Seanad Éireann debate -
Tuesday, 3 Oct 2017

Vol. 253 No. 7

Nursing Homes Support Scheme: Statements

Minister of State at the Department of Health (Deputy Jim Daly)

Fáiltím roimh an deis labhairt leis an Seanad ar an ábhar tábhachtach seo. I am grateful for the opportunity to contribute to the debate on the nursing homes support scheme, more commonly known as the fair deal scheme. The Government's priority is ensuring that our older population is looked after, supported and protected. We are living longer lives than at any other time and, thankfully, it appears that this trend will continue into the future. This is to be celebrated and embraced but we cannot ignore the challenges our ageing population brings with it, not least that of long-term care. Most of our older people signal their desire to remain in their own homes and communities for as long as they are able. It is Government policy to support this and it is something we feel strongly about. However, there will always be a cohort who require access to quality long-term residential care. This is why the fair deal scheme is such an important element of the range of services available for older people. The scheme is a system of financial support for those assessed as needing long-term nursing home care. Participants contribute to the cost of their care according to their means while the State pays the balance of the cost.

The scheme aims to ensure that long-term nursing home care is accessible and affordable for everyone and that people are cared for in the most appropriate settings. With a budget of €940 million in 2017, the scheme supports 23,600 people. The Government target is that people will wait no longer than four weeks for approval for the scheme. I am able to report that target has not been breached this year.

The fair deal scheme covers the cost of the standard components of long-term residential care which are nursing and personal care, bed and board, basic aids and appliances necessary to assist with the activities of everyday living and laundry services. A financial assessment is carried out by the HSE to determine how much an applicant can contribute to the cost of his or her care. An applicant will contribute up to 80% of their accessible income and a maximum of 7.5% of the value of any assets per annum. The State will then pay the balance of the cost of care. It is important to note an applicant's principal private residence will only be included in the financial assessment for the first three years. This is known as the three-year cap. The first €36,000 of an individual's assets, or €72,000 in the case of a couple, is not counted at all in the financial assessment. A person's eligibility for other schemes, such as the medical card scheme or the drugs payment scheme, is unaffected by participation in the nursing home support scheme. Nobody will pay more than the actual cost of care.

Although the nursing homes support scheme covers core living expenses, residents can still incur some costs in a nursing home. In recognition of this, anyone in receipt of financial support under the scheme retains at least 20% of his or her income or 20% of the maximum rate of the State pension, whichever is greater. An operator should not seek payment from residents for items which are covered by the scheme, the medical card or any other existing scheme. Registered providers of nursing home care must agree a contract in writing with each resident on his or her admission to the nursing home, which includes details of the services to be provided and the fees to be charged. Residents should never be charged fees that are not set out in the contract. Registered providers of nursing home care are also obliged to provide an accessible and effective complaints procedure. Concerns about additional charges should, in the first instance, be taken up with the nursing home provider. I encourage anyone with concerns to raise them with the nursing home through this complaints procedure. The Office of the Ombudsman can also examine complaints relating to the administrative actions of private nursing homes once the individual has already gone through the complaints procedure of the private nursing home concerned.

I have met Nursing Homes Ireland, NHI, on a number of occasions to discuss the issue of additional charges in an effort to ensure more consistency and transparency on the part of nursing homes in dealing with additional charges. I have asked that nursing homes advise prospective residents of these charges at inquiry stage rather than on admission. I also requested an updated contract for care template to be used by all nursing homes. Nursing Homes Ireland has already undertaken work on this with regard to its members. I have also met Age Action, the National Treatment Purchase Fund, NTPF, the Health Information and Quality Authority, HIQA, and the Ombudsman on the topic. It is important that older people are protected and have all the information they need to make an informed decision.

A review of the nursing homes support scheme was published in July 2015. An interdepartmental agency working group chaired by the Department of Health has been established to oversee the implementation of many of the recommendations contained in the review of 2015. These include improvements to the administration of the scheme, a review of how prices for private and voluntary nursing homes are set by the NTPF and a value for money and policy review of the cost differentials in public and private voluntary residential facilities which will commence in 2017.

Significant progress has been made on the implementation of the administrative reforms to the scheme. Separately, the NTPF is progressing work on its review in conjunction with my Department and the Department of Public Expenditure and Reform. I have also asked the interdepartmental group to consider the matter of additional charges in nursing homes and to examine the options that might be available.

Turning to the matter of farms and small businesses, concerns have been raised about the treatment of farms and in particular the potential impact of the annual contribution on the sustainability of family farms and businesses and specifically in circumstances where care may be required for a long period. On this front, I have had ongoing negotiations with the IFA. As recently as last week, I advised it of my intention to apply the cap that applies to private residential properties to farm assets and small business assets. It is an ambition of Government and Government policy to encourage orderly succession arrangements for farms. It is also endorsed by farming organisations. In most cases, early succession arrangements in families should ensure farm assets are transferred well in advance of five years before nursing home care is required, meaning a levy on the farm asset is avoided entirely.

As outlined in A Programme for a Partnership Government, we are fully committed to introducing changes as soon as practicable to remove any discrimination against small businesses and family farms. It is important to note the scheme is underpinned by primary legislation and that, as such, any changes made to the scheme will require amendment to this legislation. My Department is liaising with the Office of the Attorney General regarding the potential changes to the fair deal legislation which will address the concerns raised.

The issues currently being examined are legally complex and all aspects of the scheme need to be taken into consideration.

I mentioned at the outset that it is Government policy to promote care in the community for older people so they can continue to live in their own homes for as long as possible. The only statutory scheme in place at present to support older people is the fair deal scheme. However, the Government is committed to establishing a new, separate statutory home care scheme, along with a system of regulation for home care services. The Department of Health is currently engaged in a detailed process to progress this. The statutory scheme for home care will introduce clear rules in regard to the services for which individuals are eligible and in regard to how decisions are made on allocating services. For that reason, developing a new statutory scheme will be an important step in ensuring that the system operates in a consistent and fair manner for all those who need home care services. It will also help to improve access to the home care services that people need in an affordable and sustainable way. The system of regulation for home care will help to ensure that the public can be confident the services provided are of a high standard.

