Dáil Éireann díospóireacht -
Thursday, 9 Nov 1989

Vol. 392 No. 9

Health (Nursing Homes) Bill, 1989: Second Stage.

Minister for Health (Dr. O'Hanlon)

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

The purpose of this Bill is to promote the highest standards of care for dependent persons in nursing homes, to change the arrangements for the subvention of persons in nursing homes and to facilitate health boards to make arrangements for the boarding out of persons who can no longer live at home.

The existing legislation, the Health (Homes for Incapacitated Persons) Act, 1964, is now 25 years old. It is important that developments in relation to the care of dependent persons during that period are reflected in new legislation. We must ensure that the public will have full confidence in the standards of care available to vulnerable people in private and voluntary nursing homes. The standards of care being provided at present are of a high quality but there is a widespread consensus that aspects of the legislation need to be changed.

Private and voluntary nursing homes receive a considerable amount of public funds for the care of eligible patients under the Health Act, 1970. In 1986, the amount of the subsidy paid was £15 million. The existing arrangements for subventing the care of dependent persons have been criticised for a number of reasons. A further purpose of this Bill is to ensure scarce resources are used in the most effective way to care for dependent people.

Population projections reinforce the need to define the responsibilities of health boards and nursing homes. The 1986 census revealed 382,000 people over 65 of which 143,000 are over 75. The latest projections suggest that the number of elderly will increase slowly up to the year 2000 and then rapidly after that date. By 2011 a population of 414,000 elderly people is forecast, an increase of nearly 10 per cent. The increase in the elderly population will not be spread evenly throughout the country. Along the western sea board, the numbers of elderly will decrease by about 12 per cent by the year 2000 while in the greater Dublin area, numbers will increase by 30 per cent. The rate of increase in those reaching advanced old age will be particularly marked. These figures give some idea of the challenges facing us in providing for the care of the dependent elderly.

Most of the changes proposed in this Bill were recommended in the report of the working party — The Years Ahead — A Policy for the Elderly which was presented to me in October 1988. The Government accepted their recommendations in principle and this Bill is a mojor step towards implementing those recommendations.

The working party recommended that a licensing system for all nursing homes be introduced. This reflects the need to ensure that high standards in nursing homes are kept under regular review and are maintained at the agreed level.

It is proposed that a health board should be able to subvent the care of eligible patients, following medical and social assessment, in nursing homes licensed by the board and that the level of subvention should reflect the patient's needs.

The recommendations of the working party report reflect the views of the National Council for the Aged, which advises me on policy towards the elderly and which commissioned the first research study on nursing homes in this country. It has also recommended that a licensing system for all nursing homes be introduced and called for changes in the method of subventing the care of elderly people in nursing homes. The National Association of Widows in Ireland at their annual conference this year called for a code of standards and regulations for nursing homes and for the registration of homes. The Irish Private Nursing Homes Association have also made representations to me about the need for revised legislation on nursing homes.

This Bill addresses the main problems identified with the existing legislation, building on the recommendations of bodies with expertise in this field. It aims to ensure a high standard of care in each nursing home without interfering unduly in the management of the home. It is not my intention to put obstacles in the path of persons wishing to set up a nursing home. The Bill provides safeguards against unreasonable action by health boards while providing a framework within which nursing homes and health boards can each carry out their responsibility in caring for dependent persons.

There are at present 332 private nursing homes in operation. Of these, 286 are private and 41 are voluntary homes. Nursing homes are being opened at an increasing rate. Over the past year some 20 new homes have been opened. The greatest concentration of nursing homes is in the Eastern Health Board area. The existing homes can cater for approximately 6,500 people.

It might be helpful to Deputies if I explained the existing legal situation and the problems which have been identified in the legislation. The Health (Homes for the Incapacitated Persons) Act, 1964, is the Act which governs standards in nursing homes. Voluntary nursing homes are excluded from the scope of the 1964 Act.

Under this Act a person who proposes to set up a private nursing home must notify the relevant health board in writing one month before it is proposed to commence the home.

Regulations are laid down under the Act to govern the standards of care in nursing homes. The first regulations were made in 1966 and updated in 1985. The regulations govern the standards of care, accommodation and food, the number and qualifications of staff and the description of homes among other matters. The health boards are responsible for enforcing these regulations.

At present, the health boards inspect homes at least every six months to ensure compliance with the regulations. Nursing homes charge their clients for the care they provide, either fully or partially. Some homes are approved for subvention under section 54 of the Health Act, 1970, and in these cases residents can avail of a subvention towards the cost of their care which is paid by their health board. The current amount of the subvention is £6.78 per day.

The Eastern Health Board have made arrangements with a number of private and voluntary homes under section 26 of the Health Act, 1970, to subvent the care of dependent elderly people. Other health boards grant aid voluntary homes under other sections of the Act.

A number of unsatisfactory elements have been identified in the present legislation. For example, a health board is given very short notice, only one month, that a private nursing home is about to commence operation. A home may be set up which does not in all respects comply with the regulations and the health board may, after the fact, have to set about ensuring that the regulations are met. This is not always a satisfactory way to proceed.

The only sanction available to a board is of prosecution, a remedy which should only be used in relation to serious breaches. While the vast majority of nursing homes comply with the regulations and co-operate well with the health boards, it would be better if health boards as the statutory or regulatory authority had more flexibility in carrying out their functions. Boards should be able to ensure that a nursing home complies with the required standards before admitting its first patients. The best way to do this is to require a nursing home owner to have a licence before opening for business. Future compliance can be encouraged by a requirement that a licence be renewed on a regular basis.

There are many charitable nursing homes in operation which are not covered by the 1964 Act but which are caring for dependent persons. Many are in receipt of public funds. I agree with the recommendations of the working party report and the National Council for the Aged that all homes providing nursing home care for dependent persons should be covered by legislation. Many of these homes have in the past set the standards for the care our society gives dependent people. Compliance with licence requirements should not pose either a problem or a threat to the overwhelming majority of these homes.

I will now outline the main provisions of the Bill. A nursing home will be a home caring for more than two dependent persons. The term "incapacitated person" is replaced by the term "dependent person". A dependent person under the Bill will be someone who requires assistance with the activities of daily living, like dressing, eating, walking, washing and bathing due to physical infirmity, disease or defect or mental infirmity. These are the activities which are now used in modern nursing to assess the level of dependency of a person. Most persons covered by the Bill are elderly, but dependent people in younger age groups will also be included. All homes providing nursing care for dependent persons will be included whether or not run for profit. Acute general hospitals, maternity homes, children's homes, homes for members of religious communities and people being cared for by their families are excluded.

A person wishing to set up a nursing home will apply to the health board for a licence. The health board will consider the person applying for the licence and the proposed premises to ensure that all is in order. To assess licence applications or licence renewals, boards will require certain information relating to the suitability of the applicant and the person in charge to run a home, the standard of accommodation, the facilities offered and so on.

This information will be provided in the licence application and the type of information required will be standardised between all health boards. A licence will then be granted which will be valid for two years and then must be renewed. It will not be possible to open the nursing home until the licence has been granted and only a licensed home will be entitled to call itself a nursing home. The licensed home will be included on a health board register of all homes in the health board area. This register will be available to anyone who wishes to consult it free of charge at all reasonable times. It will enable anyone to obtain information on nursing homes licensed by the board.

The detailed requirements which a home will have to meet will be set out in the regulations. The 1985 regulations under the existing 1964 Act will continue to apply until new regulations are published. Officials in my Department are working on these new regulations which will be based on the experience gained from the existing regulations. There will be widespread consultation on these new regulations before they are enacted.

Under the provisions of this Bill, health boards will not just play a regulatory role. They will also be authorised to provide training for nursing home staff and to provide a range of ancillary services, such as chiropody and physiotherapy, on mutually agreed terms and conditions. The best features of the existing regulations will be retained, such as the requirements that health boards inspect homes on a regular basis, that qualified staff be available at all times and that proper records be kept. Through the proposed process of ongoing inspection and regular licence renewal, there will be a constant learning situation for both the boards and the authorities of the homes, which will add greatly to our ability to set and maintain good standards that are in tune with the needs of the residents.

A licence holder must apply for a new licence at least two months ahead of the expiry date. This gives the health board a reasonable period in which to respond to the application for renewal. If the board do not inform the renewal applicant of their decision within two months of the application, then the licence will be granted automatically. This decision will encourage boards to assess applications promptly and protect nursing homes from delay which might otherwise occur.

If a nursing home is sold during the licence period the licence expires, the new owner must apply for a licence within two weeks. A health board can only refuse to grant or renew a licence or revoke an existing licence for specific reasons. They can do so if they consider that the premises or the manner of running the nursing home does not comply with the regulations. They can also act if they had not been furnished with necessary information. Finally, they can use their powers of refusal if the person in charge has been convicted of a serious offence under nursing home legislation or of a serious offence which would render the person unfit to carry on a nursing home.

A health board will be able to attach conditions to a licence when they grant the licence or later. A condition could, for example, require certain improvements to be carried out to the home by a certain date. If a licence applicant or holder feels aggrieved by a health board's decision on any point, he-she can ask the board to review the decision and if still not satisfied, appeal the decision to the District Court.

Health boards will charge a fee for a licence which will help to defray their costs in inspecting homes to ensure that standards are being met. The amount of the fee will be set by regulation. The fee has not yet been decided. It will be a matter for negotiation with both the nursing homes and the health boards.

Concern has been expressed from time to time that the title "retirement" or "rest home" is being used to avoid the obligations of the existing legislation. I am not concerned with the genuine retirement home where the residents are independent and receive no nursing care. I am concerned that a home could call itself a retirement or rest home but in practice be looking after dependent persons requiring nursing care. At present health boards have no authority to inspect such homes. Under the new Bill, they will be given power to inspect any premises where they consider dependent persons are being maintained. Heavy fines will be imposed on people found guilty of caring for dependent persons without holding a nursing home licence.

Situations have arisen when standards in a nursing home have fallen so low that urgent action is needed to protect the interests of the residents. It may be impracticable to transfer the residents to other homes. One solution which has been found to work is to allow the health board assume the management of the home until the problems have been resolved. Under this Bill, a health board will have the power to assume the management of the home with the consent of the licence holder or alternatively, in pursuance of an order from the District Court, if a nursing home fails to comply with the standards of care in the regulations.

The period of the management order may not exceed three months or, if the board are acting on an ex parte court order, not more than two weeks. Any expenses incurred in managing the home during the period will be paid from the nursing home's income. The health board will be able to recover from the nursing home the salary costs of the person they appoint to run the home.

These provisions allow health boards to protect the welfare of dependent persons in nursing homes where the standards are such that the health of the residents is in jeopardy. It is intended as a temporary measure pending longer term action being taken, such as the transfer of patients to a more suitable location or a change of management of the home.

Technically, every person entering an approved nursing home is eligible for subvention since the extension of eligibility for care in public hospitals to the whole population in 1979. Under section 54 of the Health Act, 1970, a health board may pay a subvention to a person in a home approved by the Minister for Health. The scope of section 54 has been curbed as no new homes have been approved since 1980. Unfortunately, due to constraints on the financial resources in the health services it was not possible to approve new homes. Deputies may be interested to know that there are 94 approved homes out of 332 private and voluntary nursing homes. The present system of subvention discriminates against the many excellent modern homes which have opened since 1980.

Under the Bill, if a dependent person requires nursing care, but the person is not able to pay all the costs involved, that person or his or her relatives will be able to apply to the health board for a subvention. Health boards will be able to contribute to the costs of maintaining a dependent person in any licensed nursing home. The health board will assess the individual's level of dependency and their financial circumstances in making their decision to contribute to the costs involved.

It is important that an individual seeking a subvention is assessed before going into a nursing home. It may be that the health board can arrange for some other form of support to solve the problem and allow the person to remain independent and in their own home. If the person is assessed as requiring nursing home care and is unable to pay the full cost, the health board will be enabled to pay a subvention. The health board will be able to vary the subvention to match the individual's dependency.

I am proposing that there would be payments for three categories of physical dependency — light, moderate and heavy and one category for those with severe forms of dementia.

The amount of the payment will vary because the more dependent a person is the more expensive the care. The level of payment will be fixed by regulation, following consultation with the interests involved.

I wish to stress that any person in receipt of a subvention at present under section 54 will not be affected by the Bill in any way. These subventions will continue to be paid as long as the person is in the home. However, no new applications will be accepted for section 54 subventions when the provisions of this Bill take effect.

I would like to give an assurance that the overall level of financial support for people cared for in nursing homes will not diminish as a result of this Bill. This provision is not about saving money; it is about enabling health boards to target their available resources most effectively and to respond flexibly to the changing demands of dependent people for whom they have responsibility. This is the approach which the new subvention arrangements provide for.

Under a general provision of the Health Act, 1970, section 61, health boards may make arrangements to assist in the maintenance at home of a person who would require to be maintained otherwise than at home. These persons are frail elderly people who do not need nursing services but who require care and companionship.

One of these arrangements is boarding out. Boarding out is a practical response to helping an elderly person maintain his or her independence by assisting them to live in their own community, near to their family and friends. The Bill gives health boards specific legal authority to make boarding out arrangements for persons who can no longer live at home and who consent to be boarded out. Regulations governing boarding out will be made to set standards and ensure proper monitoring of placements. Health boards will be empowered to contribute to the cost of a boarding out placement.

This Bill does not set out to limit in any way the establishment of nursing homes. The State already, under the 1964 Act and the 1985 regulations, has a statutory responsibility to ensure a minimum standard of care in nursing homes. This Bill updates the existing legislation to take account of developments in the care of dependent persons by establishing a framework for licensing and registration of nursing homes.

