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Dáil Éireann díospóireacht -
Thursday, 13 Nov 2008

Vol. 667 No. 2

Nursing Homes Support Scheme Bill 2008: Second Stage.

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

Of all our needs as human beings, perhaps the deepest are for family, health and home. They touch on our most profound psychological security and sense of well-being. Following closely is the need for financial security. Not all of us are fortunate enough to live all our lives in a loving family, enjoy constant good health or have a home of our own. Few of us have no financial worries. If the security of just one of these, family, health or home, become an issue or are called into question it can be emotionally difficult. If all three are at issue it is not just unsettling but traumatic. When financial issues are added, it can seem overwhelming. That is what many families and individuals face at the moment when there is no option but to move out of home and into a nursing home. That moment is often put off for many years. Adult children are often beseeched to avoid making the decision in question, which no one ever wants to make. At that moment, there is just one realistic option if a loved one is to get the best possible care. At such a time, everything possible must be done to reduce upset and insecurity, to give assurance, to provide the best possible care and to put the interests of the person needing care above all other interests.

The House has an opportunity to put the best interests of each person who needs care above all else, to provide reassurance and to remove financial issues from all the strains of that most difficult moment in the life of any individual or family. Less than one in 20 people over the age of 65 will ever develop high dependency needs, fortunately. Therefore, relatively few people will need to deal with the need for long-term residential care. Approximately 25,000 are in such a position at present. This legislation will help them and future generations. It will also assist people under the age of 65 who need long-term care. I refer to those who have high-dependency needs as a result of debilitating conditions, for example. This Bill will reassure those who fear they may need long-term care in the future, even if that never comes to pass.

This House does not often get an opportunity to pass legislation that fundamentally improves people's lives, even if we are talking about just one person in 20 in this instance, while at the same time introducing a fundamental and comprehensive new system of long-term care support. This legislation provides for the cost of nursing home care to be shared fairly, introduces a clear and consistent standard for assessing the care needs of everyone and provides for a new legal support — the care representative — to assist people with diminished mental capacity. We are bringing order to what has been a mess. We are making fair what has been unfair. We are making consistent what has been haphazard. We are making sure what has been in doubt. What has been unsettling will be reassuring. What has been unclear will be clear. What has been unpredictable will be predictable.

It was deeply unfair that people of the same means faced radically different costs for nursing home care, depending on where they lived or whether the nursing home was public or private. It was deeply unfair that a person with modest means could face high care bills, while another person might pay relatively little even though he or she had substantial means and assets. We are fixing that. It was deeply unfair and unsettling that many people and their families had no option but to sell the family home to pay for care. As a result of this legislation, no one will have to do that any more. It was inconsistent and unfair that care needs assessments, means assessments and financial support varied across the country, depending on the health board area one lived in. This legislation will provide for consistency for everybody. People often felt uncertain and doubtful when considering how, when and to whom public nursing home places were available. This mattered, not least financially. In a public nursing home, nobody, no matter how well-off, was charged more than the equivalent of 80% of the State non-contributory pension. In a private nursing home, even with subvention payments, the cost to an individual was substantial. The State met 90% of the cost of public nursing home care, but just 40% of the cost of private nursing home care. We are putting this right.

Families face deeply unsettling issues when there is doubt about the mental capacity of a loved one who needs care and when legal and financial arrangements need to be addressed. We have a deep obligation to prioritise the interests of such a person. Up to now, it was unclear how we could do this, short of availing of the ward of court system. This legislation offers reassurance and provides a new legal protection to help individuals and their carers. The public and private care provision services have been operating in parallel, with increasingly blurred lines and unintended effects for patients. We will now have one system for all people who need care and for all providers of care. The system, which involves different contributions, will be based on a fair means test. It was described by the National Economic and Social Council, in its report, The Developmental Welfare State, as a type of "tailored universalism". It is designed to be sustainable for many years to come, when the number of older people in our population increases and through the ups and downs of economic cycles. The State will continue to meet approximately 70% of the cost of long-term care for the population. I am particularly pleased that the Government has decided to introduce the system despite the difficult economic circumstances we face.