The Minister, Deputy Harris, and I launched a public consultation on home care which opened on 6 July and closed yesterday. A report on the findings of the consultation will be published in the coming months. While these are important steps in the process, a significant amount of additional preparation needs to be carried out before final decisions are taken on the form of the home care scheme and system of regulation. This is required if the reforms are to be successful, affordable and sustainable. Every effort will be made to progress this matter as quickly as possible.

Senator Keith Swanick

The fair deal scheme is fundamentally a good scheme and the former Tánaiste and Minister for Health, Mary Harney, deserves credit for its introduction. It was, of course, introduced at a time when there was a desperate need for a solution to the financial hardship faced by people who had to sell their homes, in some cases to pay up to €1,000 a month in fees for private nursing homes. At the time there was a stigma, whether real or not, associated with some health board facilities - that was not my view but it is a fact. Prior to the scheme being formalised, care was patchy at best and elderly people often worried what would happen to them when their money ran out. The fair deal scheme created something of a level playing field at the time and gave a level of security and comfort to those utilising it.

As I say this, however, I am acutely aware of the problems that exist within the scheme. Fianna Fáil recognises the many concerns surrounding the fair deal scheme and, in particular, those of many farming families and small businesses, as I have discussed with my colleague, Senator Paul Daly. We agree it is vitally important that the issues around residential care for older people do not generate a situation that undermines the family farm model. The programme for Government recognised the discrimination under the scheme against farm families and small businesses, and it pledged to make changes. It is critical that this commitment be honoured. Reports last week that the scheme will be changed to extend the three-year cap from the principal residence to the full family farm are welcome. We looked for the financial assessment to only apply to the assets that had been transferred prior to entering the nursing home for less than a three-year period. It is also worth noting that many farm families are opting not to avail of the scheme and are putting themselves under severe financial stress to find money to cover the costs of care in the short term. Family farms are passed down from generation to generation, as we know, and no one wants to be the generation responsible for making the farm non-viable for the next generation. The pressure is immense and this must be recognised.

There have also been quite negative aspects such as the overcharging that appears to be occurring within certain nursing homes. I was very disturbed by the reports of people being charged for services they could not possibly have participated in, or for extras such as orange juice, for example. As a medic, I find this absolutely disgusting, and it is the most blatant form of elder abuse I have seen in recent years. I echo the call made by my colleague, Deputy Billy Kelleher, that any older person, or his or her representatives, should check and double-check the small print in the contracts they have signed with nursing homes. I acknowledge they should not have to do this but, in too many circumstances, unfortunately, there are nursing homes which see older people on the fair deal scheme as opportunities to make excessive profits. We must condemn this type of behaviour at every opportunity.

This evening at 8 p.m. the Minister for Health will join Brendan Courtney live on Facebook to speak about the state of the health system. It is something I plan to tune in to. Brendan Courtney and his family had to become very familiar with the fair deal scheme as a result of his Dad’s illness. Brendan’s Dad, Frank Courtney, who passed away over the summer, featured in a documentary that highlighted the lack of supports available for families trying to care for older people. What we saw was a family in turmoil trying to navigate the fair deal scheme, realising that it does not cover care in the home and learning that they will have to make hard decisions on behalf of their Dad. In my own family we were fortunate enough to be in a position to care for my mother at home in the months prior to her passing but in the case of my father unfortunately there was no facility in the locality to care for him before he passed away. He was too sick to be cared for at home. He passed away in an acute award in Roscommon hospital, something I am not proud of, but unfortunately at the time there was no suitable accommodation in the vicinity. Thanks to the sincerity and candour of the Courtney family, people were made very aware of the lack of viable options for home care or step-down facilities and the difficulties in applying for a nursing home place.

In January last year the Fianna Fáil Party introduced the Nursing Home Support Scheme (Amendment) Bill. It provides for home care packages as an alternative to long-term residential care. It will apply in circumstances where the provision of a home care package is less costly to the State compared with long-term residential care. This necessary measure not only benefits the individual concerned and his or her family but also the State because there will be fewer demands placed on long-term residential care services. We believe the funding allocated to enable older people to remain at home provides not only the best value for money but also the most humane result for older people. The HSE has estimated that some 2.2 million extra hours of home help and a further 3,500 home care packages for older people are required. We must ensure this happens as part of our commitment to ensure older people remain independent in their homes for as long as possible. It is worth remembering that in Ireland over the next 30 years, the number of people aged over 65 will double and the number aged over 85 will almost quadruple. Inevitably as we grow old we will all experience ailments and disabilities, which are part and parcel of ageing. Budget 2018 must take this reality into account.

Senator Colette Kelleher

I welcome the Minister of State, Deputy Jim Daly, to the Seanad and welcome the opportunity to speak on this important issue. I was delighted to see the reference to home care because, as with my colleague, Senator Swanick, I want to speak on that issue.

While the focus of this discussion is on the fair deal scheme, I want to focus my remarks on home care and the need to provide a real alternative to residential-based care and for the inclusion of this preferred option in the fair deal scheme. Every year the State spends about €1 billion on the fair deal scheme, which benefits 23,000 people. In comparison, approximately €370 million is spent on home care, with 49,000 people receiving home help and 16,700 people receiving home care packages. This €370 million is not earmarked; it runs out and is not demand led. Members will know this from their constituency offices where people will be coming to them who are in dire straits and looking for support. Yesterday I was advising an Oireachtas colleague about what she could do with a man in a very rural area where residential care is not an appropriate option. The poor man is on his knees but the budget in that area has run out.