The Bill does not interfere with a person's right to choose nursing home care. It does not attempt to direct individuals towards particular homes. It will, in fact, widen the choice of persons entitled to a subvention from the limited number of homes with section 54 approval to all homes. Where someone needs financial assistance to pay for nursing home care the purpose of the assessment is to ensure that a nursing home is the most appropriate option and that the health board are directing their resources to those in need.

The Bill promotes the welfare and wellbeing of dependent people in nursing homes. Legislation, by its nature, is concerned with minimum standards. I would hope that in partnership with the health boards and the nursing homes we could go further and agree a code of good practice for nursing home care. It would set out the best practice to which all homes should aspire. Such a code was recommended by the National Council for the Aged and I believe it could make an important contribution to achieving high standards in all homes. It is my intention to circulate a code of practice with the regulations to be made under this Bill. Dependent people and their relatives must be assured that there are many safeguards in the arrangements made for the care and protection of those who can no longer fend fully for themselves.

Nursing homes and health boards have a complementary task of caring for the elderly. The growth of the nursing home sector has been rapid in response to the number of elderly people and their increasing income. The right of elderly people to make private arrangements for nursing care in their later years is not in question, but the nursing home sector cannot be considered in isolation from publicly organised services and the standards that should be expected from all service providers. It will be necessary to consider the role that nursing homes can play in the future in caring for dependent persons through full time residential care, day care or respite care. We will have to be aware of how private and State funded services can work together effectively.

There is a need to explore the implications for policy of a closer relationship between health boards and nursing homes in the future. My officials have been discussing with representatives of the National Council for the Aged, the Irish Private Nursing Homes' Association and the health boards, the commissioning of research on this topic which I hope will be undertaken shortly.

The provisions of this Bill will make for a new relationship, a new partnership between nursing homes and the health boards. Both parties will have to work closely to ensure that the Bill's requirements are met. This co-operation will contribute to a clearer appreciation by each party of the other's difficulties and responsibilities. A co-ordinated approach between health boards and nursing homes can only improve the quality of care available to dependent people.

It is worth noting that only 5 per cent of our elderly are in institutional care at any time, under the care of health boards or private and voluntary nursing homes. A much higher proportion of the elderly — 17 per cent — are being cared for at home by their families. We must do more to support these families through help at home and respite facilities. I would like to see more arrangements between health boards and nursing homes to provide day care for dependent elderly people cared for by their families or respite facilities to allow carers a break from their heavy responsibilities. The framework provided in this Bill, should encourage this kind co-operation.

Nursing homes are an indispensable part of services for the elderly. There are many advantages to well run but home homes which are convenient to relative and which provide care at various level This Bill seeks to strike the right balance between ensuring that the interests of some of the most vulnerable members of our society are protected without undue interference in the management of homes. I would welcome all suggestions on this and committee stages to improve this Bill to promote the best interests of dependent people in nursing homes.

Mr. Yates

My party welcome and support this Bill in general terms. I am sometimes very quick to criticise the Minister's officials for their tardiness and all sorts of other things, but I should like to compliment them on this occasion. I should like to single out for special praise — as the Health Commission Report and others did — the work of Ruth Barrington who has been exemplary in this area. Indeed, I should like to thank all the officials who worked in this area.

It has been recognised for some time that the safeguards to protect dependent and elderly people in nursing homes are inadequate. There have been a number of significant reports, the Minister alluded to all of them and I will also be referring to them in some detail, which have consistently, since the 1985 regulations were brought into place, identified legal defects and gaps which the Bill will rectify. We support the findings of these reports.

Other issues have been raised by this legislation. There are areas of serious neglect by the Government and we will use this opportunity to try to rectify that situation. We will also be tabling a series of amendments to try to ensure maximum fairness to the operators of nursing homes under the law and at the same time improve where possible, safeguards to the public.

Undoubtedly, this whole area will assume a growing significance in future simply because of the increased numbers of nursing homes cropping up right across the country and because of the very large growth in our elderly population. Between the years 1981 and 2006 the over 75 bracket of the population will increase by 20 per cent. That is a very significant change and we all know from our own constituencies that there is a huge growth in private nursing homes and, by and large, the most modern and new nursing homes have the highest standards.

Not only are we dealing with greater numbers, we are dealing with an increased life expectancy and, therefore, the higher the age the greater the increase in that proportion of the population. That means greater dependency and a higher level of care requirement. We are dealing with people whose mental and physical incapacity is such that they will require the homes with which this Bill seeks to deal.

The Minister did not refer to the State's policy in regard to where these elderly should be cared for. Is it in long stay geriatric hospitals, private nursing homes or district hospitals? There is a choice and the important thing is that we now have to plan for this extra requirement and make those choices. In 1986 the cost of long stay geriatric beds was £59.28 million, the cost of running district hospitals, which are predominantly full of elderly people, was £25.4 million and the cost of subvention somewhere between £14.5 million and £15 million.

You cannot make general comparisons because some of our long stay geriatric facilities have back up care such as physiotherapy and other services which nursing homes do not have. The average cost of a nursing home to a patient is somewhere between £100 and £150 and the average cost in a geriatric long stay hospital, many of them in old buildings which are very inefficient in running costs for heating — is between £350 and £450 per week. Later I will mention the financial subventions to date and the anomalous situation which has arisen in that regard.

We need to adopt the plan in The Years Ahead on what will be the numbers per thousand of population of extra beds that will be required so that there will be provision to increase them. I favour using high quality nursing homes as a vital ingredient in that process. I am not talking about removing geriatric facilities from the existing system but about extra future needs for the simple reason that there is no capital cost to the State in using subvented beds.

Boarding out is a greatly under-utilised policy option for elderly people although it has many advantages. Coinciding with this debate, especially on Second Stage, we should not just deal with the pure legal controls that have been put in place but we should also have a clear understanding where these statistics will apply in the nineties and at the turn of the century. We should have planned extra provision for the sensitive needs of the elderly so that they can live out their lives with dignity and independence and that there will be places for them. I hope that there will be positive discrimination in favour of nursing homes in that regard.

It is increasingly the case that families do not want to mind their elderly dependent relatives. There are more women in the workforce and that is a good thing. The Minister gave the percentage of people being cared for in the home but my fear is that that will reduce even if we introduce a carer's allowance under the social welfare system there will still be a greater demand for residential care. We must also take into account that years ago people had a dozen children but now they only have two which means that there are fewer people to mind elderly relatives. All this means that there will be a growth in the need for nursing homes and a vital element of planning which was missing heretofore.

In relation to care within nursing homes, the most important thing is to ensure that elderly people who live there do not develop a sense of total dependence. How many of us have visited hospitals and nursing homes to discover that, within three or four weeks of a patient being admitted, they become helpless, they have to be fed, tasks they were able to do in their own homes they are unable to do there? It is very important that the quality of life in a nursing home is such that it is not custodial in orientation, is not institutional, but rather involves outside voluntary groups. There is no provision in this Bill to cater for circumstances in which the authorities in a nursing home turn around and say: no, this local organisation that provides back-up support for the elderly will stay out of our nursing homes. There is no provision to ensure access of external voluntary groups to promote the welfare, quality of life and outside interest of elderly people.

Another difficulty encountered to date is that there has been no assessment whatsoever as to whether certain people should be in nursing homes. The single most important development in recent years in relation to geriatric policy development has been the establishment of geriatric assessment units right across the country. I would quote the North-Western Health Board as the best example of this — although these units exist in nearly all the health boards now — with a team that meets every week comprised of the geriatric placement officer, the meeting chaired by the director of community care, general practitioners and the matrons of geriatric hospitals. They sit down together and, before anyone can be admitted to a geriatric, long-stay bed, they must have a full, prior assessment. In fact, there is even an assessment carried out during the two weeks that somebody may be admitted temporarily. That means that, where possible, an elderly person is rehabilitated and got back into the community. Where possible they endeavour to say that this person would be much better in sheltered housing or, definitely, this person requires a long-stay bed. But there is no point in truncating the active lives of people by admitting them to long-stay beds when they should not be there. It would be my hope that in future before any admission to a subvented bed, a bed in a private nursing home, paid for in part by the State, the same prior geriatric assessment procedure entered into for long-stay beds would be applicable to nursing homes. I say that not because I am trying to keep people out of nursing homes but because I am endeavouring to get the most appropriate level of care for them. I have seen reports from the National Council for the Aged who have ascertained that as many as one-third of occupants of geriatric beds and centres are not sufficiently sick or incapacitated to be there but rather are there because of social circumstances.

I want to deal next with the subvention itself. Here I shall have some very harsh words to say in relation to the general performance since 1980. The Minister did not deny this position in the course of his remarks; in fact, he was quite straight-forward about it. There is a farcical position obtaining in this respect, recognised by the policy for the elderly. The position here is something akin to the provisions of the 1970 Act in relation to dental services. In my view, people have a legal right to subvention. In this respect I might quote from section 54 of the Health Act, 1953, which stipulates that people who require institutional care they cannot fund themselves should be given assistance. Section 54 (3) of that Act reads:

It shall be the duty of a health authority, subject to and in accordance with the provisions of this section and the regulations thereunder, to give to every person in their functional area who is eligible for institutional assistance such institutional assistance as appears to them to be necessary or proper in each particular case.

That clearly indicates to me that there is a legal responsibility on health boards and on the Minister for Health to provide that assistance, where applicable, in terms of somebody who needs institutional care, who is in receipt of an old aged pension and who cannot afford to pay for it themselves. There has been no court challenge to this. It strikes me that there is no way out of that obligation should someone challenge it.

The operation of such subvention has been rendered farcical in so far as no new nursing home has been approved for a subvention since 1980, not because they were not deserving, not because they did not meet any criterion but because, effectively, there was an embargo on the funding of any new beds. In the Minister's own health board area, the North-Eastern Health Board, there is not even one approved nursing home, if I remember correctly from what was said in The Years Ahead. For example, there are no approved private nursing homes in the North-Eastern Health Board area. That is simply because there was none approved prior to 1980. That means that if one is unfortunate enough to live in, say, Drogheda, Navan, Cavan or wherever, one is not entitled to a subvented bed even though exactly similar circumstances might apply to somebody living in, say, Dún Laoghaire who would get a subvented bed. In the South-Eastern Health Board — the health board of the area Deputies Howlin, Ferris and I represent — for some years, even where nursing homes have been approved, they have refused to give extra subventions because of financial constraints.

It is unacceptable that the quality and standard of health care one gets in this country is dependent on where one lives. That applies to every facet of health care. That is why we will be tabling amendments to ensure that the operation of this Bill, when enacted, will be undertaken by the Department of Health, not the health boards, in terms of the inspectorate and the issuing of licences. I have no confidence whatsoever that health boards can operate uniformly.

We are fast reaching the stage at which elderly people have no rights whatsoever in terms of being able to speak up for themselves or exercise their rights. Their life expectancy is limited, probably they are in bad health and in very bad form and are not in a position to extract their rights in any legal form. It is the duty of this House to protect those people. Therefore, we will be tabling amendments that will endeavour to ensure — pending what we would rather see, which is a Bord Sláinte guaranteeing one delivery structure for all of the health services — equality of service countrywide.

The position can also obtain — and many nursing home operators and many Members of this House have lobbied in this respect — that there may be an individual in a given health board who might have a personality problem, who might have completely different, exacting standards from those laid down by other people, or they may be simply pedantic people.

If we do not succeed in our amendments to have these provisions adminstered by the Department of Health, then we will be lobbying to have two persons involved in any inspection so that the types of problems about which I have heard time and time again will be eliminated. In some areas one does not hear of problems because the personnel implementing the 1985 regulations are reasonable people. In other areas there are problems.

All of us have an interest in the fair and reasonable implementation of the provisions of this Bill. I would ask the Minister to seriously consider implementing these provisions within his Department. It would not require a very large inspectorate. In the fullness of time we would be dealing with a maximum of, say, 400 nursing homes. Once they have been inspected and granted a licence, the idea is they would be renewed. It strikes me forcibly that we need the same people operating these provisions from Donegal to Kerry and from Dublin across to Galway. If it is undertaken by the different regional health boards, as has been the case to date, then there will be different standards obtaining, different levels of subvention, different geriatric assessment teams, different approaches, which is unfair and does not make sense.

In relation to the subvention I would ask the Minister to effect a number of changes some of which have already been envisaged. First, I would support the proposal for a graded subvention in respect of people with higher levels of dependency. I know for a fact that many nursing homes will not take patients with Alzheimer's disease simple because of the high level of care involved. I know of a man whose wife has Alzheimer's disease, who is incontinent and is in need of a very high level of care. I know that these patients sometimes do not recognise people, can be upset, violent, and so on but we must remember that they are totally incapacitated and can live for a very long time in so far as they are physically quite healthy. Spouses cannot cope in these circumstances and go from nursing home to nursing home seeking accommodation for the patients only to find that nursing homes are not interested in taking in Alzheimer patients because of the extra staff requirements in caring for them.

I agree with the Minister's proposed changes in relation to the three categories of physical dependency: light, moderate and heavy, and the one category for those with severe forms of dementia. Perhaps, though, when the Minister is replying to the debate he could clarify what he said in relation to subvention. He said that no new applications will be accepted for section 54 subventions when the provisions of this Bill take effect. He went on to give an assurance that all the people who are presently subvented will continue to be subvented, that there will be no threat to them in that regard.