This legislation is the immediate product of four years of work by many people. When the problem of illegal nursing home charges became evident, I decided that we needed to start from the beginning by fixing the fundamentals and dealing with all the anomalies that had arisen. Many people contributed to this work before and after 2004. I refer to Deputies and Senators, the Ombudsman, the social partners, clinicians, leading academics, specialists in the public service and, most of all, the families of those in long-term care. Many previous health Ministers played a part in trying to alleviate the burdens faced by people who need long-term care. They worked on the nursing home subvention scheme and other matters in good faith. The anomalies and inconsistencies I have mentioned ultimately needed to be addressed as part of a fundamental overhaul of the system. I am proud of the legislation that has been produced to that end. I am proud to have the privilege of bringing it to the House. I am proud of the work of the officials in the Departments of Health and Children, Finance, the Taoiseach, Social and Family Affairs and Justice, Equality and Law Reform, the Office of the Attorney General and the Courts Service who contributed to the legislative process. Above all, I am proud that this legislation puts our loved ones who need long-term care first. Rightly, in my view, it is a fair deal.

I propose to briefly outline the main provisions of the legislation before the House. Section 3, which sets out the scope of the Bill, defines certain terms used in it. The definitions of "long-term residential care services" and "approved nursing home" are of primary importance because, essentially, they circumscribe the scope of the scheme. The definition of "long-term residential care services" refers to maintenance, health and personal care services which are provided in designated public and voluntary facilities and approved private nursing homes. Such services must be provided for not less than 30 consecutive days, or periods aggregating not less than 30 days, within a period of 12 consecutive months. For the sake of clarity, the definition also explicitly excludes certain services, such as respite care services. To qualify as a designated facility, a public or voluntary facility will have to be designated in writing by HSE as being a facility that is predominantly used for the care of older people and will have to provide 24-hour rostered nursing care.

To qualify as an "approved nursing home", a private nursing home will have to be registered under the appropriate legislation, reach an agreement with the National Treatment Purchase Fund on the maximum price charged for care under the scheme, be tax compliant and provide 24-hour rostered nursing care. Another key term used in the Bill is "financial support". This encompasses straightforward financial assistance towards nursing home costs, which is referred to as "State support", and the option to defer payment of certain contributions during one's lifetime, which is termed "ancillary State support".

Section 4 defines a "couple" for the purposes of the scheme. A couple is defined as either a married couple, or a heterosexual or same sex couple who have been cohabiting as husband and wife for at least three years. In each case, the people in the couple must have been habitually living together when they applied for State support or when they began to receive care services. Sections 5 and 6 set out the rules governing the establishment of, and eligibility for, the scheme. Section 5 establishes the nursing homes support scheme and stipulates that the scheme is resource-capped. Therefore, the scheme is premised on the principle of eligibility rather than entitlement. Section 6 further provides that eligibility for the scheme extends to those who are ordinarily resident in the State. In other words, the scheme is not limited to older people.

Sections 7 and 8 relate to the assessment of care needs. Section 7 provides for a care needs assessment to be carried out to ascertain whether a person needs long-term residential care services. It stipulates who may carry out such assessments and what factors may be taken into account. These factors include the person's ability to carry out the various activities of daily living but also the medical and social supports available to the person.

Section 8 sets out the basis for unsuccessful applicants to seek a review of care needs. Sections 9 and 10 provide for an application for State support and for a subsequent financial assessment of means to establish the contribution an individual may have to pay towards the cost of his or her care. Section 10 stipulates that the assessment shall be carried out in accordance with Schedule 1. Parts 1 and 3 of the Schedule set out the rules for calculating the contribution payable by a single applicant. In summary, a person will make a contribution of up to 80% of income and up to 5% of the value of assets, after deductions and safeguards have been applied. Parts 2 and 3 of the Schedule contain the rules in respect of the contribution payable by a member of a couple. In this case, the assessment is based on the principle of each member of the couple owning 50% of the couple's combined means. A person who is a member of a couple has an annual assessed contribution of 40% of the couple's combined income or 80% of half the combined income and 2.5% of the couple's combined assets or 5% of half the combined assets.

