that, but a significant amount of detailed preparation needs to be done in addition to that already done before final decisions are taken on its form. For example, there are legal difficulties with the Bill proposed by Senator Burke in that it seeks to include home care providers within the current regulatory arrangements by extending the definition of "designated centre” in the Health Act 2007 to include them. However, home care services are not delivered in any one centre but at different locations and in people's homes. Legal advice obtained by the Department confirms that a separate legal instrument will be required to establish a regulatory regime for these providers.

Work on developing an appropriate regulatory system is already well under way. I have arranged that it shortly be given further impetus by the establishment of a new unit in the older persons services function of the Department which can focus on it to the level required. I accordingly propose that Second Stage of the Bill be read again in 12 months’ time and I look forward to engaging further on this critical issue with the Senator and with this House as our work progresses. We are all on the same page in respect of this issue. We all want the same results and it is important that we work together to make sure the final result is the best it can possibly be to ensure we realise this vision.

Senator Paul Gavan

I welcome the Minister of State to the House. I reiterate my colleague, Senator Devine's support for the Bill. We welcome the fact that Fine Gael recognises the need to regulate the sector. It is extremely important and Senator Burke has put a lot of work into this Bill. I ask him to take my comments constructively. They concern what is missing from the Bill and, with all due respect, from the Minister of State's speech.

The big issue in home care is terms and conditions and pay. Senator Nash referred to this. Of course regulation has to protect the client and professional standards but if the elephant in the room, the appallingly low rates of pay in the sector, is not tackled, a quality service will not be provided. There will be such a high level of staff turnover that clients will find that the person who cared for them last month has left and another has moved on. I have personal experience of this because prior to getting this job I was a trade union official and we had a dedicated campaign on home care for years. There is a shocking differentiation between the rates of pay for HSE home help workers, who are relatively well paid because they are unionised and have campaigned for that pay over the past 25 years, and the shocking rates of pay for private home care providers, the ones whose wonderful radio advertisements we hear each day. Someone working for a private home care provider earns the minimum wage or slightly above that. Is that all our loved ones are worth, €9.15 an hour? If we are serious about improving standards we have to tackle that issue and there is a simple way to do it, bring in the various partners, work towards an employment regulation order that sets standards of pay for the industry. It can be done but there seems to be something in the Fine Gael DNA that means it always forgets about the workers and their pay and conditions when it is regulating.

In the Minister of State's speech, she says many fine things. She makes reference to the tender process. She says "all new home care packages approved by the HSE will be provided by organisations that have been approved by the HSE following a detailed tender process". Is there anything in the detailed tender process that references a decent rate of pay for home-care providers? There is not. Until the Minister of State incorporates that, she is not being serious about dealing with one of the key issues in the sector.

The other issue I will raise about HSE home-care packages is that what always struck me from my work in the sector is that almost all of those home care packages are outsourced to private providers even when we have HSE home-care workers looking for more hours of work. They are outsourced because it is easier. The shocking thing is it is more expensive. While the HSE providers are paying €14 to €16 an hour and the private providers are paying anywhere between €9.15 and €10 an hour, the private providers end up charging a higher hourly rate than the HSE home-help providers. They do that because it is their profit. It is more expensive for the taxpayer to do it this way yet it seems to be orthodoxy in HSE policy. The attitude is that the Government is giving it a certain amount this year so it will outsource it. The problem is that the outsourcing process is fundamentally flawed because the rates of pay are so poor. I do not think the Minister of State will contradict me because I have demonstrated that there is nothing in the regulations being proposed, the Minister of State's speech or the tender process that addresses the issue of pay.

The issue of pay is a very simple thing to address. It can be regulated. I will give a different example from a different sector. We have just signed an employment regulation order for the contract cleaning industry which stipulates minimum rates of pay above the minimum wage and stipulates a range of increases. The only reason that will not happen in this sector is because the Minister of State lacks the political will to do so. I would welcome the Minister of State standing up and saying she will prove me wrong and tackle the issue of low pay. If we do not tackle the issue of low pay, we will never really tackle the issue of quality care. Does anyone in this room really believe our loved ones are worth nothing more than €9.15 or €9.50 an hour? For the level of care and attention that is required, we need to be serious and ensure the system is regulated, the sector is regulated and that decent pay rates apply. Unfortunately, I have not seen any evidence of the political will to tackle that. I would love to hear a response on that.

Senator Alice-Mary Higgins

I welcome the Minister of State and commend Senators Burke, Hopkins and Richmond on the Bill. It is a very positive and necessary step forward and a really constructive proposal. I previously had the opportunity for a number of years to work with Older and Bolder which was an alliance of older persons' organisations across Ireland that worked with groups such as the Alzheimer Society of Ireland, carers, active retirement groups and Age and Opportunity. Of the many common issues, a key area of focus for us was health and home care. I had the opportunity to be part of a national campaign called Make Home Work which specifically addressed and highlighted the need for quality, predictable, sensitive and appropriately regulated home care in Ireland.