If both of those things happen together what will be the position of the new people? Unless extra funding is provided there will be no hope for them and we will be back to the status quo. The Minister gave no indication as to whether the subvention will be £50, £90, £100. The one level of subvention is not being paid any more and the Eastern Health Board have stopped providing added beds in recent weeks. There is little credibility in talking about higher rates if we cannot pay the basic rate. A commitment should be given by the Minister in terms of his support for this as opposed to a general commitment about resources. He should give a commitment in regard to the likely number of extra beds or subventions which will be made and the rates of payment. This needs to be clarified. We support the graded subvention prior to the necessary assessment taking place on all geriatric placements. I very much favour the subvention being linked to the old age pensioner or the dependent person so that they can carry the approval with them and have the right to go to another nursing home if they so desire.

Where there is no subvention patients have the choice to go where they like. Has the Minister given any consideration to price control in relation to nursing homes? There is no provision for it in this Bill. I have not made up my own mind on whether it is totally desirable but I would not like to think that elderly people were being ripped off to any extent by excessive over charging or profiteering by nursing homes. Perhaps the Minister can tell us when he is replying if he has any proposals in that regard.

We will be putting down a number of amendments to the provisions in the Bill which have not been made clear. For instance, I am not happy with the definition of nursing homes under section 2. This definition seeks to exempt certain categories and I do not support this. I do not believe an institution managed by the Minister or a health board should be excluded. There is no reason they should have less stringent standards than anybody else in terms of care for the elderly. We will be proposing the deletion of that provision in section 2 (1) (a). Section 2 (1) (b) provides that there will be an exemption for premises set up by general practitioners. I have my doubts about this provision in so far as it is too open as currently worded and could mean centres being set up and seeking to gain exemptions.

Section 2 (1) (g) provides an exemption for premises in which a majority of the persons being maintained are members of a religious order or priests of any religion. I cannot understand why members of the religious community should not be afforded the same protection as the rest of the community. I would be interested to hear the Minister's reasons behind this provision. There was a celebrated case of a fire in a religious home in this city. It is important that elderly people wherever they are should have the highest possible standards of care. We will be seeking to ensure that nursing homes do not have those three exemptions. This is the one opportunity this House will have to debate these provisions because the nature of regulations produced under an Act are not something which come before the House in the normal procedure and therefore they should have the maximum scope.

The Minister said that private retirement homes should also be included where possible. It is not explicit in the Bill that homes dealing with the mentally handicapped or with people addicted to alcohol or drugs should have the same minimum standards as set out in this Bill. Not alone should we afford protection to the elderly but we should also afford it to the handicapped and other people who are in convalescent care for either short or long duration.

Another recommendation of the National Council for the Aged in their study into this whole area was that there be an independent complaints procedure for patients and their relatives and a general consumer input into the whole process. The Minister has made no provision for this and we will certainly be tabling an amendment to provide for a complaints procedure. One has heard stories of elderly people being locked in their rooms or experiencing certain indignity in regard to toilet facilities and so on. In such instances, people should have an opportunity to complain if they so desire. We will be seeking to insert an amendment in this respect. That is not to say, of course, that the standards by and large in the 332 nursing homes are not of the highest standard. I concur with the Minister that the vast majority of nursing homes will obtain licences under these regulations. I do not wish to be extremely punitive in that regard.

I might say that we will be tabling a series of amendments which will seek to take out some of the subjective elements of this legislation. I am referring specifically to terms like "in the opinion of the health board." That term should be replaced by the term "have reasonable cause to believe." Anyone can have an opinion which can be damaging to someone else and some of the present provisions leave too much scope in this regard. Under the appeal procedure laid down for District Courts they have to determine whether the health board were of the opinion that such a state of affairs existed and that the standards had dropped beneath a certain level. It would be quite difficult to win an appeal in these circumstances and, therefore, I will be tabling an amendment in this regard.

One of the major reasons for the introduction of this legislation was that the biggest weakness in the 1964 Act and the 1985 regulations was their vague and general nature. They used words which can be, to put it mildly, ambiguous. They use words such as "adequate", "sufficient" or "suitable" which are very ambiguous and have very wide usage. We would like objective minimum standards to be inserted which would not bring about total inflexibility but which would make it clear what the State's requirements are. I should like to ask in that regard — I did not see any provision for it in the Bill — whether insurance is obligatory under the current proposals. That is not clear from the Bill.

I have no particular difficulty with what is proposed in section 6 but each nursing home should have to make available to all prospective patients a brochure setting out the home's facilities in the uniform manner which the Minister said must be set out for the health board. In that way a clear choice can be offered to the public as to the services that are available, the prices, the extras and so on. That would be a step in the right direction. Section 6 (2) (f) states:

prescribe requirements as to the description of nursing homes in written communications and the display in nursing homes of specified notices,

That requirement should be extended moderately to provide that brochures be made available. With regard to section 6 (2) (g) which states:

prescribe requirements as to the records to be kept in nursing homes and for the examination and copying of any such records or of extracts therefrom by officers of health boards.

I would like to raise two questions. It would not be appropriate that officers of the health board should have details of the private financial position of any nursing home. I hope they would be exempt. However if the Minister wanted to inquire into the financial situation of the institution, there should be a different procedure. By and large I do not think it is appropriate that such records should be made available. I do not think the clinical or medical records on patients should be seen by anyone other than the general practitioner or nurse dealing with the patient. It is not appropriate that the medical record files of any patient should be lying around health board offices. As the Minister knows, being a doctor, there is a long-standing tradition in Irish medicine that the confidentiality of a patient's circumstances be observed. I would not like to see section 6 (2) (g) taking from that tradition.

As I mentioned earlier, one of the neglected aspects of care for the elderly is the option of boarding out. The National Council for the Aged published an excellent report on boarding out schemes for older people in Ireland in 1985. Section 11 of this Bill deals with boarding out. Boarding out is a procedure whereby elderly people are placed with a family — and is akin to fosterage. They are taken in by the family and cared for as if they were a member of that family. The health board contribute to the costs involved, but at a rate less than that paid for the subvention to nursing homes. I will now quote from Home from Home? the report by the National Council for the Aged on boarding out schemes, which is the only significant survey on boarding out which I could find. The summary of findings states that at that time a total of 144 people were placed in eight boarding out schemes. A total of 63 carers were involved. Five of the eight schemes were in Connacht-Ulster, the remaining three in west Leinster. They also found that boarding out costs less than other forms of long-term care; that care was provided on a local, ad hoc basis, and there was no overall policy on boarding out; that schemes differ widely and there was little if any contact between the different schemes. The conclusions of the report are that boarding out is a very attractive policy option; that it is cheaper than other forms of residential care for the elderly; it involves no capital cost; it permits the more effective use of resources and it serves the specific needs of elderly people.

By its very nature a boarding out place is more mobile than a place in institutional care. The elderly person is placed with a family and is integrated successfully with them. It also has the advantage that elderly people can remain within the district in which they were brought up, thus minimising any disruptions as the elderly person could still meet with neighbours and keep in touch, whether that would mean going to bingo or whatever. It also helps the children in the household to have direct personal contact with the older person. The report also outlines the possible disadvantages of boarding out. There is the possible isolation and vulnerability of an old person; the success depends on the motivation of the carer and in certain circumstances the carer may lack the confidence to cope in certain emergencies. However, the report made very clear recommendations: first, that boarding out should be further promoted as it would broaden the range of policy options; second, that there should be a proper method of assessing and evaluating the potential scope of carers and the numbers of elderly people who could be boarded out; third, that proper supervision procedures be in place; fourth, that there should be an appropriate level of payment; fifth, that health boards should seek the assistance of voluntary bodies. It is quite clear from that report that boarding out is a totally under-utilised policy option. I do not think boarding out is a threat to nursing homes, even though I know certain nursing home proprietors do and they want identical standards. I want to see the highest possible standards for boarding out. More thought should go into the choice of carer, and the geriatric assessment teams which are in place should make it a deliberate policy to pilot a few boarding-out arrangements each year. In my view boarding out is the most cost-effective way of ensuring that elderly people can live out their lives in a community setting while at the same time being provided with care. For example, if they did not feel well enough to get up on a Tuesday morning they could stay in bed and yet be properly cared for.

This is the Cinderella of the geriatric services. The Minister should, as well as enacting new regulations give serious consideration, to extending boarding out and promoting it positively as a policy option for long-term geriatric care.

A problem for patients in nursing homes — the Minister has made no provisions for it in the Bill — is that the elderly invariably require back-up paramedical services, such as chiropody services, physiotherapy, ophthalmic and dental care. It is absolutely vital that the services of the nursing home include an integrated link-in to the paramedical services. There is no provision made in the regulations for the steps a nursing home should take to make these services available. In the rules relating to subvention under the 1954 Act a subvention is not just payable to medical card holders but to people regardless of income. Medical card holders would have a theoretical right to some of these services, but there are long waiting lists and the services are extremely patchy in some areas. I would like to see a provision whereby there would be a clearer requirement that approved patients should have chiropody, physiotherapy, ophthalmic and dental care provided between the health board and the nursing home. These are practical requirements for the care of elderly patients, but no mention has been made of them in this legislation.

By and large we support the broad thrust of the legislation. However, would the Minister clarify why he has favoured a system of licensing as opposed to a system of registration? Nursing home proprietors would prefer a registration system but perhaps there is some legal or administrative reason that licensing is more effective. I have an open mind on this issue, and on Committee Stage I will consider the best approach to deal with it.

Section 4 of the Bill relates to licences. Subsection (12) (a) states: "Where a nursing home in respect of which a licence is in force commences to be carried on by a person other than the holder of the licence, the licence shall thereupon expire". What would happen if the licence was in the name of Mr. Murphy and he died? Would the nursing home lose the licence straight away even though his spouse might be running it? What would happen if the licensee became very ill or even went on holidays? Is it right that the licence should fall into the hands of a manager? These are questions that I certainly have doubts about. Subsection (12) of that section is certainly unclear. Similarly with subsection (13) which states: "Where...there is a contravention of a condition of the licence in respect of the home, the holder of the licence and any person who is managing or in charge of the home shall be guilty of an offence". Surely a nurse could not be responsible for what is the fault of the licensee. I certainly would seek to exclude any person who is in charge of a nursing home in so far as the culpability and responsibility in total must rest with the person who owns the licence and not with a member of staff. There could be an element of buck passing that would make this provision unworkable.

I would also like clarification from the Minister in relation to the position of a code of practice. I would have thought that these regulations would be such that they would in effect lead to a code of practice. The Minister said that the ultimate objective is that the health boards, in partnership with nursing homes, would develop and evolve a code of practice. I hope that what we are doing here is implementing a code of practice which would be clearly laid out.

As a general rule, given the types of misunderstandings and personality problems I am aware of in relation to nursing homes and health boards, there should be an obligation on the health boards or the authorities involved — I would prefer if it was the Department of Health — to put in writing any specifications of complaints or dissatisfactions with the operation of a nursing home or any improvement that may be required. I refer in particular to section 6 (5) in that regard. Those commitments should be made in writing.

I do not wish to delay the House unduly other than to state that many opportunities arise out of this legislation to sort out the total mess that arises at present with the subvention whereby in some parts of the country people get no subvention while in other parts people in identical circumstances get it. There is also the problem of a stop-go situation with approvals since 1980.

I would like to see the positive promotion of boarding out. I look forward to the uniform implementation of this Bill when it becomes law and to the effective implementation of the excellent recommendations from the Department's The Years Ahead, and the National Council for the Aged being effectively implemented. I hope that, across this House, we can reach agreement on these points and that we can quickly and speedily enact legislation that will give to elderly and dependent people the safeguards and protection they require.

Mr. Howlin

On behalf of the Labour Party I welcome the Bill. It has been required for some time. I also commend the Minister and his Department officials for bringing it before the House. I suppose the background to it has been the unprecedented growth in private nursing homes in the last number of years. The reason this unprecedented growth has occurred is that the Minister has pursued, in recent years, a policy of squeezing the public health provision throughout the country. The Minister has, by his policy, deprived health boards of adequate resources and the consequence of that has been that in every health board region geriatric and district hospitals have closed and the number of public beds available to the elderly has diminished year after year.

As nature abhors a vacuum, the lack of adequate public provision of beds has been met by a mushrooming growth in private beds as anybody on a planning authority will be aware. A number of applications are being received from private individuals and consortia to build nursing homes to bridge the gap in that sector but unfortunately it does not bridge the gap in total. It bridges the gap for those who are in a position to fund such places for their elderly relatives or for those elderly individuals who are in a position to be able to meet the costs of private provision.

In my own county of Wexford, indeed in the home town of the Fine Gael spokesman, Brownswood Hospital in Enniscorthy was closed in recent years. That hospital was regarded for a long time as a geriatric home. I recall the trauma that the closure of that hospital by the South Eastern Health Board caused. I remember talking to ambulance drivers who, on the morning of the final closure, ferried the elderly people to alternate homes in New Ross and Gorey and indeed in a few instances to acute, very expensive beds in Wexford General Hospital. That picture mirrored itself across the country at the time. I remember also, as a consequence of that closure, getting phone calls from general practitioners around the county desperately seeking provision for elderly people who had been repatriated to homes where they simply could not cope, elderly individuals sent back to equally elderly spouses who were simply not able to cope. That catastrophe for those individuals did not get national coverage and in many instances did not get much local coverage but misery was caused for each of these people nonetheless.