The Bill contains a number of safeguards to protect the income and assets of care recipients and their spouses or partners and the residual value of the principal residence. These include the "minimum retained income threshold", which ensures a person entering care must retain at least 20% of the maximum rate of the State pension while the spouse or partner remaining at home must retain at least the maximum rate of the State pension; the "general assets deductible amount" or asset disregard, which stands at €36,000 for an individual or €72,000 for a couple; and the cap on the principal private residence, which ensures contributions based on the residence will be payable for the first three years of care only. This is often termed the 15% cap.

Sections 11 to 14, inclusive, set out the basis for determining applications and for paying State support. They provide that, subject to resources, the State will pay the full difference between the total cost of care services and a person's contribution. This State support will be paid directly to the relevant nursing home on behalf of the person. In the case of existing residents whose nursing homes are approved under the scheme, State support will be paid from the date of full commencement of the legislation.

Sections 15 to 18, inclusive, provide for another important feature of the scheme, namely ancillary State support, which is an additional support designed to ensure people do not have to sell assets such as their home to meet their care costs. It enables people to defer contributions payable on Irish land-based assets for the duration of their lifetime. It may be thought of as a loan advanced by the HSE and recouped at the settlement of the person's estate. The payment of ancillary State support is subject to a charging order being placed against the asset of the person to secure the amounts advanced. The HSE will register the charging order in the Registry of Deeds or Land Registry, as appropriate. The Bill also provides that ancillary State support will be paid directly to the relevant nursing home on behalf of the person and that it may be paid to a person even though he or she does not qualify for State support.

Sections 19, 20 and 26 deal with repayment. Section 19 stipulates the events which trigger the repayment of ancillary State support. These are termed "relevant events" and principally include the death of the person or the sale or transfer of the asset concerned. Section 20 provides for a further deferral of the repayment of ancillary State support in the case of the principal private residence. The people who can avail of this are the spouse or partner of the original applicant or certain relatives termed "connected persons" who satisfy the following conditions: the asset in question must be their only residence; they must have lived there for not less than three years preceding the original application for ancillary State support; and they must not have an interest in any other property. Where people avail of this section, repayment will be deferred for the duration of their lifetime unless they cease to qualify as a connected person or the asset in question ceases to be their principal residence. Section 26 provides that Revenue will be the collection agent for the repayment of ancillary State support.

Sections 21 and 22 make provision for care representatives. Part 4 provides for an innovative new feature within the scheme, namely that a person may apply to the Circuit Court to be appointed as a care representative of a particular person. The appointment of a care representative is only necessary where a person does not have full capacity and wishes to avail of ancillary State support. However, a person appointed as a care representative may assist with any matter relating to the scheme. The Bill adopts a functional-based approach to determining capacity, which is consistent with the recommendations of the Law Reform Commission.

Under section 21, a person is considered to lack the capacity to make a relevant decision if he or she is unable to understand the information relevant to the decision, retain that information, use or weigh that information as part of the process of making a decision or communicate his or her decision by any means. A person must be certified by at least two registered medical practitioners as lacking the capacity to make a relevant decision for a care representative to be appointed. The individuals who may apply to be appointed as a care representative are the spouse or partner of the person; a parent, child, brother or sister of the person; a niece, nephew, aunt or uncle of the person; or a registered medical practitioner or other health practitioner other than the proprietor of a nursing home in which the person resides or is likely to reside.

Section 22 is a technical provision, which amends the Courts and Courts Officers Act 1995 to allow for the appointment of care representatives by county registrars in uncontested cases.

Sections 23 to 25, inclusive, provide for the notification of certain specified matters, including the death or discharge of a nursing home resident and a material change in the circumstances of a person or connected person.

Section 27 deals with schedules of assets and it applies to a deceased person to whom financial support was provided or to whose partner financial support was provided. The personal representative of such a deceased person must provide the HSE with a written notice of his or her intention to distribute the deceased's assets and a schedule of such assets at least three months before beginning to distribute the assets. The HSE has the authority to request that sufficient assets are retained to repay any amount due to it, which is consistent with social welfare legislation.

