Deputy Ring was in possession but he is not in the House.
Health (Miscellaneous Provisions) (No. 2) Bill, 2000 [ Seanad ] : Second Stage (Resumed).
Question again proposed: "That the Bill be now read a Second Time."
I welcome the opportunity to contribute to the Bill and I also welcome its provisions. As the Title suggests, the Bill provides for a wide range of miscellaneous provisions. The main provision concerns nursing homes with which I will deal later.
The Bill amends the Tobacco (Health Promotion and Protection) Act, 1988. I welcome the provision in this Bill but I have serious reservations about it. Does the Minister of State really believe that changing the age limit from 16 to 18 and increasing the fine from £500 to £1,500 will bring about any real change in what is happening on the ground? Schoolchildren have access to tobacco at will and without restrictions. As a former teacher I was aware that one could not prevent a young person from acquiring and smoking cigarettes.
While I welcome the provisions in the Bill, I do not know if they are realistic. Will the Minister of State outline how he intends to monitor it? I am on record in this House as deploring the covert use of children by health board personnel to purchase cigarettes to catch shopkeepers in the act of selling cigarettes to an under age person. This is the only method by which prosecutions have been taken in the courts. However, we must rethink this approach as it is not right to use children to carry out the kind of act we are trying to prevent. What is the sense in this? Is it the only approach possible?
The fine could be raised to £1 million but the provisions of the Bill will still be ignored. Even though the Bill will be on the Statute Book this activity will continue. The one opportunity the Government had to prevent this activity was to increase the price of tobacco and put it out of the reach of under age persons. The Bill increases the fine from £500 to £1,500 even though there is no possibility of fining anyone unless structures are put in place. Do such structures exist and how are they administered at ground level? They are not provided for in this Bill.
Statistics show that the age at which people start to smoke is decreasing and one does not have to go far from this House to see very young people smoking in public. Nothing is being done about this. Teachers can report such incidents but nothing will happen. I do not understand how the provisions of this Bill will be implemented. Past measures proved a total failure. We have to address this issue.
There has been a great need for nursing homes and such homes are now being provided on a commercial basis. In the past nursing homes were run by various institutions and religious orders, but that element is now gone. There is a growth in the number of nursing homes providing services to the elderly.
Standards in nursing homes have improved greatly in the past ten years. New, state-of-the-art, purpose-built nursing homes have been opened throughout the country and this is very welcome. These are commercial enterprises and must be seen as nothing else. However, there is a significant difference in standards between these new, private nursing homes and existing public nursing homes. The old nursing homes which are owned by health boards were housed in old buildings which, in many cases, were totally unsuited to the provision of services to the elderly. Many of these homes, which were known as county homes, were workhouses in famine times. The Western Health Board has gradually improved standards in one such building – St. Brendan's hospital, Loughrea – to a very high standard through replacement and refurbishment. I wish the same could be done to many such buildings.
We could spend hours discussing the many horror stories we heard from the past. However, there is no comparison with the current service which is much improved. Having said that, there are serious problems in new nursing homes. The most serious problem is staffing and the cost of staffing. The introduction of minimum wage legislation caused staffing problems. The imposition of that has an effect on the cost of running nursing homes, although I am not complaining about its introduction. Combined with the increased cost imposed by that measure, there is a shortage of nursing personnel in nursing homes. It must be accepted that private nursing homes find it difficult to recruit adequate professional nursing staff. The consequence being that the ratio of professional nursing staff to the number of patients in private nursing homes is very low.
For that reason I hope the Department of Health and Children will introduce an audit of excellence in the nursing homes. An inspection is an encompassing term in that it could mean the inspection of the physical building to ascertain the type and number of beds and standard of carpets, lighting and safety installations in private nursing homes. I am talking about a complete audit for nursing homes and what that would mean. It would include what I outlined on the physical side as well as the staffing ratios, which are important, and the quality and standard of food and medicine within the nursing home structure and their application and use.
Coming from the background of being a medical practitioner, the Minister of State is aware that if patients in nursing homes need intensive care, the necessary staff are not in place to pro vide such care. Those patients in nursing homes who lack discretion are medically treated to quieten them or they are put to bed and given sleeping tablets to ensure everything is quiet.