Shortly on the heels of that closure New Ross District Hospital closed as a result of lack of funds from the South Eastern Health Board. The pattern repeated itself again when people already displaced once were further displaced and when elderly people who were used to that facility, not as an acute bed but one in which they could convalesce after an illness, no longer had it available to them. We have seen a very serious attack on the public provision of beds in recent years by a stranglehold of moneys that are available for such provision. As a consequence we have seen the rise in private establishments and private homes. The Bill before us seeks to address the problem of this myriad of private homes and to bring uniform standards into this whole area. Standards of a uniform nature are certainly required because the people we are dealing with are the most vulnerable people in our community. Some of them suffer from senile dementia, some are infirm and all are vulnerable. Many of them are afraid that a complaint would result in their circumstances being worsened. Because they are so dependent, surely they in particular among all others should have the maximum support of the State and of the caring services provided by the Department of Health.

Standards must be provided in relation to staff, training and numbers. Adequate provision must be made in relation to the numbers of trained staff available night and day in each of these homes. There must be proper medical provision with a GP on call on a 24 hour basis. There must be standards in relation to the very basics in life, in relation to food, cleanliness, heating and ventilation. All these things are already provided for to some degree by regulation. Technically, those standards have to be monitored but the reality is that the very resources the health boards require to undertake this monitoring are not available to them. The Minister has indicated that under present legislation these homes are visited once every six months, a very long time span, but, given all the new homes which have been opened, I wonder if an inspection every six months is carried out on each home in each health board area and if this inspection not only includes the basics, which I have already outlined, but also the régimes practised in these homes.

It is important that we understand what we are talking about. We are not talking about homes established by the caring State to enable the elderly in our communities to be looked after but rather homes established by individuals or consortia, many of which are excellent and are of high standard but whose raison d'etre is to make money. They are profitable organisations. They are set up as businesses. That is the bottom line and that is the philosophy behind their establishment. It is not a matter of the caring arm of the State providing for the elderly but rather a commerical division seeking to provide on a commercial basis for people whom the State has abandoned.

Having heard the Minister's speech I am beginning to wonder if the system will be given adequate resources not only to enable this monitoring to be carried out but to increase the public provision, or is it the case that we are going down the road of virtually abandoning the public provision and are seeking to lay down the required standards of private care and saying, "it is over to you, lads. Now it is the private sector who are going to look after the elderly who need institutional care."?

I have already referred to the régimes practised in some homes. Surely a person's dignity is of fundamental importance. It has come to light, and it is fully accepted, that exceptions make poor laws, that in some homes patients are not afforded the basic dignity their humanity demands, where they are expected to be in bed by a certain time when it is lights out or to be up at a certain time, and they have no control over their own lives in their twilight years. This is very sad and when the regulations under this Bill are drafted I hope the Minister will see to it that not only the basics, such as heating, lighting, ventilation and the standard of food and hygiene, are taken into account but also the practices in these establishments so that individuals will be allowed to be, if you like, humans and live their own lives with some semblance of dignity and freedom.

In fulfilling these new statutory duties the health boards will incure additional costs. However, the Minister gave no indication in his Second Stage speech if his Department will meet these costs. We will also have to consider the costs which the patients will have to pay. I shuddered when I heard the Minister imply that no additional resources will be put into this area, which will be a growth area for many years to come. In essence the health boards do not have the staff, resources or the wherewithal to implement the existing regulations. Without the Minister's assistance and more money how are they going to be able to implement the new standards envisaged under this Bill? I have already indicated that the vast majority of nursing homes are of excellent quality. However, it is the bad ones that need monitoring and it is only by monitoring all homes that we can ensure that there will be no exceptions.

State support for dependent persons is primarily provided under section 54 of the 1970 Heath Act. How much does the subvention actually amount to? Today it amounts to £6.78 per day which can hardly be described as an extravagant sum. As I have said, the Minister has not indicated if additional resources will be made available to ensure that there will be enough money to maintain high standards of institutional care. How are we going to insist on EC standards of hygiene and food if we do not provide the money to those who have not got it?

We have already heard that no new homes have been approved for the section 54 subvention since 1980. The reason for this is not technical but rather, as the Minister has admitted, financial. What does that tell us about the future? Under this Bill health boards will assess a person's means as well as the means of their relatives. I presume the dependent person's family will be required, as they are required to do in connection with an application for a medical card, to provide evidence of income before the amount of money to be made available from the health board to maintain a person in an institution or home will be determined. Different standards are applied by different health boards. Each of us on a regular basis is approached by aggrieved people about their application for medical cards and it is quite clear that the criteria which would qualify a person for the receipt of a medical card in one health board region would not do so in another because of the subjective decisions which individual health board officers are required to make.

Under this Bill individual health board officers will be required to make subjective decisions on the basis of information provided by a dependent person and his relatives. On the basis of this information the health board officer will not only determine whether a person will receive a subvention but also the amount of that subvention. This is very much a hit and miss operation. Such an approach, which we find unacceptable in connection with applications for medical cards, is almost more hideous when it comes to determining the quality of life and care available for senior citizens at the end of their days.

There will also be different categories of incapacity and the amount of subvention will also vary. Therefore, many variable factors will be taken into account in determining the amount of money which a health board will pay out. Unless a specific provision is made to a health board, depending on the number of elderly in each health board area, I fear the health board will simply have a general budget and will decide when times are bad, and when the Minister's policy is to continue squeezing money, to apply rigidly the criteria and the health board which is under the most severe pressure will give fewer grants than those who find themselves in a better financial position. That surely causes great concern. I would ask the Minister when responding to Second Stage to indicate how he will overcome that problem, how he will ensure that every individual elderly person or dependent person under this Bill will be treated in the same manner whether his application is in Manor-hamilton, Tralee, Cork or Kilkenny.

The Minister said that this Bill is not about saving money. I am glad to hear that but it must be about more than saving money. It must be about spending money on an area. The Minister wants to raise standards and increase the monitoring provision. Surely he understands that the consequence of that is greater expenditure. How can he give new functions and responsibility to the health boards and expect a uniform standard across the country without providing the resources and personnel to implement the regulations? The Minister must ensure that there is adequate staff for monitoring. There must be more money for monitoring and to maintain the increasing numbers of elderly people who need help. Neither of these issues has been addressed by the Minister. He simply says that this will not save money.

Dr. O'Hanlon

I never mentioned that it would not save money.

Mr. Howlin

I wrote that down while the Minister was speaking. I will look at it later and come back to the Minister. Perhaps the Minister would indicate that he will provide extra money, although he certainly did not say that either. The Minister indicated that only 5 per cent of our elderly are in institutional care. I take it the Minister accepts he said that?

Mr. Yates

The Minister referred to finances in his speech.

Mr. Howlin

I would refer the Minister to his script, where he said:

I would like to give an assurance that the overall level of financial support for people cared for in nursing homes will not diminish as a result of this Bill. This provision is not about saving money.

The problem about scripts having been prepared by civil servants is that we do not always remember exactly what is in them when we read them once.

In relation to the elderly population, 5 per cent of them are currently in institutional care. The demographic profile of the future has been instanced in Deputy Yates' contribution. We will have an increasing number of elderly people, an increasing number of dependent people, while at the same time — particularly if emigration continues at the level that has occurred over the past 12 months — the number of young people to look after the elderly will diminish. More and more elderly people will be dependent on the provision of the State or, if the State reneges on that responsibility on private provision. That is a prospect which we should at least address at this stage. This requires careful planning. I do not accept Deputy Yates' contention that we should address it by looking to the private sector as the main vehicle for doing that. I strongly believe that we need to have a comprehensive State plan to look after our people properly. In that way we would overcome many of the problems that have occurred not only in this jurisdiction but in others in relation to patchy provision. The private sector have a role to play but not the primary role.

We have to break away from some of our traditional views and some thought has gone into this. The reports mentioned by the Minister have signalled some new departures that need to be explored and many local authorities are beginning to develop their own plan and strategy, notwithstanding the lack of a central plan from the Minister, the Department or the Government. It is clear that the traditional way of looking at the elderly does not suffice. Elderly people increasingly value their independence, do not want to be institutionalised and want to stay in their own communities where they expect to be able to live a normal life, a life for the elderly that was not expected some decades ago.

New provision and new ideas are required. There is the notion of sheltered accommodation and many local authorities are now on the way to providing such accommodation. In my constituency a plan has been approved on a joint venture basis between the health board and the local authority to develop a site at Westlands in Wexford where there would be a core support centre, a house which could provide community services for the elderly, health services, chiropody, dental, aural and ophthalmic treatment and at the same time they can live independently in flats provided by the local authority surrounding the central provision. More of that sort of thing is happening but we need to do it on a coordinated basis. I know that the Department of the Environment are looking favourably at it and I hope that, as a policy, health boards will be encouraged to involve themselves in joint ventures with the local authorities to plan the future for an increasingly aging population who cherish their independence and want to live full and free lives. It is important that the Minister would do an adequate assessment of current and projected needs, and then set about providing adequate money to build the accommodation and support units that the assessment indicates are required.

In relation to the specifics of the Bill, on first reading I was intrigued that the definition of nursing home under section 2 (1) (g) excluded premises in which a majority of the persons being maintained are members of a religious order or priests of any religion. I wondered why that was included and why they should not come under the same protection and scope of the Bill as anybody else. I am sure there is a good reason for it and perhaps the Minister would tell us why that provision is included.

I agree with Deputy Yates' comment that under the same section at paragraph (1) (a) an institution managed by or on behalf of a Minister of the Government or a health board is excluded. In relation to boarding out, which seems to have new emphasis under the Bill, I agree that often one can put a very clear case for increasing the provision for boarding out as there are obvious advantages in maintaining elderly people in the community to which they are accustomed and because change at that stage of life is traumatic and it is important that people be maintained in a non-institutional atmosphere. However, a few alarm bells will ring if we are going to be heavily dependent on them because, obviously, they do not cost as much. I hope they will not be seen as a preference on economic grounds rather than on good health grounds. Clearly, they are unsuited to people who are heavily dependent or incapacitated in any serious way. There must be proper monitoring of standards there and I accept that that is included in section 11 which also provides that individuals can be interviewed by officials of the health board.

I welcome the Bill. We will be seeking to make amendments to it on Committee Stage. Whenever we deal with an issue like this the bottom line is generally resources. We can aspire to all the standards we like; we can seek all sorts of excellence from others, but if the Minister and the Government do not give the lead by providing the wherewithal to achieve that, we are at nothing. Therefore, the money must be provided to maintain standards. The money must be provided for the individuals who cannot afford it so that they will have provision in their old age and are not left in an isolated cottage in rural Ireland often without water, electricity and nowhere to go. The Minister knows that there are such people up and down the country.

We are one of the 25 richest countries in the world and on occasions we forget to acknowledge that. If we are a Christian country with a heritage of caring for our elderly, which I believe we have, and a regard for the elderly which is sadly lacking in many developed countries, then it is incumbent on us to provide for the elderly, not in an aspirational way alone by setting down standards for others to implement but by providing resources in money to look after our elderly people so that they may end their days with the greatest form of dignity and comfort we can provide with all the technology and resources a modern state has.

Mr. Sherlock

The Workers' Party broadly welcome the Bill even it is is somewhat limited and restricted in a number of areas. The need for the updating of the law in regard to the operational supervision of private nursing homes has been recognised for many years and the Bill is a step in the right direction. Initially, I have to say that The Workers' Party have considerable doubt as to the desirability of having privately owned nursing homes at all. Whatever way one looks at this private nursing homes are established and operated with the primary aim of making a profit for the proprietors. The problem arises when the pursuit of profit takes precedence over the welfare and interests of the patients in nursing homes. We would argue that there is an obligation on the State to provide for the care of those who are not in a position to look after themselves. However, as we know, far from extending the range of medical and health services available to those in need successive Governments, going back to the early eighties, have cut those services in half. It is likely, therefore, that the lucky few who can afford to secure health board assistance will have to continue to turn to private nursing homes.

I have no doubt that the majority of those who own and operate private nursing homes are honest and decent people who want to ensure the best possible care for those in their charge but, at the same time, it is a matter of public record that some nursing homes have been run in a way which falls short of the acceptable standard. I do not know if there are any official figures for the number of people who live in such nursing homes but I am sure there are thousands. I understand that there are 1,200 elderly people in such homes in the Eastern Health Board area and they are clearly there because they are ill, incapacitated or frail in some respect. They are particularly vulnerable and not in a strong position to stand up for their rights. It is essential, therefore, that there should be adequate legislation to ensure that they receive the standards of care they need and that they, their families or health boards are paying for. We should ensure that they are not taken advantage of or exploited in any respect.

The Minister in the course of his speech said that if a person requires nursing care and is not able to pay all the costs involved, then that person, or his or her relatives, will be able to apply to the health board for a subvention. It appears that the Minister is introducing a new category. Under the present system the geriatrician is the person employed by the health board to decide if a person is in need of full-time care and attention. That can take a long time and cause a lot of stress to the patient or his or her family. Is the Minister introducing another scheme under which another officer of a health board will have to assess the means of such people? I ask because of some experiences I have had recently. I am aware of the trauma and worry of people whose relatives are in need of long stay care. I might add that in many incidents it is the undertaker who decides whether a person gets a bed in a hospital under the control of the health board or a home that will be paid a subvention by the health board.

The Minister also told us that the amount paid will vary and that those who are at present in receipt of subvention will not be affected. He also said that the health boards may make arrangements to assist in the maintenance at home of a person who will require to be maintained otherwise than at home. I take it that the Minister is referring to the system under which a home help is being paid. They are paid a pittance. Those people are doing great work looking after elderly people who require a lot of care and attention. I appeal to the Minister to address that question. He should bear in mind that those people do not have to go into long stay care.