Section 28, which refers to joint ownership, is a technical provision that ensures a charging order in respect of ancillary State support shall not cause the severance of a joint tenancy or be rendered void due to the absence of the prior consent of the other joint tenants. The section seeks to protect both the interest of the HSE and of the other joint tenants.

Sections 29 to 31, inclusive, concern reviews and appeals. A person or the HSE may seek a review of the person's care needs, his or her financial assessment or the amount of ancillary State support payable. In addition, a person may appeal certain decisions of the HSE, including decisions taken regarding his or her care needs and his or her application for State support. A person may also appeal the inclusion of income and assets transferred prior to 9 October 2008 in the financial assessment on grounds of hardship.

Section 32 is a technical provision ensuring the existing legal basis for charges, including the exclusion of certain care groups from charges, is maintained. Section 33 is also a technical provision. In line with the Government's commitment, it ensures existing public residents will not be worse off as a result of the new scheme. It also provides that a person in an acute hospital bed who has finished his or her acute phase of care may be charged as if he or she were in receipt of long-term residential care services. This provision is necessary to ensure there is not a legal incentive to remain in an acute hospital bed following discharge.

Part 9, covering sections 34 to 46, inclusive, contains a number of miscellaneous provisions. These include technical and standard provisions concerning the making of regulations, the maintenance of records and so on. They also include transitional provisions providing that the nursing home subvention scheme will cease for new applicants from the full commencement of the legislation but that existing private nursing home residents can remain on subvention rather than transferring to the new scheme, if they so wish. Sections 38 and 39 empower the National Treatment Purchase Fund to negotiate prices with private nursing home providers for the purposes of the scheme. Section 41 renders explicit the common law principle that a person providing necessary services to a person of diminished capacity for the latter's benefit may expect to be paid for such services.

I have detailed the key provisions contained in Schedule 1 and, therefore, I would like to conclude by clarifying the final part of the Bill, Schedule 2. Schedule 2 sets out the procedure for adjusting the amounts repayable in respect of ancillary State support. This adjustment will reflect the rate of inflation, as measured by the consumer price index, between each year in which contributions were deferred and the year in which the debt falls due. In other words, the State will take account of the time value of money.

The Bill is fundamental in meeting the commitment given in Towards 2016 that State support should be equal for public and private care recipients. Critically, it offers assurance to the most vulnerable of groups in our society — those in need of long-term nursing home care — that such care will be affordable and will remain affordable for as long as they need it. I commend the Bill to the House and I look forward to hearing the views of Deputies.

We have waited for this Bill for quite some time. I fully accept it is complex legislation and, furthermore, I agree the current situation is untenable and grossly unfair on people. There is an acceptance generally that those who can afford to contribute towards their long-term care should do so. However, as ever with Bills in this House, the devil is in the detail. There is much detail in this and many areas of concern.

The Minister stated in her preamble that she is bringing certainty, making fair what has been unfair, making consistent what has been haphazard, making sure what has been in doubt, etc. I would like to believe all that but my past experience of Bills in this House, and past experience on initiatives and so-called reform, is that they have been anything but clear or sure. Therefore, I want to go through the Bill, pointing out the areas where people have concerns and where we, on this side of the House, are clear gaps need to be filled. If all these issues can be addressed during Committee Stage, and amendments accepted, then perhaps there can be agreement on this legislation. However, as the Bill stands, there are as many questions as answers.

The Minister stated that the Bill will remove the inequitable situation between support provided for public and private care, and that the contribution will be based on means and capped in some cases. The capping is of concern because last year the Minister allotted €110 million to this scheme and this year she is allotting €50 million.

One does not have to sell or mortgage one's home at the outset, a provision people will welcome because, as the Minister correctly pointed out, people have had to sell their homes in the past, and family members will not be burdened with the cost of care. The Minister has gone through how this works and I will not repeat all that. However, I am very concerned about the resource capping. Will this Bill operate on the basis that there is a finite sum, such as €50 million, and high dependency will be defined up to the point of the ability of the State to afford the care? Will the threshold rise repeatedly, in other words, that it will no longer be a medical assessment? It could well transpire to be an economic assessment on which a medical assessment is based. What I mean is that in a year where €110 million is available, many more people will qualify than in a year where €55 million is available.