We need to shift the focus and provide more people with home care options. I always give the example of Denmark which has not built a nursing home since 1987 because there are alternatives. They have nursing homes. We will always need nursing homes but they have a range of other supports including home care to go alongside that. As most Senators will know, home care enables people to fulfil their will and preference to live at home in a familiar environment linked to their communities for as long as possible. This is particularly the case for a person with dementia for whom living in a strange environment is really difficult, even for respite care. Home care is also a cost-effective alternative to long-term residential care for some older people and an integral part of a well-functioning primary care system. Good quality home care supports ensure that people get the care they need, where and when they need it.

Home care as currently constituted needs to be improved in three core ways. First, we need a statutory right to home care. I am glad to hear the Government is considering a statutory scheme because without it, fair deal for residential care or acute beds will always trump home care. Unless there is an entitlement to it, the budget will be squeezed and will run out. There is an anomaly in the current law that provides entitlement to residential care through the fair deal scheme, but not to home care. Brendan Courtney and his family are a very high profile example of that.

Second, home care should be regulated. The services provided in private homes are very personal and the people receiving them may be vulnerable to abuse or harm. We must ensure that the services provided are of the highest quality and that those providing them have been vetted and trained. There should also be regulations on the consistency of care. To that end, the proposed home care Private Members' Bill by Senator Colm Burke is very welcome. I would love us to spend time on a Thursday on that Private Members' Bill to bring it forward. We need to look at it as a matter of urgency. If we want people to live at home successfully we also need a menu of community-based care to suit individual needs, which includes broader community-based services, such as day care and respite care.

It is also vital that the same approach to how services are accessed, delivered and monitored is applied universally. At the moment the kind of assessment people get depends on what part of the country they are in. It is not equal or fair. If one lives in Macroom, one might get a good deal but a person living in Manorhamilton might not get such a great deal. That kind of postcode lottery is not fair on individuals. Equity of access must be a core principle of any new home care system. At present there are different forms of assessment, a lack of information around services and, wrongly, geography rather than need is determining access to care.

Third, to be effective and to meet the needs of the growing older population, home care services need to be well-resourced and demand led. Teasing out a fair funding model must be a priority. At present a lot of money is invested in residential care services. Within a decade the State should be spending in the region of €1 billion per annum on home care services. If we want to increase home care we need to push resources towards community care but at present we are spending nearly four times more on residential care. Earlier this year, Deputy Mary Butler and I, as co-conveners of the all-party group on dementia, organised a round-table event on the future of home care with key stakeholders including the Minister of State's predecessor, Deputy McEntee, representatives from the Department of Health, the HSE, NGOs, academics and Oireachtas Members. At that meeting Professor Eamon O’Shea from NUIG provided an excellent analysis of the funding options. If the Minister of State has not done so already, I encourage him to engage with Professor O’Shea because he has spent his entire career looking at this matter. He has the answers; we do not need to reinvent the wheel so people can remain in their homes. The Minister of State knows the pressure on the health system when people go into hospital and cannot be discharged because there are not suitable options like home care. People also deteriorate in hospital. It is not a suitable place, particularly for people with dementia. Sometimes we make people more unwell because they are in the wrong place.

By providing a right, regulating it and resourcing it, we will ensure that we have a well-functioning home care system that works for people. I am anxious to know what the next steps are and the timetable post-consultation. The Minister of State has said it will be in the coming months but I would like something a bit more specific. Will we see an uplift in funding for home care in budget 2018 which I and others are advocating for as part of the all-party group on dementia? The Minister of State is very kindly launching our proposals on Thursday.

Will the Minister of State commit to amending the fair deal scheme to include home care?

Senator Frank Feighan

I thank the Minister of State for coming here to speak on a very important topic, the nursing homes support scheme, commonly known as the fair deal scheme. Over the years my office and I have been helping many people to get around the complexities of the fair deal scheme. It is only when one has to avail of the scheme that one becomes aware of it as I did when my mother was in hospital and had to go into a nursing home.

At that time, I went to government buildings in Roscommon and the assistance, information and guidance I got from the staff there was absolutely fantastic. It is probably the same around the country. Applying for the fair deal scheme is a very daunting experience but the staff will help people in every way. I pay tribute to the people who were there to help me and my family. My mother is now in the Plunkett nursing home in Boyle and we are absolutely delighted. She was self-employed in business all her life and we really feel the State was there to support her when she was 89. I hope it is the same for everybody else. We are absolutely delighted with the assistance we got. Most of our older people signal the desire to remain in their homes as long as they are able to do so. We also availed of home help of half an hour a day and it was very successful. The people providing home help are unsung heroes. When one needs that it is very welcome. My mother and her family are very thankful.

Yesterday, in my office in Roscommon, I was dealing with the plight of a farm family facing very difficult challenges trying to meet the cost of nursing home care for their elderly father. The stress for the wife and children of trying to meet the huge costs of care was tangible. It was sad to see this hardworking family faced with this worry of how to pay considerable nursing home bills. Theirs is not an isolated example but representative of a large proportion of farm families who worked hard all their lives and are now worried the cost of nursing home care will leave them with nothing. I commend the work of the Minister of State in giving farm families a strong voice in this regard. The Minister of State has met farming representatives and discussed their concerns about the fair deal scheme. The fair deal scheme is a system of financial support where there is a need for long-term nursing home care. Participants contribute to the cost of their care according to their income and assets while the State pays the balance of their costs. We will never get it right but we try to get a fair balance. At the moment, farm families feel discriminated against because there is no cap on the 7.5% of farm and business assets contribution to nursing home care. The 7.5% is charged every year for as long as care is provided. However, I am pleased to learn that this now looks as if it will change and in that respect I welcome the Minister of State's proposal to cap the 7.5% contribution from farm and business assets for nursing home care at three years as is the case for family homes. We were not in that situation but it is something I have listened to over the years from people coming in who had serious concerns. I hope this will come to pass.

The cap is subject to a transfer between family members who are actively participating and working in the business, as is currently the case under the sudden illness clause. These proposed changes will dramatically reduce the financial burden facing elderly people and their loved ones. The removal of the uncapped liability on farm assets will help alleviate the worries of farm families.