There is also a need to appoint more public health nurses to look after such people. I am aware of an 85 year old person who was taken in by a neighbouring family because he could not take care of himself. The neighbours were told there was no accommodation available in local homes but within two weeks of that generous offer the social welfare officer knocked on the door and said, "you are no longer residing alone and I am here to ensure that your living alone allowance and your free electricity allowance are withdrawn". That should not happen. We must make provision for recognition, so to speak, of that family and for care and attention at home for an elderly person in those circumstances. Again I say to the Minister that in considering that kind of development home help is a very vital part of that system.

Existing legislation covering the area, the Health, (Homes for Incapacitated Persons) Act, 1964 is inadequate to ensure proper conditions and prevent exploitation. A number of cases of shocking shortcomings in some nursing homes in recent years have been well documented. It is probably the publicity surrounding these cases that has raised public awareness and led to the pressure for legislation. Nursing homes very often tend to be concentrated in particular towns or areas. One such town is Bray, County Wicklow. In the early eighties the record shows that the Bray Trades Council undertook a survey of the conditions and facilities in the 19 nursing homes which at that stage operated in the town. The findings were fairly alarming and although a number of years have passed since the survey was taken I do not believe the picture painted then has changed very much. The report was critical of the operation of the homes in a number of respects including the food provided, heating, standard of accommodation and standard of staff and care provided. Among its recommendations were that at least two State registered nurses be employed in each home and also an experienced cook. Other recommendations were that a therapist with training in the care of geriatrics be appointed by the health board to attend a certain number of homes, that minimum levels of heating be prescribed and that visiting committees be appointed. It is only right to refer to some of the findings of that investigation. Perhaps the alarming statements on circumstances and conditions applying in such homes have raised awareness of this need for legislation. It is also due partly to the failure of the public authority, the health boards, to have sufficient finance to provide adequately for the patients who need full time care and attention. The information supplied to those conducting the investigation was that the number of patients in homes varied from 14 to 35 depending on the size of the home and the time of the year. In one home 12 public patients, that was patients depending on health board grants, were accommodated in a basement which was very dark. In the event of an inspection being imminent they were moved upstairs. Four senile patients were locked in one room at night to prevent them from wandering out. The heating systems in the homes varied from central heating to gas fires and there were allegations that central heating was allowed to go below a limit of 70ºF. Also the heating was shut off by a master switch at night. Hot water bottles were supplied at night but since these were not put into the beds at 8 p.m. when day staff went off duty they were soon cold. In one instance the proprietor forbade refilling the bottles during the night and turned off the water heating to ensure this.

Regarding meals, the catering arrangements in some homes were totally inadequate. No experienced cook was employed and in some cases the proprietor did the cooking. Meals were usually served at 8 a.m., 12.30 p.m. and 5 p.m. In some homes a supper of tea and biscuits was served between 8 p.m. and 9 p.m.

With regard to laundry and hygiene, while the drawsheets and nightclothes of incontinent patients were changed and laundered daily, there were complaints of other bed linen being changed and laundered infrequently. One member of the public visiting a home complained of the pervasive smell of urine. In one home the residents had a bath once a month. Laundering of personal clothing was not mentioned. I refer to these matters to underline that it is absolutely necessary to have this legislation.

The Workers' Party newspaper, The Irish People, also played a significant role in exposing unacceptable standards in nursing homes. The paper in its issue of 26 February 1988 highlighted a nursing home — the Montford nursing home — which was the subject of a subsequent successful prosecution in the courts. Staff there were quoted as stating that food was grossly inadequate, that mouldy bread and bread taken straight from a freezer was served. It was alleged that milk and Complan were watered down, that special diets were not being adhered to and that in one case a diabetic resident was being fed sugary desserts. Staff alleged that at least one individual linked to the home engaged in physical abuse of patients. Staff complained that adequate care was not provided for problems such as bedsores, and that materials and medicines were not available as requested.

The paper published shocking photographs of people suffering from bedsores and gangrenous infections. For this treatment up to 40 elderly people were asked to pay £120 per week.

I am sure this home was not the only offender, that there were similar abuses in other institutions. If this Bill goes any way towards preventing that sort of abuse it will be a step forward.

In regard to the detailed provisions of the Bill, I welcome the decision to give the health boards statutory powers to license nursing homes, keep a register of nursing homes and ensure this register is open to the public. However, there is nothing in the Bill to oblige nursing homes to set up inspection procedures, to employ trained and qualified staff to undertake the inspections or to ensure inspections are done regularly. The Minister referred to this in his speech. He said, "At present, the health boards inspect homes at least every six months to ensure compliance with the regulations". That needs to be clarified. Health board officials at present are so thin on the ground and they have not the resources to carry out their duties. How, then, can it be made obligatory for them to do so even if the statutory authority is given under this Bill? As we have found in many other areas, it is pointless to pass legislation in this House requiring the health boards or other public bodies to take on additional duties unless the Government are also prepared to provide the staff and resources to enable them to carry out these tasks.

I am somewhat disappointed that the matters in respect of which regulations can be made under section 6 represent no significant advance over the provisions of the 1964 Act. Some drafting changes have been made but they remain broadly the same. Given the experience gained over the past 25 years, it would have been reasonable to expect the requirements for minimum standards to have been raised.

The Workers' Party are also concerned about the number of institutions which are not covered or are specifically excluded from the terms of this Bill. It is right that the Minister and the Dáil should be concerned about the standards and conditions in private nursing homes, but we have every right, too, to be concerned about the standards in many public hospitals and homes. The standards in some psychiatric hospitals especially are appalling. I do not attach blame for this either to the staff of such hospitals or of the health boards. The responsibility lies with successive Governments who have starved the health services of the funds required to provide decent services.

Against this background why should institutions managed on behalf of the Minister or a health board be excluded from the terms of the Bill? I refer to maternity homes, mental institutions, children's homes and premises in which the majority of persons being maintained are members of a religious order. Are the people in these institutions not entitled to independent monitoring to ensure the highest possible standards also? We are particularly concerned about the exclusion from the terms of this Bill of old people's homes or retirement homes. There has been a great growth in these institutions in recent years and while they are not technically nursing homes they are nursing homes in everything but name. The people in them may not be suffering from any illness or disability but they are there because of an inability to look after themselves; like the patients in nursing homes they are vulnerable to exploitation.

The Sunday Tribune of 28 August 1988, carried a report of how an 81 year old woman lay either dead or dying for three days in her self-contained flat in a residential home for elderly people in Dublin which was run by an order of nuns, yet this home would not be subject to the terms of the Bill. There is a number of defects in the Bill which we will be attempting to address through a series of amendments on Committee Stage. I hope the Minister will be receptive to them. This is a Bill which, through the constructive co-operation of parties on all sides of the House, can be greatly improved and strengthened for the benefit of those who have to spend long periods in nursing homes.

Mr. Flood

There is no doubt that many people involved in any kind of dealings with the private nursing home sector have felt, for a number of years now, that there was a need for much updating of the legislation in this area. Many of the contributions we have already heard this morning would certainly confirm that fact. According to the records which are kept by the eight health boards throughout the country there are approximately 332 known nursing homes. I use the word "known" because there have been complaints from various health boards that they are not notified as early as they should be in connection with the opening up of private nursing homes. The legislation we have before us deals specifically with this area of complaint by the health boards. According to the census figures — if we study them carefully — and the various excellent reports which have been published recently there has been a continued growth in the opening of new private nursing homes and in the demand for places in them.

This being the case it is important that legislation of the kind we are now discussing be enacted as quickly as possible and put in place. It spells out clearly the specific responsibilities which will accrue to the health boards. It also makes it clear to those who would wish to open and develop private nursing homes or to continue to operate and manage private nursing homes that they have specific responsibilities which are now laid down in law and which will have to be strictly adhered to.

I suggest that this legislation is in the interests of the elderly in that they will be guaranteed a specific level of care and physical comfort in conditions within private nursing homes that are acceptable and suitable. It will also give assurance to relatives, friends and family members of elderly dependent people who will be admitted to these types of caring facilities. Above all, the legislation spells out where the proper responsibilities lie for the correct management and control of the running of nursing homes as between the owners and management and the health boards throughout the country.

In turn this will lead to a clear understanding on the part of owners and management in private nursing homes that in the absence of proper exercise of their responsibilities they will suffer revoking of their licence, withdrawing of a licence, failure to get renewal of a licence or, indeed, some very stiff financial penalties which are also provided for in the legislation. The level of the penalties involved strengthen the Bill so far as it makes it clear to operators of private nursing homes that major infringements of the regulations and the legislation will lead to severe penalties being imposed. To some extent that strengthens the legislation considerably.

The legislation relates also to the licensing arrangement with particular reference to the fact that premises will have to be licensed every two years. Following the publication of this Bill we received representations from various interested organisations, including the Irish Private Nursing Homes Association and from individual private nursing home owners and operators, in which they draw our attention to the word "licence". They make a distinction between a private nursing home and other establishments requiring a licence, for example — and I am referring to their terms — dog kennels, etc., they do not want to associate a licence for nursing homes with a licence for those other institutions. I am not sure that I agree with them on that comparison but they have made their point.

They also refer to the fact that a licence has to be renewed every two years. This, they consider, is a restriction on the nursing home as a business and to some extent will have a bearing on its commercial value particularly regarding the sale of a private nursing home because the legislation now provides that if a private nursing home changes ownership it will be necessary to apply for a new licence in respect of it. It is correct to have that included in the legislation, otherwise the whole thrust of the legislation, so far as it seeks to protect the dependants within the nursing home, would lose its strength because the purchaser of a nursing home with a licence might not necessarily be the type of person one would like to see operating or managing a nursing home. They would, therefore, be able to gain an entrée into the business even though the legislation, if it were strictly enforced, might prohibit them because of various problems with regard to their suitability. It is right that the licence ought to be renewed every two years. It is clearly spelt out in the legislation that the applicant has very definite rights in this regard. The applicant must be notified by the health board if they are about to make a decision not to grant a licence, to revoke a licence or not to renew a licence. Under the terms of the Bill the applicant has an opportunity to appeal to the health board in writing and to state a case as to why the licence should be granted, renewed or should not be revoked. Even then if the applicant is not satisfied with the decision of the health board he has an opportunity to appeal to the District Court, and the District Court can confirm either in favour of the decision or proposed decision of the health board or, indeed, of the applicant concerned.

To allay the fears of those currently involved in the private nursing home business there are sufficient safeguards built into the legislation to ensure that they will be able to conduct their business in a fair and reasonable manner and with a high degree of security so far as the licensing system is concerned. The Minister and his officials are to be complimented for including that range of safeguards both for the dependents within the health boards and for the private nursing home operators. If our population continues to age as the 1986 census suggests that it will, although there will be some peaks and valleys in the process, then the demand for private nursing homes will certainly increase and the number of facilities will increase accordingly.

There has been some criticism recently of individual health boards with regard to the subvention system and its success or otherwise. Speaking for the Eastern Health Board, I believe a certain amount of misinformation has been put abroad, particularly in the news media, about the ability of that health board to meet their commitment to subvented beds in their catchment area and also to cater for new applications. It has been suggested in some quarters that the Eastern Health Board have stopped subventing new applicants. That is not correct. In the first half of this year almost 200 additional applicants were approved for subvention. Notwithstanding the fact that the health board, like any other organisation, must take account of the financial resources available to them, it is not true that they have stopped subventing applicants from June this year. Additional applicants have been approved right up to the last two weeks and this is continuing. During the past two or three years the Eastern Health Board have increased the total number of subvented bed-days within their region by approximately 30,000, which is a significant increase. According to the board there are in the order of 1,000 individuals subvented by them. It is well to put on record the situation obtaining and the continued ability of the health board to subvent new applications as and when they arise under the normal criteria laid down for assessing particular needs.

The legislation is very detailed and I wish to refer to some additional areas. The Minister sets out to make clear the correct definition of a nursing home, with particular regard to dependent persons. The Minister excludes certain other institutions and it is correct that he should be specific in these exclusions. The legislation will also allow him to make certain individual decisions if the need arises with regard to further inclusions in the definition of nursing homes for the purposes of this legislation.

The Minister details very specifically the regulations he may deem appropriate. Anyone with an interest in this area will be very pleased with the range of regulations he will consider bringing in. These cover matters ranging from the specific care and maintenance of dependent persons to the type of conditions which must pertain within the nursing home with regard to the preparation of food, management and the availability of professional personnel. The implementation of this range of regulations will ensure a high degree of professionalism within the nursing home in the future. There have been considerable complaints in this area which have been referred to during this debate.

I am concerned about the question of subvention and the assessment of means. I do not necessarily agree that every applicant for a subvention should be approved, regardless of his or her means. There are situations where elderly dependent people can have considerable means and these should be taken into account. In some cases there may appear to be unnecessary haste on the part of some less caring family members to have dependent elderly people admitted to nursing homes in order, perhaps, to dispose of their property or other valuable assets, without such disposal being to the benefit to some extent of the health authority and ultimately to the benefit of the taxpayer. We must critically examine this matter to ensure, where a dependent person has considerable assets or means that they be utilised for their benefit in meeting their needs in a health board institution or private nursing home. They should not be disbursed in a way that would not be to the benefit of the dependent person. The health board, in carrying out their assessment, will have to be fair and reasonable and conscious of the rights of the dependent person. The taxpayer should not have to pay the cost of the subvention where the means of the applicant are adequate to provide for himself or herself within the institution. This matter must be fairly assessed and should not be ignored.