An independent audit of nursing homes is required. The only body that can provide the personnel to carry out such an inspection are the health boards. It is not that I do not have confidence in them, but there is a conflict of interest in that regard. Health board staff provide a health care service for the elderly and other health board personnel inspect private nursing homes. I have a difficulty with that. I hope the Minister of State recognises the necessity to put in place an independent audit mechanism to assess and accredit nursing homes throughout the country.
It is important to recognise that all is not dark regarding the delivery of health services to the elderly. A nursing home can be a home from home for many of our elderly. In the past in many rural areas many elderly couples lived in the home as part of the extended family, but, given that one or both partners have to work to make ends meet, the elderly are increasingly having to find accommodation in nursing homes.
For that reason there is a need for a subvention. While the provision of a subvention in the Bill is welcome, it is totally inadequate. The three basic rates of £90, £100 or £120, at which the subvention will be paid are inadequate and even with the private contribution by the elderly of their pensions, most of their families face the burden of having to make up the shortfall, which is a significant burden at this time.
That is why a new policy on this area, the winter initiative, was introduced by the Department of Health and Children. I find it peculiar in that the health boards are seeking accommodation in private nursing homes for the elderly who have occupied acute hospital beds. Those elderly patients are being moved a step closer to the home situation by way of the winter initiative under which the health boards have secured accommodation for them in private nursing homes. That is a peculiar turn of events. While it is welcome that those elderly people are not occupying acute hospital beds for an indefinite period, thereby releasing them for other patients, public hospital beds are not available for those elderly patients.
I wish to draw to the attention of the Minister of State a situation in Tuam, County Galway, where there is a wonderful facility. As a Minister of State representing a constituency in the Western Health Board area, I hope he will ask the Minister to meet with the members of the Western Health Board and a delegation that has been waiting to meet him for the past six weeks to discuss this situation. I also ask him to ensure that the necessary funding is provided to guarantee the continuation of that valuable service in the Tuam area, the surrounding hinterland, into the Minister of State's county, Roscommon and north east Galway. The Bon Secours Hospital, as it was known in Tuam, provided an excellent service. When I meet the Minister as part of that delegation I will ask him to ensure the continued operation of that facility and that it be expanded and developed into a step down facility. While the Western Health Board has in the region of 60 beds under contract under the winter initiative, that facility is literally locked up. I cannot understand the wisdom of that. What is required is for the Minister to communicate with the health boards and the authorities that own that facility and for them to quietly and quickly get together to ensure the continuation of that important service. That facility could be utilised to the maximum, if it was opened tomorrow morning. I hope the Minister of State will use his good offices to ensure such a meeting takes place as a matter of urgency and that the Government provides the necessary funding to upgrade and continue the operation of that facility.
I cannot let this opportunity pass without asking that there be a quick response to address the problems in A&E departments throughout the country. I witnessed only last week a person who was left 28 hours on a trolley while awaiting an X-ray and the bandaging of an injured leg. Such delays should not be tolerated. The delay in the treatment of that patient was due to the lack of management. As has been said at various health board meetings and by the Minister, it is a major problem to throw money at the services without ensuring proper management of them. A root and branch investigation of the management of the services is required. There should be adequate staff in A&E departments to direct patients to where they will receive treatment. That would reduce the numbers waiting in line and eliminate the need for keeping patients on trolleys. Personnel should point those in need of acute medical care in the right direction. If that was done, we would get a return for the huge amounts of money being spent on health, which is acknowledged. The delivery of money is one thing but there is no response in the form of an improved service on the ground. Waiting lists increase by the day despite the increased funding. Someone must be responsible for this mess. I hope the Minister of State responds to these issues.
I support this brief but important Bill. I am aware that there are two particular provisions in the Bill, one relating to tobacco and the other to nursing homes. Both of these issues have been debated at length on many occasions and they are of continuing importance.
Regarding the various tobacco provisions, we all support the toughest possible regulations to ensure that smoking becomes a thing of the past for most people. I am a member of the Joint Oireachtas Committee on Health and Children and the Minister of State will be aware that committee has done a lot of work on tobacco. We are concerned by the ever-increasing numbers of young people, particularly young women, who are taking up smoking. Any provision which will dilute the sale of cigarettes either over the counter or through vending machines must be fully supported.