It is important to remind ourselves that commitments in the programme for Government are being delivered upon and this is one of them. The programme for Government fully committed to reviewing the fair deal scheme to remove any discrimination against small businesses and family farms. There is clear progress being made on this front. I come from a small business family and there was a time when we made money but most businesses have lost virtually everything over the years, especially as a result of the recession. One thing people do not fully realise is that many self-employed people did not have a pension per se. Their pensions were bank shares. Most business owners were advised by bank managers to buy AIB and Bank of Ireland shares. It was not speculating; it was the way business people and farmers looked at pensions. They would get a dividend which would be their pension. They lost everything. People talk about the property crash and jobs but this was a huge issue for self-employed people. If people were in the public service, their pensions were maintained but the pension pots of these people were gone because they bought shares for €12 or €15 which then went down to nothing. Most of them have lost their security. Not only did they lose businesses or the value of their property, but they lost their pension funds. It is not an issue too many people have addressed. I can say that of most of the people I knew who were in business. It was not speculation but a way of looking at pensions. Perhaps it was not the right way of looking at pensions but it was one way of looking at them. Who would have thought that blue chip shares in our two main banks, AIB and Bank of Ireland, would not be there? It is something we should talk about again.

I am also encouraged that the HSE has also made provision for the estimated costs of these changes in its budget 2018 submission. The programme for the fair deal scheme is quite exciting and we need to support it.

I am aware the Minister is awaiting a legal opinion from the Attorney General on the proposed changes to the fair deal scheme before he can bring them before Cabinet for approval as the changes will require an amendment to the Nursing Homes Support Scheme Act 2009. It is very clear the Government is committed to addressing the very real concerns of farm families and businesses across the country.

Senator Niall Ó Donnghaile

Go raibh maith agat, a Leas-Chathaoirligh. Gabhaim buíochas leis an Aire Stáit as a bheith linn. Is léir ó na ráitis go dtí seo gur ábhar thar a bheith tábhachtach é seo mar gheall ar na fáthanna uilig atá luaite ag achan duine. I am deputising today on behalf of my colleague, Senator Máire Devine, who is out of the country on parliamentary business.

The 2016 census figures show a huge and rapid rise in the number of people aged over 65 in the State. This rise poses great challenges but Sinn Féin believes we should see improved health and longevity as an opportunity as well as a challenge, celebrating and enabling the contribution older people make to our communities.

I have with me today a comprehensive document prepared by my party which outlines how we believe older people should be looked after on the island of Ireland. I welcome the statements here today on the fair deal scheme, which is an important issue for our older population. A positive aspect of the scheme is that if a person qualifies for a nursing home place, the State is legally obliged to ensure he or she gets a bed. It is important to say that it is essential that people are supported in long-term residential care and that the highest standards are maintained, as has been advocated by all the previous speakers. Funding for beds is absolutely vital and is an important aspect of any overall strategy for caring for our older population. The cost of one’s care depends on one's income and assets. An individual contributes 80% of their assessable income and a maximum of 7.5% of the value of any assets per year towards the cost of care. The 7.5% per annum contribution applies for the duration of an individual’s stay in the nursing home except where a three-year cap applies to the applicant’s principal residence. This practice unfairly affects those with small land holdings, such as farms and small businesses, whose land and assets are charged for the entire duration of their stay in care. Their assets often become unsustainable which greatly impacts on their relatives. We have heard some personal testimony on the financial and material impact coupled with the emotional and psychological impact of having a loved one in care at a time of illness.

I absolutely welcome that in the past few weeks the Minister of State gave a commitment to introduce a change to the fair deal scheme that would mean a three-year cap on the charge on productive farm assets. This change in the scheme would make a great difference to small business owners and farmers and their families.

The fair deal scheme only covers the basic needs of residents, which includes a bed, food, nursing assistance and nursing aids and a laundry service. If a patient requires any additional care or services, the nursing home must charge them. For example, residents are being charged for toiletries, prescription charges and transport costs among other things. Perhaps more seriously, patients must also pay for all therapies, social programmes and chiropody, despite having already paid for their care under the fair deal contribution. This is happening despite the fact that medical card holders are entitled to receive a number of services and therapies such as physiotherapy, occupational therapy and wound dressing free of charge from the HSE. This is blatantly forcing elderly people, many of whom are vulnerable, to pay twice for their care.

This is clearly an unfair system. All services required by elderly people living in nursing homes should be covered by the contribution paid by residents and calculated under the scheme. I urge the Minister of State to address this issue specifically in any future changes to the fair deal scheme.

It has been suggested that the fair deal scheme should be extended to include home supports. Sinn Féin does not believe this is the way forward. The fair deal scheme was designed specifically for long-term residential care. Home supports, although inadequate and underfunded, are provided free of charge based on an assessment of need. Sinn Féin believes these supports should continue to be provided on that basis.

We need to urgently move to a rights-based system whereby vulnerable citizens can receive long-term care in their home in the community when needed and thereby reduce the reliance on acute hospital beds and long-term nursing home care. We also need to move towards a fairer deal nursing home scheme, whereby elderly people do not have to pay twice for their care and smaller business owners and farmers do not pay disproportionate amounts for their nursing home care.

This is what Sinn Féin believes and we have communicated this with the Minister of State, Deputy Jim Daly, previously. We hope he takes those suggestions on board with the sincerity in which they are offered.

Senator Joe O'Reilly

I welcome the Minister of State, Deputy Jim Daly, to the House. This is the first occasion publicly I have had to congratulate him on his appointment. I acknowledge the huge energy, commitment and activity he has brought to the role since his appointment. He participated in a public meeting in my area in Bailieborough, County Cavan, on this very issue. There was good participation from those who attended that meeting that night. I hope, in some way, that his interaction with those people at the meeting has informed the good outcome in his deliberations since. It was appreciated that he took questions from people in an open way and listened to the views of the people that night.