Deputy Howlin was critical of the Minister, particularly with regard to the Wexford region and changes in hospital facilities. If he were present I would remind him that his colleague some years ago had some proposals with regard to the closure of hospitals. I am not sure if they were implemented. Deputy Howlin also referred to the need for a State plan. I agree that we should have such a plan, possibly based on the health board system. A State plan does not necessarily mean an increase in the number of State institutions. I am quite satisfied from my knowledge of the needs of elderly and dependent people that they would far prefer to be accommodated in small units rather than the larger traditional institution which, regardless of the expert care and compassion of its staff, simply could not give the same feeling and the same family closeness as a much smaller institution, similar perhaps to most of the private nursing homes about which we were speaking.

Deputy Yates and Deputy Howlin criticised the operation of the licensing system through the health boards. Deputy Yates specifically said that the licensing system should be controlled, operated and staffed by the Department of Health because they felt that there would be an unevenness in laying down guidelines and in carrying out inspections of private nursing homes throughout the country. The last thing we want to develop here in support of the legislation is additional layers of bureaucracy or organisations.

The professional staff of the health boards are quite capable or making assessments based on their training and experience. If one examined variation in assessments across the country they would not be very great. For that reason, the operation of the licensing system and the inspections, etc., should be based in the Department of Health. The Minister could easily have done that but in devolving powers to the health boards he has made the correct decision as most of us have confidence in the professional capabilities of the technical and caring staff in the various health boards. Therefore, I do not agree with the criticisms this morning.

The question of the register is very important because the public need an opportunity to be able to check with their health board, free of charge, the range of private nursing homes available. I hope the Minister will ensure that very detailed and specific information regarding costings, location, services nearby, transport, the availability of professional staff and information concerning any commitment by the nursing home to work closely with the professional staff of the health board will be available on the register. This is allowed for in the legislation so that the people who need to inquire about private nursing homes will have information available to them, through the health board, which is accurate and will help them to decide when they wish to be accommodated themselves or are seeking accommodation for a member of their family. The register will play a very important role and will be a very useful means of precise and specific information. For that reason, I hope the Minister will ensure that detailed and specific information is maintained in the register and that it will be kept up to date.

The other aspect of the Bill relates to the boarding out of persons by the health boards. This is a most welcome inclusion in the Bill because the health boards now take the view that instead of removing a person from his or her community, the family, relatives, friends and environment in which they have possibly lived all their lives and transported them to what — for them — would be an alien place, it would be much better if structured arrangements could be made to allow for the boarding out of dependent individuals in their own community. A number of health boards have been trying to make progress in this regard and they will welcome the inclusion of this provision in the Bill. It would be a big help to individuals who want to be located in their own community and they deserve a great deal of sympathy and support.

I want to compliment the Minister and his staff for the thought that has gone into the drafting of the legislation and the regulations which will follow regarding penalties, etc. It will strengthen the health boards and make private nursing homes more professional in their approach. Maybe it will encourage private nursing homes to put more finance into proper development and management.

Deputy Sherlock referred to the fact that The Workers' Party has considerable doubts about private nursing homes. That appears to be a movement from the traditional position of that party which has always been to oppose anything which is not a State enterprise. However, we should remember the last Ard Fheis when they decided to change their modus operandi and to drop their more rigid approach to private enterprise. Deputy Sherlock also referred to the fact that a private nursing home is run for profit. I suggest that it is better to run any enterprise for profit than to run it at a loss and take more from the hard pressed taxpayer, whom we all represent in this House.

Mrs. Fennell

It gives me great pleasure to contribute to this debate. I highly commend the Minister and his Department for bringing forward this Bill which is so comprehensive. He is also to be complimented for introducing it so quickly after the recommendations of the working party report, although I know that that is not the only reason. I am very happy with the Bill because it is generally regarded that there are not any votes in helping old people. They are a low priority and tend to be overlooked because they do not have great political clout. I am very happy to see so many people wanting to contriubte to this debate.

Yesterday, the Minister for Social Welfare at Question Time was very sad because nobody recognised the good things he is doing. Although I have disagreed with the Minister on other issues, I commend him for introducing this Bill. In general its provisions aim to tackle the very real problems that have obtained in many areas with regard to old people's residential homes. There are in the region of 7,000 people in long-stay residential homes; I extracted that figure from the Minister's speech. These people are divided between private and public homes. This area of care service is expanding rapidly with new homes opening almost weekly countrywide. It is a development reflecting new demographic trends. There are now more people living longer, with a greater move from rural to urban areas. Also family size has become smaller in recent years. In addition, emigration has exacted a very high toll, particularly in the western and northern regions. More wives are going out to work. All this leaves older citizens in a very vulnerable and difficult position. This is not merely an Irish phenomenon; it has become a worldwide trend, perhaps one that emerged in other countries earlier and with which they have dealt with varying degrees of success.

In reflecting on the problems of the old we can regret the passing of the old order — that which obtained when the Minister and I were growing up, when the younger generation took full care of their elderly, never viewing it as an infringement of their privacy or as putting them out in any way. I very much regret the passing of that old order. For all the reasons I have given I know it is very difficult for people to cope when living in a small house with a growing family, with limited space and time, to take in an older person who can no longer live alone. Some families have attempted to meeet this need by building granny flats or extra rooms. To some extent that is a good move.

It is also regrettable to note the role of the older person in modern Irish society. Unfortunately, because of the financial and time constraints on younger families, older people are perceived as presenting a difficulty or problem. This is in great contrast to countries like China where people refer constantly to the role of the aged. Some years ago I visited China for three weeks and was very struck by the role many very old people played in society. It is they who are honoured, who are looked up to, whose wisdom and experience of life is very highly regarded. The Chinese would not dream of endeavouring to marginalise any old person, to dismiss them or not take account of their needs. There I noted a very sensible idea in that older people who had retired some years earlier would be given a special job to do during the day, whether that be looking after children coming from school, acting as traffic wardens or some other small task. This meant they felt important, useful and were also consulted on important issues arising in their communites. By affording old people a place in the community, recognising that, while physically they may be unable to cope as well as, say, 20 years previously, it is recognised that mentally they can still contribute a great deal. They have great understanding, they have feelings, needs and, indeed, the same expectations as ever. That is the awful aspect of old age; just because people are old and a little infirm they tend to be treated like children, which is very regrettable.

Care of the elderly presents many problems. It has to be said that very often old people are cranky, somewhat difficult to satisfy and, if they are ill, their needs become specialised in terms of nursing care. I commend the people who have undertaken this role, particularly those who have looked after those who are old and ill.

The old pattern of life still prevails in some rural areas where an older person is still regarded as part of the extended family, given a special position with theirneeds being met. However, that attitude is fading very fast. Families need substitute care and help, that is those families who have, say, fathers, mothers or inlaws living with them. I know they seek an assurance that they will get this substitute help which will be of a high, reliable standard.

Many people who at present run and manage homes are good, caring people who employ well trained staff and maintain good standards. However, we would be less than honest if we were to pretend that this is so in every case. I have spoken to several people who are very anxious about conditions prevailing in certain old people's homes. They told me stories of poor care, lack of privacy, inadequate food, bad diet, poor heating and gruff, if not violent, treatment of residents, all of which constitutes an enormous difference to an old person between the home they may have lived in, which was pleasant and comfortable, and being treated absolutely intolerably.

The year before last I visited an old man in a home in County Galway where I was horrified at the conditions prevailing. The drive up to the house was very impressive, as was the facade. It was an old country home but, once one went beyond the reception area and up the stairs, the accommodation was frightening. In the room in which I visited this old man there were six or seven men whose beds were all pushed close together. There was little storage space, bad lighting, an air of overcrowding and clutter. Two men in that room were quite ill but there had been no special nursing care provided for them that I could ascertain. Overall it was a dank atmosphere with a dreadful odour of urine and bad air. I wondered whether that home had ever been inspected by the local authorities. Certainly if the inspectors went up the stairs and saw what I saw, it must have presented them with a dilemma since to date they had not the powers to do anything about it. That home contravened every rule in the book. I was particularly concerned about their fire precautions because I was quite sure that, if there were a fire, there was no way those old men could escape from that overcrowded room.

Health boards and old people alike have had a problem. Health boards had not the powers to inspect nursing homes. In the past two years there has been some publicity about an old persons' home with which I am quite familiar and about which I received a number of telephone calls. This home is situated in my constituency and there were serious complaints voiced about abuse and neglect of patients, yet it could not be closed down. Members will probably remember the home in question, which was the subject of some newspaper coverage. The conditions prevailing were really quite horrific. After prolonged legal proceedings action was taken. But what amazed me was the length of time and the aggressive approach adopted by the manager of that home who held out, despite the fact that clear evidence had been advanced that conditions were far from proper before that home was closed down.

At the end of the day, I suppose there will always be people who have nowhere else to go, who will remain in homes even where there is evidence that conditions prevailing are far from good. Nonetheless, it took a long time and much publicity before that home was closed. I wonder how much the residents of the home suffered before the problem was resolved. I suppose we have to think in terms of the residents of homes who have no relatives and who may have gone into homes ten or 15 years previously, are powerless to help themselves and are not able to research the area and decide on a different home to go to. To an extent people like this are in a very weak position and we need to ensure that the conditions in these homes are as they should be.

When I read the Bill one of the requirements I looked for — of course, this would be provided for by way of regulations — was the provision of occupational therapy or recreational facilities in homes. There is a requirement in the existing regulations that there should be recreational facilities in all homes but I want to emphasise that there is a great need to look at this whole area. When people come away from old people's homes they remember the rooms where old people sit and stare at television sets. Many homes seem to fulfil the requirements of the regulations by leaving television sets on all day. This is a very inadequate facility because it does not stimulate the residents of homes and leaves them filling in dull meaningless days with no variety and nothing to change the environment in which they live. I am very concerned that some basic requirements should be brought in, along with the other proposals made by other speakers, whereby community services such as chiropody and hairdressing can be provided in homes. Some attempt should be made to integrate the old people in the homes into the community and ensure that a level of occupational therapy — it does not have to be medical occupational therapy — is provided. Some other pastime other than a television set should be provided for elderly people, who need a greater degree of occupation than that.

I want to make a few brief comments on the Bill, many of which have been covered by other speakers. I cannot understand why there should be such a long range of exceptions under section 2. I cannot understand why the institutions managed by the Minister or the health boards should be excluded from the provisions of that section. Perhaps the Minister will give us an explanation as to why he has excluded these institutions. I would also question why maternity homes — and perhaps there is a reason for this — should be excluded. Under section 2 (1) (f) the premises in which children are maintained in pursuance of an arrangement with a health board are also excluded. We have discussed the need for health boards to provide facilities for children and I should like to know why this is not provided for in the Bill. Perhaps the Minister will tell us why the premises in which a majority of persons being maintained are members of a religious order or priests of any religion are excluded. I should like uniform standards and regulations to be introduced to ensure that all homes which care for old people come up to scratch.

Deputy Yates referred to the subjective nature of many of the sections. I agree with him that the term "it is of opinion that" in section 4 (3) (a) (i) should be taken out because it weakens the section. I believe that both the section and the Bill would be better without this term. There should be a requirement placed on the health boards without necessarily having to say "it is of opinion that".

I was also contacted by the association dealing with the owners of nursing homes. They seem to have a difficulty in relation to licences and registration. I do not know if it is a very valid criticism and could be upheld but I will look at it again. One of the things I would look for is to have the register of nursing homes made available in libraries. This register is very necessary and fundamental aspects and details of nursing homes should be included in it but it might be difficult for people to get access to it at a health board office. Would it be possible to make it available in libraries so that they can go and look at it and make up their own minds? We all get requests from concerned children or relatives of old people who want to go into nursing homes but we are not in a position — I certainly am not — to give information or talk about the credentials of any particular nursing home. If the register is made available in libraries it might make it easier for people to get information on a suitable home.

I want to refer to section 4, which deals with licences. I have absolutely no problem in regard to profit. The Workers' Party in their contribution said that there was a question mark over the whole area of private nursing homes but I have no problems in this regard. If people recognise that there is a growth area for which they can provide a service they should be allowed to provide that service but they must do so adequately, live up to regulations or legalities and not abuse anybody's rights. I suggest that the amount of the licence should be pitched high enough so as not to be unfair on them but recognises that large profits can be made by them. A good return can be made by the people who run these homes. People have to work very hard, expend a lot of capital and take a lot of responsibility in setting up a nursing home. It is not an area I would want to make my money out of but if those homes are making money the licence should be suitably high so that a proper supervisory and administrative system can be implemented and personnel paid to carry out proper inspections and administer the provisions of the Bill. All I can say is good luck to the people who are setting up these homes, running them properly and making them pleasant places for the old people to live in, but they should pay the necessary registration and licence fees.

I want to refer to boarding out. This is a new provision which has been welcomed by all speakers so far. I agree absolutely with the views expressed by Deputy Yates and other contributors who see boarding out as an ideal arrangement. It is the next best thing to being in your own home. If you are at the end of your days and cannot look after yourself and need to live with somebody, boarding out and living in a replica of the family home must be the next best thing. This is very important in a situation I came across in my own family. A relative of my father lived in a very remote part of County Galway. He was not well but he would not leave his little house. He caused us endless problems. He fell many times and he did not feed himself properly. The problems were acute in the winter months, but in summer he came alive again. If such persons were boarded out somewhere near their home, they could spend the cold months with a family and return to their own home when the weather was fine. Of course, they would need some help from their neighbours. In such circumstances, boarding out is very useful and a marvellous provision. May I ask if the boarding out allowance will be paid to relatives or members of the extended family? It might be possible for older people to live with another relative and pay something towards expenses. Many homes cannot take in another person and pay for the extras involved. Will the extended family or relations be excluded from receiving payments under the Bill?