It is regrettable that so many young people are smoking. There was progress in the late 1980s and early 1990s with getting people off tobacco but more and more young people seem to be reverting to it now. It is a social drug that became acceptable in the Ireland of the 1950s to the 1970s. Despite the maximum effort by Governments in the interim period, we have not succeeded in getting the message fully across – that cigarette smoking is one of the biggest killers in Ireland and that the associated diseases are very preventable. This Bill's provisions will, I hope, help in some small way to stem the tide.
Legislation is only one side of the equation. We must also look at tobacco industry advertising. I welcome the recent changes in this area and the fact that it is now more difficult for the tobacco industry to advertise its products. However, it still has opportunities to promote tobacco in other sports, such as Grand Prix racing, which is probably the major vehicle for promoting cigarettes. This needs to be tackled more thoroughly by the authorities and I know the Minister, Deputy Martin, has been making efforts in this regard and has promised a total ban. He will find that difficult but we will support him in his efforts. It is the view of the Joint Committee on Health and Children that we must try to put in place a total ban on advertising and the display of cigarettes in any retail outlet and we must make it genuinely difficult for people not just to promote but to sell or purchase tobacco products. We are speaking of a compulsive drug which kills thousands of Irish people every year. I welcome this legislation in as far as it goes but there are other areas we must try to progress.
The point has been made that nicotine substitute products are effective, even if they are not the answer to everyone's addiction problem. They are also quite expensive and I hope we can agree that these products should be available on medical cards. Many people who find it difficult to give up smoking are from a relatively poor financial background. They may have medical cards and if nicotine substitute products were available under the GMS system it would help thousands of people to give up cigarettes. The cost to the State would be more than offset in the long run by savings on the broader health front. Every person who smokes adds to national health costs, so for everyone we can take off cigarettes we will save money in the long run. I hope nicotine substitute products can be made available under the GMS system.
I welcome the Bill's provisions for nursing homes, which are now an integral part of our system for caring for the elderly. Most of us deal with problems in our constituency that stem from the lack of nursing home beds. The joint committee has dealt with this matter from time to time and presentations have been made which suggest there is an adequate number of beds but that from a geographical perspective we do not have an adequate bed complement throughout the country. In my area of north and east Cork there is always a deficit of private nursing home beds. There are both supply and demand problems. The first thing we must do is recognise that private nursing homes play an increasingly important role in looking after our elderly. Even when the maximum subvention of £120, except in exceptional circumstances, is paid, that is still a small subsidy that the State is handing over, as the cost of a bed in a public, district or community hospital is much greater. That subsidy is good value for the taxpayer and the Department but I hope to see a big improvement in that subvention rate in the future. I know the Minister touched on this in his budget speech.
The nursing home subvention system has been with us for quite a few years and the maximum rate did not increase, though costs have obviously increased dramatically in recent years. There is no nursing home now in which the £120 subsidy plus an old age pension would cover weekly costs. I hope we see major improvements in this regard.
I was disappointed that in the Budget Statement there were not more measures either to assist people to care for the elderly at home or to provide more nursing home places. Obviously, an increased subvention rate will be helpful in this regard but we must also consider tax incentives on a broader front. The best solution would be to ensure the maximum number of people are cared for in their own homes. The carer's allowance is a step in the right direction regarding care in the home but, at a risk of repeating what I am sure every speaker has said, the carer's allowance is simply insufficient in many cases.
There was a change in the means test announced in the budget statement last week. The Minister for Finance and the Minister for Health and Children assured us that about 5,000 more people will now qualify for the carer's allowance. I welcome that but it is only a small step out of many which should be taken. More than 100,000 people, at the very minimum, are providing full-time care to elderly people in their own homes and are not getting any assistance from the State. If we reflect on how much it would cost if all of those people could be transferred into a State system of care, we will recognise that home carers are not just doing a great social service for their families and communities but are saving the Exchequer million of pounds per week. They have not received a good or fair deal from any Government. Every political party in this House is guilty but now that significant resources are available, we must try to reach out to those people and give them the sort of resources they need, financial and otherwise. It is an integral part of the issue of care for the elderly. The Minister as a general practitioner knows that where people can be cared for at home, it is by far the best solution. However, we must put incentives in place. I hope through tax allowances and an adequate carer's allowance we can make major progress over the next 12 months. The budget proposals are a step in the right direction but we must go much further.