It is not clear from the Bill what is the care needs assessment process, which, obviously, needs to be independent. There have been instances abroad in other areas where health authorities, unable to provide a particular service such as for autism, have a remarkably low diagnosis of autism because if they do not have the facility, they must pay for its purchase from an adjoining health authority. The same principle of conflict of interest may arise here.

The Minister mentioned the National Treatment Purchase Fund, NTPF. It will negotiate fees with the nursing homes. We will all be happy that there is a body which negotiates fees with nursing homes. However, throughout the Bill and the explanatory memorandum, the Minister refers to €800 a week as an example. Anybody who lives in Dublin knows she will not find a bed in a nursing home for that amount. Will we end up with a situation similar to the one I encountered in my clinic only a number of weeks ago?

A constituent of mine in Rush has been assessed as needing nursing home care and unable to continue to live independently at home. He is prepared to go into a nursing home which, as the Minister will be aware and as she has already alluded to, is a significant decision — an major emotional break for such a person. The good news is there is a bed available for him, but it is in Portlaoise. This man lives in Rush. To my mind, this decision is designed to let this gentlemen go and wither on the vine 50 miles away from where all his relatives, friends and family could visit him. Somewhere local would at least make the move to the nursing home less of a shock to the system and he could continue to be engaged in his community. Nobody wants people put that distance away and if this Bill allows the NTPF to operate solely on price, on what it can buy down the country versus what is required in the reasonable locality of a patient, then this is a matter that needs to be further clarified.

It is not clear what happens if nursing homes drop out of the scheme. Will patients be moved out of the nursing home? Will they no longer qualify? What will happen? For example, what if regulations change? There are two sides to this — the NTPF is at one end but HIQA is at the other. HIQA will establish the standards. Those standards have not been agreed; they are only in draft form. They need to be seen by Members of this House and agreed. I understand there is general consensus on them, but I have not had an opportunity to go through them. There does not appear to be an issue but, for example, if there is a future recommendation regarding major infrastructural developments in all nursing homes, such as, that they should have a certain number of Parker baths which would involve an additional expense, will some nursing homes find themselves outside the loop or will the NTPF operate reasonably and allow for such matters above and beyond normal inflation?

A major current concern is that nursing homes can be inspected by the HSE, but who is inspecting HSE nursing homes? HIQA is to do this, I hope, independently. Another issue is unclear. Will the HSE remain both a purchaser and a regulator of care or will those functions be separated, one to the NTPF outside the HSE and the other to HIQA?

This Bill is limited to long-term nursing home care, which is defined as anything over a year but which is not limited by age. Therefore, I presume this will apply to younger people who find themselves incapacitated through brain injury, etc. We need to consider whether we accept these concepts. As I stated, there is broad agreement on the basic principles.

Another issue which requires further debate is that the 5% charge on the primary residence is capped at three years, but it is not capped on all other assets. If one lives ten years, it is 5% per annum. That might seem reasonable in certain circumstances, but it may cause tremendous difficulty, hardship and problems for people in rural areas. This will involve siblings, another major aspect of this matter. That charge will be a major issue for people who live on smallholdings, perhaps a brother and a sister, with the land being devalued over time.

Is it realistic to expect this will remain capped? The amount of €55 million will not address long-term nursing home care needs. Why is it capped at €55 million this year? Is it because the Minister does not intend to introduce it for half a year? Is it money for half a year? Is the €110 million additional to the money currently being spent on subventions or is it included?

Who are the winners and the losers? Obviously, the winners are those with limited assets, a home and nothing else. For them, this will be a welcome relief. For many others, it will cause a problem. Those in public nursing homes pay up to 80% of their assessable income. New patients in this category will have their other assets brought into consideration. Those who opt to enter a nursing home but who may not be regarded as medically highly dependent may not qualify.