I am happy that since then the Minister has recently given a commitment to introduce a cap on the charge for farm and small business assets in the fair deal scheme. I know he is seeking legal advice in this area and that the whole area around private property is complex. However, the fact he is committed in principle to deal with this is what is important. That will be greatly appreciated by farmers, particularly young farmers who want to be in a position to inherit the farm. As Senator Swanick said earlier, this is a personal family and intergenerational matter. That is also the case with many small retail outlets. A similar cap should exist in these cases to ensure parity.

The IFA ran an effective and reasoned campaign on this issue and I acknowledge its good work in this sphere. An individual is allowed the first €36,000 of his or her assets, and a couple €72,000 of their assets, to be exempt from the assessment for the 7.5% annual charge. While it is not completely punitive, at the same time, the reforms are necessary to ensure family continuity in small businesses and farms.

I share the national abhorrence felt towards the overcharging in nursing homes, specifically the overcharging for services already freely available on long-term illness and medical cards. That is a horror. It is wrong and unethical and it is particularly distressing that it would happen in a sector where the whole ethos should be different. I know the Minister of State is concerned by this. I appeal to him to stamp it out by whatever process is needed and however punitively. There needs to be a high level of regulation of nursing home charges. The Minister of State may recall when he met my local community in Bailieborough that many people made the point there should be an assessment and control of excessive charging in nursing homes. I join the national clamour on this matter. It is appalling.

I am delighted we will put home care on a statutory basis. It is the preferred option. In surveys 85% of people have indicated a preference to stay at home in their old age. That is their prerogative and that is where people are happiest. It is the right choice for people’s personal happiness, welfare and fulfilment. It is also the economic right thing to do because it is more cost-effective than institutional care.

It might depart from some of the national consensus but, in some instances, where people have a certain income level, they should be prepared to make a contribution to an effective good home care package which would make living at home a viable option rather than coping with a stressed situation of a mediocre package. Rather than a package which is not adequate and only tampers with things, they should be given the proper package and, where it is affordable, to ask them to make a contribution. It may not be a populist view but it is actually right. Sometimes we have to depart from populism for the sake of what is right. This is one such example.

I thank the Acting Chairman for allowing me a level of latitude in parochial and time terms. A level of that is allowed but we would not want to overdo it.

Senator Niall Ó Donnghaile

Never.

Senator Joe O'Reilly

Senator Feighan’s point was correct and the Minister of State should be cognisant of it. Many people have lost through bank shares and pensions. Many people have a huge issue here but are too proud to say it. They will not go on the Joe Duffy show or talk about it publicly because it is a private but distressing reality. It needs to be addressed in this context.

This has been a fruitful and wonderful exercise. I am confident our contributions are not wasted because I know how sincere and effective the Minister of State is in this role.

Senator Maria Byrne

I thank the Minister of State for attending the Seanad this afternoon to discuss this crucial and important issue. I welcome his statement that he will look at the fair deal charges for farms and small businesses. This is important, as Senator O’Reilly so eloquently put it, for young farmers and young people who want to inherit farms and businesses. It is difficult because many find it prohibitive and do not see any future because they feel they will lose their farm or business once their parent or loved one dies.

Many people contact my office every week who would love to keep their loved ones at home but are not in a position to do so because of medical conditions. I agree with my learned colleague on my right, Senator O’Reilly, that it would make so much financial sense to have a proper package in place to support these families. Many families are willing to do the work themselves, but they may not have the medical expertise. By putting the right people and supports in place, more people would opt to stay at home.

I have in mind one particular couple who are quite elderly. The gentleman's wife has been in a nursing home for a long number of years. He goes to the home every day to feed her breakfast, lunch and dinner. He never takes a holiday or goes out socially because he spends all the time he can with his wife in the nursing home. Many people are like this. If the right supports were put in place, that gentleman would be delighted to have his wife at home.

The financial levels also have to be looked at. As noted by Senator Feighan, many people lost money or, while on paper they own property that is worth money, it is about the money that is available. This is very relevant to the Department's deliberations. The more people we can give access to care in the home with the right medical supports, the better, and it is something the Minister of State should consider. I know from his own personal interest how committed he is to making changes in this regard and also that he is willing to listen. I wish him luck for the future in his ministerial position.

Senator Colm Burke

I welcome the Minister of State and wish him every success in his role in this area. Many people have referred to the fair deal scheme. We are spending roughly €1 billion per annum and, at the moment, there are some 23,500 people in nursing homes under the scheme. If we take the number of people who will retire and require support over the next ten years and apply the same ratio, then, technically, we will end up with some 40,000 people in nursing homes. I do not think that is a viable option so, obviously, we have to look at alternatives, make sure those alternatives are suitable and make sure that people get adequate support in their own homes, if at all possible, although there are a number of challenges in that area.

There are also a number of challenges for the nursing home sector. I have to declare my interest in the sense that I was nominated by Nursing Homes Ireland to contest the Seanad election. While they come in for criticism, nursing homes also face many challenges in regard to cost, including issues like insurance and commercial rates. One nursing home in Leitrim saw its commercial rates rise from €52,000 a year to €104,000 a year as a result of a revaluation. There are many costs that do not apply to the community hospitals. For example, the HSE facility in Donegal is costing over €20 million for 130 beds. When considering the costs for that facility, it must be remembered it is not paying off a loan or interest, whereas, if it was private enterprise, it would be. That is one of the issues we seem to be missing when we are discussing public and private. We have a very high level of costs in regard to our public facilities, in some part because there is a higher degree of care required. This is one of the issues the private nursing homes are highlighting, namely, if they are expected to look after people with greater needs, then they have to be adequately provided for in order to provide the level of care those people require. It is a very important point.

On another issue, many of the community facilities throughout the country do not come under the fair deal scheme. I know of one case where there are 26 people in a facility which was run by an order of nuns who have all retired. The fire authority recently inspected the place and said it wants three staff permanently on duty at night. The cost to the HSE of running that facility, even though it is not a nursing home and although all of the people are living independently, is working out at some €35,000 per patient per annum. It is a challenge we now have in a number of facilities throughout the country and one we will have to address.