On the subject of the nursing home regulations and subventions, I must reflect on the recent case in County Cork. I do not know any of the people involved but that case resulted in a nursing home proprietor being sentenced to a term of imprisonment for apparently breaching some of the regulations. All the local evidence indicates that the level of care in that nursing home was outstanding and the level of commitment offered by the proprietor and her staff was second to none. However, she was in breach of some minor technical regulations. One or two nursing homes in my constituency were closed down because of similar difficulty in meeting regulations in relation to the number of full-time nursing staff.
I am aware of one case where the proprietor of the nursing home tried unsuccessfully for weeks to find alternative accommodation for people who, in many cases, had been with her for years. The nursing home proprietor and her family were emotionally distressed, first, at having to close their facility which had provided outstanding service and second, at having to find alternative accommodation for people who did not wish to go elsewhere. When we put regulations in place we must try to see the human side of the problem as well as the legal side. We must try to ensure that people with nursing homes today are given the maximum time, assistance, grant aid and tax reliefs where they are required to upgrade and to maximise their facilities. There is a growing need for private nursing homes. They are part of the solution to the wider issues of care for the elderly and they need whatever support and assistance we can give.
I thank Deputies for their overall welcome for the Bill and their response which has been generally constructive. I look forward to an interesting debate on the detail of the Bill on Committee Stage. I will comment on some matters raised by Deputies relating to the contents of the Bill on a section by section basis.
One of the purposes of section 1 of the Bill is to better provide for the provision of community pharmacy services in the context of section 59 of the Health Act, 1970 as a whole. Deputy Mitchell referred to the community pharmacy contractor agreement between community pharmacy contractors and health boards and, in particular, to clause 9 of that agreement. As the Deputy indicated, clause 9 provides for a review by the pharmacist of a medicine therapy of the patient for whom the prescription is issued. This review includes screening for any potential drug therapy problems and the pharmacist shall offer to discuss with the patient or carer all matters which the pharmacist, in the exercise of his or her pro fessional judgment, deems significant. I agree with Deputy Mitchell that this is an important element of the kind of quality pharmaceutical care envisaged in the contractor agreement as a whole. To facilitate clause 9 coming into effect properly, the contractor agreement itself contained a requirement for the initiation of a programme of continuing education for pharmacists engaged in the delivery of community pharmaceutical services. A centre for continuing pharmaceutical education was established since the new contract came into being and much of the focus of the centre so far has been concentrated on facilitating pharmacists in meeting their obligations in regard to clause 9 and in advancing the quality of care message underpinning clause 9.
Deputy McManus spoke of the key role of the community pharmacist in primary care and about regulations which provide a system to regulate the granting of pharmacy contracts in accordance with public health criteria. These regulations specify the criteria and procedures under which the chief executive officer of a health board shall determine the issue of new community pharmacy contractor agreements for the provision of community pharmacy services under the Health Act, 1970. They regulate the granting of contracts with a view to bringing Ireland into line with other EU or EEA States where such controls exist in one form or another, improving standards in existing pharmacies and promoting patient access to pharmacy services in rural areas.
The regulations came into force in tandem with the introduction of a new contract, as mentioned by Deputies in the debate, for the provision of community pharmacy services under the Health Act, 1970. This contract is pro-active in promoting a quality driven service to the patient. In addition, the contractor agreement is designed to improve the quality of services by encouraging greater investment in the pharmacy and facilitating the involvement of a greater number of pharmacists in a given pharmacy.
I appreciate the view that the Health (Community Pharmacy Contractor Agreement) Regulations, 1996 may appear at first glance to be anti-competitive. However, I argue strongly that the usual free market rules of competition cannot apply to health care and, an unregulated system, in addition to being out of step with arrangements elsewhere in Europe, would lead to a diminution of the quality of professional community pharmacy services with greater emphasis inevitably being placed on the non pharmacy aspects of the business. In this context, I also argue that the provisions of the regulations in regard to determining definite public health need for community pharmacy services are a necessary component in the advancement of a quality service for the public and that the definition of definite public health need in the regulations is designed to prevent the further clustering of community pharmacies, to the detriment of the service, in areas already provided with pharmacies while promoting the establishment of pharmacies in areas not currently served.