The Law Reform Commission report of 2011, which followed on from that campaign, is very substantial. It is an excellent report and I welcome that it has so heavily informed the Bill and the proposals put forward. I also commend a number of the important elements within the Bill which are very sensitively and well done. I commend the Bill for looking at companionship plans and because it takes such care to look to the principles of independent living. For far too long, we have had a system whereby older persons have been placed in residential care and, as a result, are placed out of the public mind and removed from active engagement in society. As well as them losing in terms of their participation in society, society has lost out by the removal of so many older people who have immense experience, insight, ideas and engagement. Home care has a huge role to play in ensuring independent living. I also welcome the principles of privacy and dignity which are very important. I would like the Minister of State to address our national positive ageing strategy and our fulfilment of our UN obligations in that regard. Those principles are crucial.

I share the concerns expressed by my colleagues in the Labour Party and Sinn Féin about the quality of terms and conditions for those working in care, not just the question of pay rates but also the question of genuine pathways to progression, security of contract, predictability and management of contract. We should ensure that working in care in Ireland is something that people can commit to. We need to ensure that those persons described by Senator Kelleher who choose to do this with great care and sensitivity are not being asked to offer that up but are valued and have a pathway to a career in delivering quality care. It is important that there is progress towards an employment regulation order to accompany any such Act. The pathways and precedent are there and it is very important.

I will touch on something that was mentioned around the tendering process. I share the concern at the moment, which the Minister highlighted, that only 30% of our home-care services are being publicly provided. We need to really look at strengthening public delivery within this model. We need to look at the quality of training and recruitment in the HSE to ensure we have a huge cohort of care providers so that they are directly accountable for the care that is delivered in homes in Ireland. They should not simply be regulated but also accountable within the HSE. That will set the model which we expect and demand from any other providers in the sector, whether they are voluntary, community or private.

When I was with Older and Bolder we went into residential care homes and talked to older people about their preferences. The strong and clear preference is for people to be cared for in their own home. We have seen funding chipped away very seriously. Units of time of 15 minutes, 30 minutes and 20 minutes have crept in and are absolutely contrary to the principles of dignity. We talk about companionship plans because it is important that someone can sit and have tea and speak to somebody. That is part of it. The Bill is very positive. Unfortunately in recent years the working practice has been moving in the wrong direction. I have heard so many cases of people who move from two hours to one hour, who find they are on the clock, and are having a rushed bad meal. I urge the Minister of State to take immediate high quality action in those areas. The research is there. As I said, we engaged in campaigns on this seven years ago. There is a substantial body of work. I urge that this be moved forward speedily.

As a note of caution, I will bring up, as I often do, the Comprehensive Economic and Trade Agreement, CETA. There are proposals to introduce new investment court systems under which the introduction of new regulations that compromise profit can be subject to a claim of compensation. It is absolutely imperative we get the regulation in place now while we have the freedom to do so and while it does not come with an additional potential price tag as a result of companies taking cases because of the introduction of absolutely reasonable health care focused regulation. It is imperative we do that. Unfortunately, as my colleague has mentioned, some of the companies working in this area have approached it with a view to increasing their profits at all costs. We have seen companies fighting payment of staff who move from one home to another.

We have also seen them fight, for example, holiday pay for staff. There is a negative trend in how home care is delivered, and it is important that this Bill and the regulatory and other orders progress and that speedy action be taken to address that trend.

My very last point is that health care needs, as mentioned by the Minister, must be paramount. It is very important that any further conditional review ensures that no obstacle is put in place that may discourage a vulnerable person or his or her family from accessing or seeking home care supports. Regarding the question of contribution of payment and entitlement, it is important we do not end up creating barriers to a service which must remain determined by health care need.

Acting Chairman (Senator John O'Mahony)

Senator O'Donnell is the last speaker.

Senator Kieran O'Donnell

Until what time is this business due to continue? The Minister of State-----

Acting Chairman (Senator John O'Mahony)

The Senator has eight minutes.

Deputy Helen McEntee

I have to leave, so I thought perhaps I could respond-----

Senator Kieran O'Donnell

I will only speak for two minutes.

Deputy Helen McEntee

I am not sure if I am allowed to respond.

Acting Chairman (Senator John O'Mahony)

I think the protocol is that the Minister is not allowed to respond. I do not make the rules.

Senator Kieran O'Donnell

I thought we had amended that and that the Minister could be allowed to respond.

Deputy Helen McEntee

I can come back to the Deputy, though, on the final question.