I want to address the issue in regard to farms as it is very important. I know of a number of very difficult cases. In one case a farm was left to the son. Unfortunately, the son died tragically without having made a will and, therefore, the farm reverted to the parent. The parent delayed transferring to a second son, partly because none of the family qualified for the agricultural relief. The second son who got the farm then had to pay the full amount of inheritance or gift tax. Some 12 months later the parent was admitted to a nursing home and the farm is now being taken into account in calculating the contribution. The second case is where a father died and half the farm went to the sons and half to the wife. She developed a gradual illness and, at the age of 55 or 56, was admitted to a nursing home. They are now paying €2,500 a month to the nursing home because, again, the farm was taken into account. They are not in a position to do this and are finding it very difficult. They are supported from off-farm income because the farm is not generating enough. Those are two cases I am dealing with at the moment.

It is an issue we need to consider. There were proposals in regard to inheritance tax whereby the land would be devalued by 90% and that valuation would be taken into account as a way of calculating the asset value. That needs to given serious consideration.

The other issue I want to raise is how we calculate interest on money invested. I will give an example. The current position is that if I sell a house and have €190,000 in the bank, I am deemed to be earning €520 a week, which is over €25,000 a year. The Minister of State and I know that I will not earn that kind of interest on €190,000. We then wonder why people will not sell the family home. The interest calculation is very simple. The first €35,000 is not taken into account, the next €10,000 is calculated at €1 per week, the next €10,000 is calculated at €2 per week, the next at €4 per week, and so on. On €190,000, I am deemed to be earning €520 per week in interest. That needs to be changed if we want to encourage people to sell the family home so we do not have vacant houses. It is a very important point that we need to take on board because we cannot leave matters as they currently stand.

With regard to home care, as I have said before in the House, if I serve ten years in prison, I can come out the following morning and set up a company to provide home care, and there is no regulation to prevent me doing so. I have no difficulty with anyone who totally reforms, having served time in prison, but I believe we are wide open at the moment due to lack of regulation. I know there are voluntary codes and all the rest but we need proper regulation, which is why I introduced a Private Members' Bill on this matter. The Law Reform Commission has prepared a very detailed report on this and we should take it on board in regard to future regulation.

Senator Kieran O'Donnell

I welcome the Minister of State. I want to touch on a number of points in regard to the nursing homes support scheme, which is a very important scheme. We all have people coming to us who are going into nursing homes. It is a very traumatic time for the families and the individuals themselves. The nursing home support section in Limerick does fantastic work and we all deal with such people on a daily basis. I compliment them on the work they do on the ground.

I have two issues. As the Minister of State knows, if the scheme involves someone who has a home of their own, who has an old age pension and no other assets, it is relatively straightforward. Some 80% of their income is retained and, depending on the circumstances with the home, 7.5% of the value of assets per annum for three years.

Issues have arisen in more recent times, particularly in respect of farms and people who continue to live at home in some cases when it is not really suitable. Many such people are very elderly and live in isolated areas. I welcome this initiative on the part of the Minister of State and the fact that he is currently looking at it with the Attorney General. I hope we will get full details of the smoke emanating and of the particular details around budget time. I expect we will. It is very much an issue for both farmers and small business. In many cases with farms there are issues around land and defined property. It is the same in the small business sector. These changes will bring a lot of relief to many people.

I welcome the fact that the home care scheme is being put on a statutory footing. I note the points Senator Colm Burke has made. If people want to remain in their homes, everything possible should be done to ensure they can remain in their homes. When we look at the home care scheme itself, we must factor in the carers, what they do and what they bring to the table. In many cases the work of carers is very emotionally draining. They are looking after family members. In many cases the work goes on around the clock. It is the evolution of primary care to its purest form and that is where home care schemes come in. In my experience, the private home care providers with which I have dealt are doing a very good job. They have their own internal standards and, in the main, they are very good. Typically, with the home care scheme, the providers have local people working for them - both men and women. Therefore, when the carers come in to look after elderly people, in many cases the elderly person will know the carer. That is to be commended. It is something which should be fostered.

We need to look at whether we can put in place a scheme similar to the fair deal scheme in the area of home care, which would tick the boxes in that way. We have an ageing population and dependency rates are increasing. In my experience, most people want to live at home but for many people, the infrastructure is not there. We should develop a home care scheme which works off the structure of the fair deal scheme, which is more formally called the nursing homes support scheme. It is the way to go. The Minister of State ran a consultation scheme, which finished yesterday. Will the Minister of State indicate when he anticipates the findings of that consultation will be published and when he expects to set about putting in place a statutory, formal home care scheme in which people will know that they have the same level of certainty they have with the fair deal scheme?

Minister of State at the Department of Health (Deputy Jim Daly)

I thank all the Senators for their contributions, their thoughtfulness, the amount of time they have put into considering these issues and their assistance in formulating my thoughts on a new home care scheme, which seemed to be the focus of most contributions. That is, of course, linked to the fair deal scheme. I will answer a few questions, if I may.

Much was made of farm assets and small businesses. Nearly ever Senator referred to those matters. People will be aware of the story to date. The Irish Farmers Association, IFA, among others, has been leading the lobby on these matters for a number of years. It has put forward a number of different proposals for ways to ease the burden on farm families who are subject to the fair deal scheme. I have had a number of meeting with the IFA, as did my predecessor, the Minister of State, Deputy McEntee. On taking office I committed to getting this issue off the table as quickly as I could and to try to move it on. We went through a period of negotiation, I dealt with my officials and we looked at a number of different scenarios. I came back to the IFA last week and confirmed to it that my preferred option would be not to negotiate any further schemes based on 90% of assets and so on. I explained that progress could take another four years if we were to negotiate on those terms. I told them that it would be cleanest and most efficient to treat farm assets and small business assets in the same way as the principal private residence and to apply the three-year cap. That is the most efficient way I can deal with this and the IFA seems to be reasonably happy with that suggestion. I have outlined the process from here. Obviously there will be legislation, because the fair deal scheme was established through legislation. Primary legislation must be changed and that will probably take me to the end of the year. Subsequent to completing my negotiations with the Attorney General's office we should be in a position to draft legislation and begin the legislative process early next year. That is my hope and my ambition. Sometimes it is a case of "events, dear boy, events" and things can be overtaken, but that is my ambition and that is where the scheme stands.