Deputy McManus and Deputy Ring referred to specific applications for community pharmacy contractor agreements which had been refused by the relevant chief executive officer of the relevant health boards. These are a matter in the first instance for the chief executive officer of the health board concerned. The regulations, however, provide for an appeal to the Minister where an application has been refused on the basis that a definite public health need has not been established under the regulations. In the two cases mentioned by Deputies, the decision of the chief executive officer is the subject of an appeal to the Minister for Health and Children, Deputy Martin, and it would not, therefore, be appropriate for me to comment any further at this stage.
I thank the Deputies for their contributions to this debate and for their broad welcome of the anti-smoking measures outlined in the Bill. We are all agreed that the battle against smoking is one of the most important public health challenges facing us in the new millennium. This is one of the Minister's main priorities. Deputy Burke raised the issue of policing tobacco sales. Additional staff resources were provided to health boards in the recent budget to improve compliance with the law. The tactic of using children, with their parent's or guardian's consent, has been successful in improving compliance with the law. The Western Health Board has employed this tactic and the publicity generated by successful convictions has proved a deterrent to shopkeepers.
As I stated in the House last month, the report Towards a Tobacco Free Society launched by the Minister on 7 March this year recommends, among other matters, raising the age limit at which tobacco products can be sold to young persons to 18 years as does the report of the Joint Committee on Health and Children on smoking and health published in November 1999. The proposed amendment to the Tobacco (Health Promotion and Protection) Act, 1988, will have the effect of raising the age from 16 to 18 years and will raise the maximum fine on persons convicted for selling to underage persons from £500 to £1,500. The Government, at its meeting on 3 October 2000, approved the drafting of the heads and general scheme of a Bill to give effect to the proposals in the report Towards a Tobacco Free Society. Work is urgently under way in my Department to prepare a comprehensive tobacco Bill which will take on board many of the other proposals recommended in the report.
The Minister also announced last week that, with effect from 1 April 2001 and in line with the recommendations of the advisory forum for the implementation of the cardiovascular strategy, he will be making nicotine replacement therapy available to medical card holders. This was raised by Deputy Bradford whom, I am sure, will be happy with that.
Deputy McManus referred to the contracting of private nursing home places as part of the winter initiative recently announced by the Minister, as did Deputy Burke. As previously explained, this includes the contracting of over 500 additional nursing home places which will allow for a greater throughput of patients and will alleviate the pressure on acute services over the winter period. A major factor affecting the ability of hospitals to provide beds for patients over the winter period is the high number of acute beds which are inappropriately occupied by patients who have completed the acute phase of their illness. Many of these patients are in the older age category and require a further level of care in a more appropriate environment.
There are approximately 12,600 private nursing home places of which approximately 7,100 are either subvented or contracted by health boards. The initiative which the Minister recently announced will provide at least 500 additional nursing home places over and above the 7,100 places. This represents a more than doubling of the number of additional places provided under previous initiatives. These places are being made available exclusively for patients from public hospitals who have completed the acute phase of their treatment in general hospitals and who require to be cared for in less acute settings. Additional management resources have also been provided to enable health boards to manage this initiative to ensure the optimum use of the extra contracted places. Health boards are now in the process of contracting these additional nursing home places.
As part of the winter initiative, approximately £1.5 million has been provided this year for the purchase of medical aids and appliances for older people. This will facilitate the discharge of older persons from hospital and also support them in remaining in their own homes. These supports will include a range of items such as walking aids, wheelchairs, special beds and other supports in the home. This initiative will run during the winter period at both the beginning and end of 2001 and, in this regard, an additional £10 million has been made available.
With regard to the question of responsibility for standards in private nursing homes which was raised by Deputy McManus and Deputy Burke, the Nursing Home (Care and Welfare) Regulations, 1993, were made under the Health (Nursing Homes) Act, 1990. These regulations set out the standards which nursing homes must meet to fulfil the conditions for registration by a health board. They cover a number of issues including welfare and well being of patients, contract of care, personal possessions, staffing, accommodation and facilities together with inspections by designated officers. It is a matter for each health board to ensure that the regulations are complied with.