Senator Kieran O'Donnell

I looked to speak on this Bill. I very much commend Senator Burke on it. I know from first-hand experience the benefits provided by home care providers. My mother-in-law lives with my family. She is 90 years of age. Home care providers come to our home, which allows her to stay in the home, and I could not praise them highly enough for the work they do. They are caring, they work many hours and they provide what is in my view the primary care model. I would have major problems with anything that would jeopardise that, which is why I support Senator Burke's Bill. The providers with whom I come into contact operate to very high standards. If the current system which allows providers to operate did not apply such standards, it would be to the detriment of both the providers employed and the people they look after in their homes. I feel very strongly about this.

The accident and emergency department in University Hospital Limerick has been perennially overcrowded. I am the first to acknowledge that the structure is repugnant to proper care. There are low ceilings. It is very much like being in a pressure cooker because there are so many people crowded in there. We want to ensure people do not have to go into accident and emergency departments. Having home care providers, professionals providing services in the home, can prevent that from happening. We have a new accident and emergency department coming on stream. It will not be a panacea but it will go somewhere towards alleviating the pressure on the existing accident and emergency department.

There are other issues. I very much support the Bill that Senator Burke has brought forward. I want to look on it as a positive measure. It is about ensuring the reputation of and service provided by the professional providers are not undermined by someone who could operate under a system that does not have detailed regulation in place. I therefore hope this legislation is brought forward. I ask the Minister that this issue, which has been effectively pushed for a long time by Senator Burke, be fast tracked and we ensure it comes back before the House in some form with the contents of this Bill taken into account in order that we can ensure the primary care model we seek to promote is not only continued, but also enhanced. I commend the Bill to the House.

Senator Colm Burke

I thank each Senator who contributed to this very constructive debate. I also thank the Minister of State for her contribution. A number of important issues were raised. I agree with Senator Swanick on the issue of back-up support at local level, which cuts right across from nursing to general practitioners. As I said in my introductory speech, there was a prediction that by 2021 attendance at GP practices would increase by 33% because there would be many more older people living in the community. I also thank the seconder to the Bill, Senator Hopkins, for her contribution and her help and assistance, and Senator Richmond. Each person who made a contribution made a very constructive one.

We need to face up to a number of issues, one of which is the training of people who want to provide home care. I am not sure if we have a proper structure for that. I take on board what has been said about pay and conditions, but I think the appropriate mechanism for that would come through separate legislation. One cannot make any job attractive unless there is adequate remuneration for the work people do. That is important, and we need to consider that issue as well. I am anxious to reverse what has occurred over recent years whereby, because so much political pressure has been put on ensuring people can get into residential care, we have not considered enough the issue of home care.

I welcome what the Minister of State announced regarding home care packages and the additional funding for 2017, but we must fast-track the process. We must ensure a proper regulatory framework is in place. While I accept that, thanks to everyone involved in this area, from the HSE to the private sector, much progress has been made over a number of years, we still have much more work to do. We still must ensure there is full accountability and that we can guarantee that the supports are there for people looking to stay in their homes. I do not want to be taken up wrongly on the following point, but going back again to the Law Reform Commission report of 2011, these issues should not be parked within Departments. I accept that the Minister of State is genuine on this matter and its progression because I have discussed with her a number of other issues, such as support and the fair deal legislation. I hope this will be brought forward in combined legislation. Subject to the approval of the Minister of State and the House, I propose not to press for the Bill to proceed to Committee Stage at this time. However, we will require some progress from the Minister within the next three months. I will face pressure from my colleagues to bring the issue back for further debate, but three to four months should allow us to get some idea as to the progress being made by the Department.

The Minister of State referred to further studies being carried out. In fairness, the Law Reform Commission in 2011 carried out extensive research on what is happening at both local and international levels. I always get concerned when I hear a Department tell me that it is carrying out further research. Everyone who, like me, has served on a local authority will have had the experience a long time ago of a city or county manager saying he or she must get consultants in to carry out a further report before a decision can be made on a particular matter.

The work is done. It is now up to us to bring forward the proper structure and framework for dealing with this issue. We need to do that. I am not proposing that the Bill will go on to Committee Stage at this stage. I reserve my right to reintroduce it over the next three or four months, depending on what report I get back from the Department on the matter.

I thank all the Senators who contributed. The submissions were very constructive and I will take them on board when looking at this issue again. I also thank the Minister of State for being available.

Question put and agreed to.

Acting Chairman (Senator John O'Mahony)

I take it from the Senator's comments that he is not moving the Bill further at this stage. That is a matter for the Senator rather than for the House. When is it proposed to sit again?

Senator Colm Burke

At 10.30 a.m. tomorrow.

The Seanad adjourned at 5.21 p.m. until 10.30 a.m. on Thursday, 10 November 2016.