On the issue of additional charges in nursing homes, to which many Senators referred, as Minister of State I can choose to bring in legislation in the morning - or at least to put legislation before the Houses for consideration - to legislate on this matter but my hope is we can engage with the industry to deal with it through self regulation. If the industry refuses to deal with it, I will certainly come back to the House to introduce legislation to force it to so do. Somebody once said - I am not sure who it was - that the more legislation there is, the less justice there is. I am not sure who said it but I read it at some point. We should avoid legislation if we can and I am fairly confident from my engagement with Nursing Homes Ireland, which is the representative body for its members, that it is very anxious to deal with the issue of additional charges.

I want to give the same message a number of times and it is that I have asked nursing homes to flag additional charges at inquiry level as opposed to the day on which one lands one's loved one, one's mum or dad, into the nursing home. That day brings trauma. One's loved one is in their bed and then one is given a list of additional charges. One is typically given the charges on the day one signs the contract. That is not good enough and it is not acceptable. That is catching people blindside. I have asked nursing homes to flag additional charges in an open and transparent way, to put them on their websites and to publish them in so far as they can. I have asked that they be flagged at inquiry stage, that is, when somebody is approved for the fair deal scheme and is looking at which nursing home he or she would like to go to. The nursing homes have agreed to do that and I understand many of them are in the process of doing so already. I have also asked them to develop a standardised template for these charges and to consider preparing something like a profit and loss account which would show clearly the amount of charges collected from residents in a year on one side and, on the other side, what those charges were spent on.

We do not want to throw the baby out with the bathwater. The last thing I want to see is elderly people in nursing homes with their heads thrown sideways, sitting and staring out a window for eight hours a day. We do not want to kill social activities programmes. There are many voluntary groups and schools which are quite willing to come into nursing homes to provide entertainment and play music and so on and which do great work. We want to ensure that there is a good, lively social programme in every nursing home. If there are charges attached to that, we want to ensure that they are open, transparent and consistent. I am confident, from my negotiations and engagement to date, that the industry is making good strides towards that. It appreciates the pressure on it to deal with this, and I believe that it will.

We need to make people aware that within the last year or two, the Ombudsman got jurisdiction over nursing homes. Therefore, if any family comes into a Senator's office with a concern about charges and how they are being spent, the family will first need to take it up with the nursing home to get clarity, but if they are not satisfied they can go to the Ombudsman, who will investigate. I recently met the Ombudsman. He only received 30 complaints about nursing homes last year, only one of which related to additional charges. Again I encourage any family that has concerns about additional charges to avail of the Ombudsman's services, and I ask each Senator to get that message out. It is a free, efficient and effective service.

Senator Kelleher asked about engaging with Professor O'Shea, which she suggested to me before. I have not done so yet, but I will attempt to so do in the future. She also made a point about deteriorating in hospital, which I very much accept. That is one of the big challenges for society. People, and particularly elderly people, are very vulnerable in hospitals. It would be far better and healthier for us to protect them and support them to live in their communities.

The challenge for us all is to try to reorient the current system, with up to €1 billion spent on the fair deal scheme, into the community, where we are spending approximately €360 million on home care packages and home help hours, and to try to get the money away from the one side. However, one cannot just remove something and not replace it with something else. We must gradually bring down the nursing home care bill, which I hope we can do, and increase the bill on the other side. I have an interesting statistic on that. Since the introduction of the fair deal scheme in 2009, which is not that long ago in the greater scheme of things, the average stay of a resident in a nursing home has gone from seven years down to 2.2 years. It is a very welcome development that that is the average length of time people are spending in nursing homes as a result of the fair deal scheme.

Senator Kelleher also asked about the next steps and the timeline, as did Senator Ó Donnghaile, and some other Senators might have asked about them. The next steps are as follows. The public consultation finished yesterday. The Department is going through the submissions received. When I last checked, I think there were about 2,300 submissions. I suspect there were many more in the final week. Whatever came in the final week will be added to the 2,300, and the Department will, I hope, have a report published on those submissions by the end of this year. Then it is up to us to go back out and deal with HIQA on the regulation of a home care scheme. Someone spoke about including the home care package under the fair deal scheme. That will not be considered. The fair deal scheme is a very separate scheme. It is there for long-term residential care. We want to create a fair deal-type scheme in the community. Bearing in mind that this is not an ambition or a target, it took nine years to devise the fair deal scheme. I certainly do not intend anything like that length of time to be spent devising the scheme and its introduction. The next steps are to get the report published by the end of the year, start engaging with HIQA on the regulation of it and carry out some other work teasing it out. I envisage getting a scheme up and running in its entirety in probably 18 months to two years.

Senator Kelleher mentioned dementia, which is a societal time bomb awaiting us all and is a hugely pressing challenge. I had meetings today with the HSE and the Department on this very issue, trying to increase funding for dementia care and recognising it as a top priority because that is what it is for society. For whoever will be here in years to come, in the next three, four or five years, and for all of society, this will become an increasing challenge.

Senator Feighan spoke about farm families, his mum's care and the self-employed. Again, I will just say that I have noted his comments and his concern for people who do not have pensions and the self-employed who have shares instead of pensions.

Senator Ó Donnghaile spoke about celebrating longer years as an opportunity. I could not agree more with him and I speak all the time about the fact that while we have been very successful in adding years to life and that the number of people living over 65 and 85 is doubling and tripling, respectively, we must add more years to life. That is the real opportunity. The Senator is absolutely right. It is an opportunity for us to add years to those lives. He also spoke about small businesses and voiced his concern about additional charges, which I have addressed.

Senator O'Reilly spoke about the public meeting in his area and the charges and contributions towards home care, which I think I have addressed.