Article 11 in the care and welfare regulations relating to accommodation and facilities states that the registered proprietor and the person in charge of the nursing home shall ensure that the maximum number of persons to be maintained in the home and the maximum number of persons to be accommodated in shared rooms in the nursing home shall not exceed a number for which the nursing home is registered by the health board. This article further provides for adequate space, lighting, heating, equipment, bed and bedding, etc. The health boards are empowered under the regulations to enter and inspect nursing homes not less than once in every period of six months. There is no limit to the number of inspections which may be carried out. The Act provides for penalties in the event of a breach of the regulations. I note Deputy Burke's comments regarding an independent inspection. We will look at that on Committee Stage.
Deputies McManus and Ring raised the issue of the application of inspection procedures provided for in the Nursing Homes Act to health board extended care facilities. At present, there are no statutory provisions regarding standards in residential facilities for older people operated by health boards. As the House will be aware, a social services inspectorate was set up on an administrative basis last year. The plans for the inspectorate were that it would concentrate for the first three years on child care and, in particular, on children's residential centres run by health boards. In the longer term, it is planned that the work of the inspectorate will be extended to cover the full range of personal social services provided by the health boards, including residential care services for older people.
Access to induction courses for foreign nursing staff was referred to by Deputy Batt O'Keeffe. Funding has been made available to the Health Service Employers Agency to employ a nurse manager to co-ordinate the provision of supervised clinical placement for nurses recruited from abroad. Nurses from the Philippines and certain other non-EU countries are required to undertake such placements prior to registration with An Bord Altranais.
The recruitment of nurses from abroad is helping to ease staffing difficulties across a range of health care settings. However, some problems have arisen regarding the availability of supervised clinical placements. This Government is determined that nurses requiring such placements will be provided with them. The Health Service Employers Agency co-ordinator will have a nationwide remit in ensuring the availability of sufficient clinical placements.
The Minister for Health and Children met representatives of An Bord Altranais last week to discuss the need for greater flexibility in relation to clinical sites where nurses from abroad may undertake their supervised placements. We are confident that the board will respond positively to the proposals made. This Government is prepared to provide funding to teaching hospitals involved in the provision of supervised clinical placements in respect of the salary of a clinical co-ordinator for the duration of such placements. Since this is the biggest single cost element, the availability of funding to cover it will greatly reduce the overall cost to agencies such as nursing homes which are recruiting nurses from non-EU countries.
As far as tackling the abuse of older people is concerned – Deputy Ring referred to this – Deputies will be aware that a broad based working group has been established to advise on the formulation of procedures and guidelines on elder abuse. The group is chaired by Dr. Desmond O'Neill, consultant physician in medicine of old age. The working party has a broad remit in regard to making regulations as to how elder abuse can best be overcome by advising on appropriate structures, including any necessary changes in legislation and legal procedures to deal with the problem. I have made the necessary resources available to enable this group to complete the comprehensive work programme which it has set out and which includes the organisation of pilot projects, the implementation of awareness and training programmes and the preparation of an evaluation report.
I am aware that the working group has reached agreement on draft practices, procedures and guidelines for the detection, assessment and management of elder abuse. Pilot projects in two community care areas are expected to start from January next. Training programmes will be provided for staff members and ongoing evaluation will take place. When the working group makes its final report and recommendations to me, I will give immediate consideration to the implementation of the group's recommendations.
In regard to the issue of subvention rates, which was raised by Deputies Ring, McManus and Bradford and others, I would like to point out that in the Action Programme for the Millennium, this Government gave a commitment to increase the rates of subvention and Deputies will be aware of the recent announcement regarding the intention to increase rates by 25% with effect from 1 April 2001.
I am sure Deputies will support the necessary changes to the Health (Nursing Homes) Act, 1990, which will facilitate the management of appropriate standards and the effective operation of the schemes. That covers most of the issues raised during this debate. I thank Deputies for their assistance and their remarks during the debate. We will look at them further on Committee Stage.
Question put and agreed to.