In the main, people will welcome the Bill. It is a good sign that the task force report is beginning to be implemented. I hope that when the Act is in place it will be fully implemented so that no old person will have to stay on in a bad nursing home. At present such nursing homes cannot be closed down because there is no other place to send patients. I hope that bad nursing homes become a thing of the past, and that we will not read of nursing homes on trial by the newspapers or have to read scare stories such as we have all read in the past. Given the lack of regulations at present, that is a risk.

I commend the Minister on the Bill and I wish it a speedy passage. I look forward to contributing on Committee Stage when we will be tabling amendments.

Miss M. Wallace

I am pleased with this Bill, it seeks to alleviate some of the present problems relating to care of the elderly. Without doubt, the current situation is unsatisfactory, particularly in relation to legislative powers and control that health boards have to inspect nursing homes and take action against those who breach the present laws. In general the provisions with regard to inspections and registration of nursing homes is very important and very welcome.

We have all been affected by the growing waiting lists for geriatric beds. The Bill before us today will make a major difference. Section 7 enables a health board to contribute towards the cost of maintenance of deserving individuals. I am a member of the North Eastern Health Board and have seen the distress and hardship of elderly people in need of care. Indeed many cases could be covered by this type of legislation. There are 200 odd geriatric beds available in County Meath, which are full all of the time. When urgent emergency cases arise, as they do, it is possible that people would have to wait for up to three months to get a bed in the county home, as there are always about 20 urgent cases on the waiting list. The provisions in the Bill give the health board greater flexibility in dealing with what are evidently emergency cases and the problems that crop up when dealing with elderly patients. It came to my notice recently that a husband and wife who were both old age pensioners needed full-time nursing care. They were admitted to a private nursing home. They were charged £150 each, making a total of £300. Eventually the woman was offered a bed in the county home. I found this very sad because the wife was in the county home and the husband was in the private nursing home which was on the other side of the county. If a subvention had been available at that time, the health board could have offered a subvention towards the cost of the wife's stay in the nursing home, thus allowing the couple to stay together. In cases such as that, the provisions of the Bill will be very helpful.

In our area, as I am sure in many other areas, no homes have been added to the approved list in the past ten years under section 54 of the Health Act. For example, for those of us in County Meath the nearest public nursing home is in Mullingar, County Westmeath, which is in the Midland Health Board area. In the past our patients would have had to reside in nursing homes long distances from their home if they were to obtain subvention. That situation is unacceptable and the provisions in the Bill improve matters.

A further anomaly which has come to my notice is that the Eastern Health Board were in a position to subvent beds in private nursing homes in County Meath and currently had beds subvented there while this facility was not available to patients in the North Eastern Health Board area because of the provisions of section 54 of the Health Act. This is being addressed in the Bill. The fact that the patient rather than a number of beds will be subvented is a good idea. The subvention will also depend on the extent of nursing care that the patient requires. For example, in some cases a patient could require constant nursing care perhaps at a cost of £200, whereas another patient might require less nursing care and the cost would be reduced to, say, £100. This will be of help to individuals. Indeed, I can see a situation arising where nursing homes will scale their fees in accordance with the care required as distinct from the flat rate charges, where they charge £150 or £170 depending on the institution. In cases where a patient may have a pension of £50 or £60, and their family may be able to provide £20 or £30, the health board will be able to make up the balance. The provisions in the Bill will not only make it easier for the health board and the family but will also free geriatric beds in the county home, so that people who can afford to pay a little will be given the opportunity to do so while at the same time being assisted by the health board.

Ministerial regulations cover the means test and dependency and this is to be welcomed. My only concern about subvention is that sufficient money be available in the health boards to subvent the needy cases. All the health boards are scarce of finance, and the North Eastern Health Board is no exception. I hope that sufficient funding will be made available to the health boards to subvent very needy cases.

The licensing and registration of nursing homes is of importance. It is vital that control be exercised over the management of institutions. The health board may grant or refuse to grant a licence. The fact that a nursing home is not in compliance with the standards set down in the regulations or the person in charge is being convicted of an offence shall justify a refusal. If a person has been charged or convicted of an offence in relation to a nursing home the board may refuse or revoke a licence. I have found, from most of the private nursing homes that I have visited, that there is a high standard of care available but I am glad to see that those who abuse their position of trust will be made accountable.

There are other regulations which are of merit. In section 6, full disclosure of relevant information — the word "relevant" is important here — can be requested by the board and under section 4 the notification of any change of ownership will aid monitoring. Ultimately the provisions define more clearly the role of the health boards in licensing nursing homes. Proper standards of care are provided for in the Bill. The vital point here is that there would be national regulations as regards standards of care. I have witnessed good cover in our own health board from the medical and nursing people who check on the nursing homes every six months or so. It would be vital that across the country there would be some type of national regulations rather than the individual health boards deciding their own standards. We have faith and confidence in the people who carry out this work but a national standard would be useful.

I am pleased that all the requirements regarding standards of care for dependent persons are covered in the Bill, for example, the numbers, qualifications and availability of staff and the physical conditions of the premises. We all have visions of the premises that are kept well and in which there are good conditions and sufficient staff available but again there will always be the few which need to have these regulations enforced upon them.

Should scrutiny of the home be deemed necessary, provision is made for it. The activities within the home may be examined by reference to the records. Interviews and examinations of persons in a nursing home may also take place and it is good that this is specified in the Bill. This applies to cases where the health board have reasonable cause to believe that a person in a home is not receiving proper treatment. Again, this rarely happens but it is important that the provision is there. The Bill allows for inspections of nursing homes and also premises where it is believed the work of a nursing home is being carried out. The possibility of an inspection should deter persons who are tempted to abuse their position in this regard.

In the past, the terms "retirement home" or "rest home" have been used to frustrate attempts to impose and enforce standards of care. The Bill's provisions are intended to ensure that this will not occur in the future and they give appropriate powers to the health boards. The proposal to provide training of nursing home staff on an agency basis is interesting. It will contribute to the high standard of care and good relations between the homes and the boards. With such regulatory measures in force it is appropriate that reasonable action should be taken against those who break the law. Disqualification for a period as determined by the Circuit Court from managing a nursing home should act as a deterrent and indeed adequate punishment; custodial sentences and monetary sanctions, also exist.

Section 10 of the Bill permits the assumption by a health board of management of a home on a temporary basis. This may be by consent or in pursuance of a court order. Again such a provision is a vital guarantee of the welfare of dependent persons, particularly in cases such as the one that was cited by Deputy Fennell earlier. With the pressure of available places in institutions, the possibility of boarding out patients, as provided for in section 11 of the Bill, is practical. It is vital to ensure that qualified staff and proper insurance cover are provided for, particularly as it is dependent persons who are referred to in this section as regards boarding out.

This Bill features practical and timely reforms. It serves to ease the pressure on many health boards and cater for those in need of care. However, I qualify my comments by saying that it would be important for all of us involved in health boards and in the different areas of health to ensure that proper funding is made available for the much needed subventions. I commend the Bill. It is legislation which, if fully implemented, will be of assistance not only to the health boards but to the elderly and dependent patients and indeed to their families.

Mr. Ferris

The Minister must be pleased at the level of interest in this legislation which has been proven by the number of people offering to speak on it. It must be reassuring for the Minister that there has been a widespread welcome for it from all sides. There is also a general acceptance of the legislation by the association representing nursing homes. They share the concern of all of us that the highest possible standard of care and attention is forthcoming for our elderly people who are in need of it. I have a particular interest in this subject having been a member of the South Eastern Health Board and having chaired a committee which set down a programme for the care of the elderly in that region. I would suggest that it was from that region initially that the concept of boarding out of adults came. I have an interest on many fronts and I am also concerned that we provide in the autumn of their lives the best possible care for our old folk, the elderly in our society.

I agreed with the Minister when he stated in the last paragraph of his speech that nursing homes are an indispensable part of our services for the elderly. It is also a fact that the State has been unable, because of lack of finance or constraints on finance, to provide this type of service for patients who need it and who are unable through their own incomes to provide it for themselves. It is certainly the concern of the Labour Party, first of all, that we point out the responsibilities of the State in this area and indeed its failure over a number of years to provide a service as is set out in section 54 of a previous Health Act. It is because of that failure to provide services at health board level that this concept of private nursing homes has come about. All of us have come in contact on a regular basis with people who are on waiting lists to get into these nursing homes and indeed with the operators of the nursing homes who are faced, on a daily basis, with trying to provide a service for people who would normally be entitled to the service from the State. Because we cannot fulfil that responsibility due to the closure of hospitals — sub-acute and auxiliary — and other institutions, and due to the reduction in the number of beds in geriatric hospitals and the policy foisted upon the Minister, and indeed previous Ministers, greater demands are being put on the private sector to provide a service. It was also because of this policy that health boards began providing subventions. On the question of providing subventions, to my knowledge no new homes have been approved to receive subventions since 1980. Therefore, there is a discrepancy in what Deputy Flood has said. He says that the Eastern Health Board are continuing to do so. Perhaps they are operating a system similar to the one envisaged under this legislation and instead of providing subventions towards the cost of maintaining beds they are providing subventions to patients, which, of course, is the ideal.

One of the problems we face is that varying numbers of beds in nursing homes are subsidised. We are also faced with the problem that many new nursing homes of excellent quality have been unable to obtain subventions despite meeting all of the criteria laid down. Also, there was a quasi-legal responsibility on health boards to continue providing subventions to particular nursing homes, despite the fact that they may have changed hands and that is probably the reason this Bill does not disturb the existing right of nursing homes to subvention.

I welcome what this Bill seeks to achieve, which is to move away from the existing norm of providing subventions towards the cost of maintaining beds to providing subventions to patients, and I have no problem with health board officers or other officers as specified in the regulations carrying out assessments to ensure that those who request access to this type of nursing care are actually in need of it. I also hope we do not ignore our responsibility to provide this care once this new system of providing subventions to the patient is introduced.

Some nursing homes have been forced to close down because they were unable to obtain subventions under the old system. I am aware of one case where the Eastern Health Board, even though they had formally approved the provision of a subvention to a particular home, had to plead inability to pay. The nursing home in question has been forced to close down in recent days simply because they were at a disadvantage vis-à-vis other nursing homes in the area and were expected to provide the same level of service with a smaller amount of funds. They could not achieve the standards required by the health board. This is a pity because if this nursing home had available to it the level of funding available to other nursing homes, possibly they could have met the new demands being placed on it by the health board, the fire officer and others, demands which we would want them to meet. However, they would have been able to do so only with the expenditure of between £50,000 and £60,000 and were forced to close down. What worries me is that these patients may have nowhere to go, as the State is unable to provide alternative accommodation for them and their relatives cannot afford to send them to more expensive nursing homes. Many of them in fact fall into a particular category. The problem arose out of the fact that this nursing home was providing accommodation for certain categories only. Elderly people who suffer from double incontinence require special care and special facilities in the institutions in which they are confined.

Problems are being experienced in health board areas where rationalisation programmes are being implemented and where as many people as possible are being reintegrated into the community. All of us would welcome such reintegration. Deputy Flood referred to the attitude of the previous Minister on this issue. Unfortunately, that Minister was much maligned and was criticised in many places, including this House, for trying to ensure that people would not be institutionalised but, rather, would be cared for in the community wherever possible. He identified with the document Planning for the Future, which dealt with the psychiatric area, and it was because of this he was much maligned and received a reputation for closing hospitals. He did say, however, and, as a colleague of his, I should put it on the record of the House that he had no intention of closing district hospitals because, as sub-acute hospitals, they provided some of the best care available at little cost to the health boards and acted as a buffer between acute hospitals and the need to discharge people into the community, where there was no one to look after them. Unfortunately, a different Government closed five sub-acute hospitals at the request of a newly elected health board in the south-eastern region. Those are the hospitals identified by the Labour Party spokesperson on health, Deputy Howlin. The list includes a hospital in my home town of Tipperary, a hospital called St. Vincent's. It was a tragedy to close this hospital because, as I said, it acted as a buffer between the acute hospital and community care.

In relation to the registration of nursing homes, we ought not forget that nursing homes have to be registered and have to display in their reception areas a certificate indicating that they meet certain requirements and have been approved by the local authority, planning office and health board. Therefore, there is nothing new in the concept of a register, but it would be a good idea to have this register available in public places, such as in libraries, as suggested by Deputy Fennell. It should certainly be available for inspection in acute hospitals by people who are about to be discharged into the community where, because the health board are short of staff, there is no proper community care team. Also, many vacancies for the post of public health nurse have not been filled and because of this there is a need to ensure that people are not discharged into homes where an older spouse is incapable of looking after them or when no bed is available in a public institution, geriatric hospital, long stay care hospital or welfare home.

This places a major responsibility on all of us, as legislators, to ensure that people with medical cards receive hospital care when required. In case people may feel that this would infringe upon the rights of the private sector, let me point out that our legislation permits the taking of up to 75 per cent of their pensions to pay for this service. These unfortunate people are not looking for something for nothing. They are prepared to surrender a large proportion of their income for the sake of the State providing care. My only problem with private nursing home care is the amount of money they require over and above the income from the medical card or the old age pension. This puts major stress on the family of a patient. Many of these families will have other family commitments. Many of the nursing homes to achieve the required standards must invest substantial levels of capital which means that they must charge a reasonable amount of money. If these homes are unable to continue to give the service and the State do not provide it old people will be left without services and that must be a source of concern to all of us. The Bill, because it addresses the need to subvent the person rather than the bed or the nursing home, will address the problems in some way but it will do so only if finance is provided. My colleague Deputy Howlin upset the Minister by quoting from his speech in connection with financing where he said:

I would like to give an assurance that the overall level of financial support for people cared for in nursing homes will not diminish as a result of this Bill. This provision is not about saving money. It is about enabling health boards to target their available resources most effectively and to respond flexibly to the changing demands of dependent people for whom they have responsibility.