Senator Byrne spoke about farm assets and home care and the nursing home payment to clients. Many people ask the question, if my mum were in a nursing home, it could cost €1,000 or €1,100 a week to have her there, so why can I not get some of that money to continue to support her at home? I think this is what Senator Byrne was talking about. Unfortunately, we do not have that flexibility in the fair deal scheme. It is very much committed to the long-term stay and one cannot pick or choose. However, the ambition is that in another two years one will be able to decide whether one wants to go into a nursing home or put one's loved one into a nursing home or whether one wants to be supported in the community.

Senator Colm Burke spoke about the challenges ahead and said that if current trends continue, there will be 40,000 people in nursing homes, and if 23,000 cost €1 billion, we will be looking at a doubling of the cost to €2 billion. It is vital, therefore, that we very rapidly take the steps towards reorienting towards community care. Senator Burke also spoke about the rising cost of nursing homes. I am aware of many of these issues and have had numerous engagements with Nursing Homes Ireland. The National Treatment Purchase Fund, NTPF, is the body that negotiates nursing homes. It is reviewing its pricing structure with nursing homes at present and will have that concluded by year end. Something that will be done next year is a look at the cost of private nursing homes versus public nursing homes. There is a commitment as part of the implementation of the review in 2015 to look at that into next year. I have also been speaking recently to Nursing Homes Ireland about adequate payments to reflect the level of care in the context of delayed discharges and dealing with those challenges. At present it is a very rigid payment structure. It is one payment and one payment only and does not reflect the level of care provided. I have been speaking to the Department, the NTPF and the HSE to try to bring about solutions to this. It will take some time before we get what is called the SAT, the standard assessment tool, up and running, which can assess the level of care, but I am aware of the issue and am interested in seeing its resolution. I am aware of the increased cost of staffing in some hospitals because of their geography. I ask Senator Burke to send me a note on the calculation of the interest on moneys invested. He seems to have a good grasp of it, but I am not aware of it. I will certainly have it looked into for him and would welcome his thoughts if he had time to send me a note. The regulation of home care is a feature of the new home care scheme. It is not there at present, which I regret. I would like it to be there. There is no point in bringing in regulation through the existing scheme because it would delay the introduction of the new scheme. I would prefer to concentrate on getting the new scheme up and running as quickly as possible, and that is my present ambition.

Senator O'Donnell spoke about the role of carers, which is very important for us to recognise and protect. He spoke about the timeline from here on, which I have also reflected in my comments. I note that there was no mention at all of HIQA, which is interesting from the point of view of our discussing nursing homes. I will make one point about HIQA, which often arises as an issue and a challenge, and various nursing homes and the HSE find the HIQA experience very frustrating. We as a society have an awful lot to be very grateful to HIQA for because it has really upped the ante beyond recognition in the past ten years on the standing of living of our elderly, and I always want to commend it on that at every opportunity. However, I am aware it creates a very healthy tension between providers of care for the elderly and, of course, it represents the system, and I as Minister must keep away from involvement in that regard. It is an independent body. I do not tell it how to do its business. Issues arise from time to time but, on balance, the winners of the healthy tension it has created have been our elderly, which I very much welcome.

Overall, the fair deal scheme, by and large, for most of us - all of us here are practising politicians - does not come up an awful lot in our day-to-day business. Of all the schemes on which we get representations and with which we have difficulties, notwithstanding the complexities of it and issues with it, I think it works fairly well and is a good scheme.

I like to acknowledge good practice when I see it. I was in Galway yesterday. COPE Galway - I do not know whether any Senators are aware of it - provided 45,000 meals last year as part of its traditional meals on wheels. This ties in with the fair deal scheme and our ambition to keep people at home. COPE Galway has a superb service. Senators should go and see it and try to replicate it in all our communities. It has the highest standards as regards the Q mark and hygiene. Its key focus is nutrition and it delivers meals seven days a week to elderly people living on their own. It has a bus service going out into the communities and many volunteers helping with it. It is a very noble aspiration. For those of us who are practising politicians in our own communities, this is something we should all try to see replicated. Again, there is an awful lot of a voluntary effort to it, which I very much welcome and support. The State cannot and will not do everything. We can spend all the time we want giving out about the State's failure or we can ask what we ourselves can do about it, getting communities up and running, tapping into the volunteerism that is there and seeing something like COPE Galway, which, as I said, provided 45,000 meals with the highest nutrition standards to elderly people living on their own last year. It is doing an enormous amount to keep people well in their own homes and out of nursing homes.

I hope I have answered all the questions.

Senator Keith Swanick

Would the Minister of State agree with me that we cannot really make the necessary changes within the fair deal system or regarding home care provision without liaising with some of the stakeholders that provide that care, be it the general practitioners, GPs, or the public health nurses? Often within the Department, through no fault of anyone, there can be disjointed thinking. Will the Minister of State commit to engaging with some of the representative bodies that will provide this care? There is no point in having people staying at home if there are not enough public health nurses. Only 20% of young GPs are staying in the country. Will the Minister of State liaise with the Irish College of General Practitioners, the Institute of Community Health Nursing or the other-----

Acting Chairman (Senator Diarmuid Wilson)

Senator Swanick-----

Senator Keith Swanick

-----multidisciplinary team members? Will he look at that in the coming weeks?

Deputy Jim Daly

I am very happy to do that because part of the Department's ambition is to have the widest consultation possible. While the formal consultation period has closed, I will continue to consult informally as widely as I can, and we would be more than welcoming of the views of any particular group.

Senator Keith Swanick

Especially the public health nurses?

Acting Chairman (Senator Diarmuid Wilson)

That was not a point of order, but I gave Senator Swanick a little latitude there. I thank the Minister of State for his answer. That concludes statements on the fair deal scheme. When is it proposed to sit again?

Senator Colm Burke

At 10.30 a.m. tomorrow.

The Seanad adjourned at 6 p.m. until 10.30 a.m. on Wednesday, 4 October 2017.