That means that further money must be made available to health boards if they are to carry out their responsibility. The Minister has said that the existing level of subvention by health boards to private nursing homes will continue undisturbed. The Minister also said that no new beds were subvented since 1980. How under this legislation will individual applicants be assessed to qualify for subvention? How can the Minister do all those things without ensuring that the health board have sufficient resources? My health board is already £2 million in debt, so how can they channel existing resources into subventing applicants? This is the failure in this legislation. It can be properly implemented only by injecting additional funding to health boards with a specific request that health boards would use this money only in the area of community care where old people are assessed as being medically suitable for admission to one of these nursing homes.

I have no objection to means testing. We should first set down a standard to say, for instance, that all medical card holders should be eligible. If additional staff were appointed under the existing community care programmes they could decide on who qualified under the means test. Deputy Howlin has identified anomalies in the system of granting medical cards in that the same norm is not used throughout the country. If a uniform eligibility for medical cards existed we could at least agree that medical card holders would be entitled to a subvention under this Bill for a bed in a private nursing home because we cannot provide the bed in the State area and when members of the family would assist in paying the difference between the £6.78 provided by the State and the figure required by the private nursing home. Certainly people should be medically assessed before they go to any of these places. If we had used such an assessment programme in the old days half of the patients now in psychiatric hospitals would not be there. They were hidden in these hospitals for social reasons. Many of the patients in psychiatric hospitals could be accommodated in the community if we had a proper community care programme and they would probably qualify for care in a nursing home.

We will deal with other problems in detail on Committee Stage. I am particularly worried about the qualification of the officer involved in the inspection of nursing homes. Will the person be medically qualified or just technically qualified? One can imagine a nursing home being run by a person dedicated to community care and to the health service being subject to a person with book, pencil and ruler who has no concept of the needs of the sick. We should have clarification as to the kind of people who will be involved in assessing the suitability of homes.

I am worried about the section which allows a home to be taken over, admittedly with the owner's approval, by an officer who would then charge the owner of the home a fee for having interfered. That seems a draconian provision. The only redemption in it that I can see is that it has to be with the approval of the owner.

It is also an extraordinary process where if one is refused registration or a licence one has to go to court to prove the case. The Minister must be aware that if anyone had to go to court in any of these areas his reputation as being suitable to provide nursing care facilities would be gone even if he was vindicated in court.

There are problems in the Bill which we should be able to iron out by way of amendment or agreement with the Minister. We in the Labour Party want to be positive about this Bill. We want to make sure that at the end of the day the legislation will deal properly with the problems and we do not want the concept of putting people into private homes as a way of excusing the State from its prime responsibility to look after our old people. In private homes which are offered as providing this service we must ensure that there is at least some level of medical expertise, for instance, the wife may have had previous nursing experience or have some interest other than just providing bed and breakfast. Bed and breakfast hostelries, even those approved by Bord Fáilte, can give a cheaper service at much lower capital expenditure than some of these unfortunate people who give nursing home service. The fees are so competitive in this area that it is almost cheaper to run a bed and breakfast service than to run a nursing home because of the restrictions being put on them.

However, if we consider the full implications of boarding out elderly people in homes, full consultation should take place with the elderly we intend to deal with in this way. They must have some say and they have little say at the moment in regard to home help, which other speakers have referred to as being ludicrous. The amount of funds available in the home help area is negligible. Also, in respect of assistance for home help, private room fostering or other institutional care we exclude all relatives from benefiting. Many relatives give a level of care and attention to old relations that is second to none in any country, and they are totally ignored by the State. They save the State up to £500 and £600 a week on institutional care and they do not get any compensation or recognition. As a matter of fact, if they provide this care and are entitled to other facilities under the social welfare system or otherwise, they can lose their social welfare benefits if the Department know they are looking after an elderly relative and not available for work under the social welfare code. There are discriminations in social welfare clauses which pensalise people who try to give care and attention to their older relatives at home. I would welcome a breakthrough in this concept of helping people to look after older relatives. We have listened for years to the argument motivated by the Department, the Department of Finance and many others, that we should never pay people to look after old relatives. That attitude does a disservice to the people who do this, often never requiring help or assistance. However, at times they require help and have often approached us but we are precluded under every regulation from assisting them. Possibly this new type of private home facility will enable us to approach it in that light without creating anomalies in the minds of people who have to regulate our finances.

There is an expenditure of some £15 million by the State every year providing subvention, subsistence or help for care for the elderly. I hope in the coming budget there will be some commitment to increase that amount of money. I and my colleague, Deputy Howlin, have no doubt that unless additional funding is provided the sections in this Bill that we welcome cannot be put into operation. The health boards will be obliged to be so strict in their assessment of people who need help that possibly the people we hope will be provided for will be excluded on economic grounds and the health boards will be unable to meet their responsibilities as laid down in the legislation.

The Minister has not identified the cost of the fee for registration or the licence. I do not blame the nursing homes for being worried about the word "licence"; in the fishing industry it is a very nasty word. Perhaps that is their only reservation. I have no problem with the word "registration", but we have no idea yet what the registration fee will be. We know registration will last for two years and is subject to inspection every six months, but, following consultation with the nursing homes and the health boards, could the Minister tell us if the regulations will be laid before the House and if we can debate whether that is a fair reflection of what will be required of people to qualify for registration in this area?

It is hoped the legislation we have welcomed in general terms will meet the needs we now see as a result of the diminution of public services for people in public institutions, the closure of sub-acute hospitals, the closing of beds in geriatric and State long-term care institutions, the lack of progress in increasing day care facilities which were normally associated with sub-acute hospitals, the lack of progress in providing additional welfare homes and the general lack of action by the Government in that area. It may meet the problem in some way provided there are sufficient funds to enable the health boards to carry out the new responsibility this Bill will place upon them.

Mr. Wyse

I congratulate the Minister for bringing this Bill before the House. I am very pleased that it is broadly in line with the recommendations contained in the report The Years Ahead — A Policy for the Elderly published last year. It is the first move to establish a proper structure for the running of both voluntary and public nursing homes.

The purpose of the Bill is to update the law on nursing homes. It aims to ensure a high standard of care in nursing homes without interfering unduly in the management of the homes. The Bill also provides a statutory basis for boarding out arrangements by the health boards for elderly persons. The private and voluntary nursing homes offering extended care to dependent elderly persons has a long tradition in this country. To judge from the rapid increase in the number of private homes in recent years, there is a growing demand for the kind of care they provide. As the elderly population increases demand seems certain to rise for better community support for the elderly at home. I see no reason this trend should be discouraged, since these elderly persons wishing to provide privately for their latter years are entitled to do so.

In this country at present there are basically two types of nursing homes. We have the private nursing homes and the voluntary nursing homes. Private nursing homes are operated primarily on a commercial profit-making basis and are frequently located in houses and buildings which were not purpose built. These homes generally cater for ten to 30 patients. Indications are that a high proportion of patients in such homes do not require full time, constant nursing care because they are ambulant and quite mobile, requiring welfare accommodation. Some private nursing homes make it a condition that they will take only ambulant persons while others are quite prepared to take elderly persons who are dependent on continuous nursing care. The usual position is a mixture of both categories with places being interchangeable.

However, most nursing homes operate a policy of retaining a person permanently once admitted. When such persons require continuing nursing care, as their dependency increases with advavcing years, they are discharged to acute hospitals and the homes sometimes refuse to have them readmitted into their care. This is one big problem confronting an unfortunate old person in a home. Once such persons are transferred to an acute hospital their chances of being readmitted are nil. I hope the Minister will consider this when drafting the regulations.

The position of voluntary nursing homes regarding admission is somewhat different from private nursing homes. The voluntary homes tend to be more of a welfare type with a higher percentage of residents ambulant and mobile. The general trend is for such voluntary homes to accommodate 30 to 40 persons, with some homes catering for up to 100 persons. Like the private homes, the trend in voluntary homes has been to retain people once admitted. This has created a need for nursing care as the dependency increases. In recent years the tendency in many voluntary homes has been to provide a small infirmary unit to cater for those who are in need of nursing care either on a short term or a long term basis.

There has been a considerable increase in the number of nursing homes coming on the market since the early seventies. At present there are approximately 260 nursing homes in Ireland, of which 85 are provided with assistance under section 54 of the Health Act, 1970. The fact that a particular nursing home has not been approved by the Minister for Health for the purpose of subsidies does not necessarily mean that the service provided is below an acceptable standard. For financial reasons the Minister has not approved any additional nursing homes since 1980. The difficulty for health boards, under section 54 of the Health Act, 1970, is that they cannot by law refuse to subsidise the care of an eligible person who chooses to be cared for in an approved nursing home but the cost of subsidising all elderly persons who choose nursing home care would be excessive. Expenditure under the section can be controlled only by reducing the level of payment or limiting the number of approved homes. If the 260 nursing homes currently in existence were to be approved, under section 7 of this Bill the health boards under the general control of the Minister should expect certain mínímum standards of care and accommodation.

While the private and voluntary nursing homes are providing a valuable and necessary support service, there are a number of shortcomings. Most of the existing accommodation, particularly in private nursing homes, does not come up modern standards; many of the buildings are old and of poor quality and were originally built for other purposes. They result in a lack of privacy and personal environment for the residents. The adequacy of nursing staff in terms of numbers, qualifications and training is open to question in respect of a number of private nursing homes. It would seem that most homes tend to employ minimum numbers for both day and night cover, the latter being particularly light. In a number of instances where nursing aids are employed these can often be untrained and inexperienced.

The provision of special facilities such as assisted baths and specially equipped showers and toilets, wheelchair toilets and other aids for example, ramps, grab rails and hand rails are lacking in a number of homes. Most private homes lack any programme of activity aimed at rehabilitation or even the maintenance of basic functions for the elderly resident. Most forms of recreation and entertainment or diversional therapy are lacking. This is where everybody has a part to play because homes for the elderly should be linked up to some community activity within their own area rather than have a person lying there aimlessly all day long without any type of recreation.

Unsuitable location of nursing homes frequently results in elderly residents being cut off from their former environment, friends, or even relatives. This tends to militate against the development within each community care area of a balanced range of services for the elderly. This is especially relevant in the context of the implementation of the policy which aims to keep elderly persons in their own homes or in a sheltered environment within the community as long as possible with the aid of various back-up services.

Complaints which are made concerning the unsatisfactory conditions in private nursing homes generally refer to understaffing, overcrowding, inadequate heating, insufficient or poor food and unhygienic conditions and practices. I sincerely hope that the Minister takes these types of complaints into consideration when he is drawing up the regulations in relation to the standards of care in nursing homes generally. It is very important for the Minister to ensure that the conditions for nursing homes are well teased out.

I should like to refer briefly to licensing and registration, which are dealt with in sections 3 and 4 of the Bill. I would ask the Minister to consider amending the proposals to allow a licence to be renewable at five year intervals. My reason for asking the Minister to make this amendment is that the Irish Private Nursing Homes Association — which has already been mentioned here this morning — has submitted that to bring certain nursing homes up to the required standard, which I have outlined earlier, might involve huge capital costs in terms of renovations, etc. If they were not then granted a licence after two years they could be in serious financial difficulties and might be put out of business. On the other hand, if the licence was to be extended to cover a five year period it would have to be subjected to the particular nursing home passing an annual inspection by the local health board. This is one aspect of the Bill which the Minister might look at. I am suggesting that perhaps the word "registration" rather than "licence" be used. I am not going to push this issue but I think there is some objection to the word "licence". If "registration" would suffice I would welcome it, but it is for the Minister to decide.

I would also like to ask the Minister about the whole question of transferring licences and change of ownership. Once a nursing home is licensed for a five year period it should remain a licensed nursing home, irrespective of the ownership. This would be subject to the nursing home at all times meeting the required standards of the local health board. It has been argued by some people that the transfer of a nursing home as a viable business, either by sale or within a family, could put it in a very precarious position if the licence was to cease automatically. Under the terms of the legislation a licence is not transferable and once the ownership changes the licence shall then expire. I would ask the Minister to look at this aspect of the Bill before Committee Stage.

I am very concerned about a provision of section 5 which deals with appeals. This section provides for an appeal against a decision of a health board to the District Court and a further appeal, on a point of law, to the Circuit Court. As the High Court is a court of first instance and as the Supreme Court is a court of final appeal, I would like to be reassured that people who are refused licences, people who have had a licence revoked or people who have had conditions attached to a licence, might frustrate a health board by going directly to the High Court and subsequently to the Supreme Court while continuing to operate an unsatisfactory nursing home. The Minister should have his legal advisers look at this aspect of the Bill because it may not be constitutionally sound. The District and Circuit Courts are of limited jurisdiction. I would like to know the legal basis for a person not having a right of appeal against a decision of a Circuit Court in relation to the licensing of nursing homes. What legal basis does the Minister have for limiting an appeal to a Circuit Court? I would have thought it much better that the decision of a health board to refuse a licence or add a condition to a licence or revoke a licence should be capable of being appealed to the Circuit Court and subsequently, if necessary, on a point of law, to the High Court. Perhaps the Minister might clarify this matter.

Debate adjourned.