These patients may also lose from the change in the tax treatment of medical expenses from the marginal to the standard rate. A great deal of confusion has arisen about this and in response to a parliamentary question from Deputy Olivia Mitchell, the Minister for Finance, Deputy Brian Lenihan, finally confirmed that from January 2010 the tax allowance for long-term nursing home care will drop from the marginal rate to the standard rate. If only high dependency patients, by current definition, will be allowed into nursing homes, one third of the 21,000 people in nursing homes at present will not qualify and they will suffer seriously as a consequence of this. How will they be looked after and how will they qualify? This issue must be addressed.

The issue of those who wish to reside in higher cost nursing homes for reasons of geography brings us to how the NTPF will choose the nursing home and whether it will be purely on a monetary basis. Previously, I mentioned nursing homes with a higher cost base.

I know it is not possible to do everything but a major gap in the Bill is that it makes no mention of care at home, and this is a major lost opportunity. Everybody in this House, including the Minister, has accepted that the preference is for people to stay at home. People live longer if they remain at home. This is a multi-factorial finding but it is nonetheless a fact. Will the tax treatment of home care packages and the cost of home care be changed from the marginal rate to the standard rate? Does the Minister plan to introduce measures with regard to care in the home?

The option to defer payment is based on the value of the asset when the initial payment was due rather than the deferred value and the CPI is then applied. If an individual's assets were valued two years ago and he or she had €200,000 worth of bank shares, and if payment were to be made now what would those shares be worth? It would be the same for a house valued three years ago. A person would find rather than paying 15% of the value of the house over the three years they would have been paying 25% of its value. This matter needs to be addressed.

In assessing support requirements, the principal private residence is treated differently to all other assets. As the Minister stated, once three years are paid the contributions stop. As I stated earlier, with regard to land, shares, property and cash the 5% contribution continues until the person dies. Many people will lose out on this. Strict rules will apply on the transfer of assets to others prior to assessment. This could cause problems for people.

The valuation will be signed off by a professional valuer appointed by the HSE. In any dealings in which I was involved or about which I have heard, two valuations are done by valuers agreed by both parties and the middle value is taken. The Bill does not contain proper protection for the individual. The HSE will have a contract with a single valuing agency in an area and it will automatically create a conflict of interest. The person, group or company holding the contract naturally will be inclined to be favourable to the HSE given that the HSE is its client. This is not a reflection on anyone, it is a reality of life. We should have a minimum of two valuations. No provision is made for an independent valuation by the individual if he or she is not happy. This is another weakness of the Bill.

The only standards which apply at present are the 1993 regulations and they only apply to private nursing homes. We need a full set of updated regulations prior to the introduction of the Bill. We need to be assured that whoever the regulator is, and I presume it will be HIQA, it will have sufficient staff to carry out inspections. The other problem we have with HIQA is that it has no teeth. It can inspect a hospital, tell it what is wrong, demand and admonish but that is all. It cannot censure. The hospital faces no consequences. It can say, "sorry, see you next year" and nothing changes. This needs to be addressed urgently whether or not it requires different legislation. It does not apply to nursing homes only but to all health facilities. I mentioned the conflict of interest arising from the HSE as purchaser and regulator. This needs to be examined.

I am extremely concerned about the medical assessment, which is to be carried out by a separate team appointed by the HSE. This returns to the point I made with regard to the health authorities in the UK. Will the health assessment be coloured by availability? It should be independent. Will the Minister address the issue of a patient in hospital assessed by his or her medical team as fit for discharge but who has not been assessed by the assessment team? This situation will arise and it is not provided for in the Bill. The health assessment team will be extremely busy and will find it cannot get to patients for one, two, three, four or five weeks. This will be through no fault of the patient but he or she will have to pay for the hospital bed. Given previous experience of this type of body and assessment, it is most improbable that the assessment will be back within 24 hours. The Bill states it will be within four weeks. Somebody could clock up a bill for three months in a hospital as a consequence of this and through no fault of their own face additional expense.

I would like the Minister to address a host of other issues. I know she cannot do so today but she can come back to us during the course of this debate and on Committee Stage. There is no provision for children over 21 years of age unless they are in receipt of welfare benefit equivalent to the State pension.

The Bill also includes the provision that recipients must be "ordinarily resident in the State". What is the position of elderly members of the diaspora in the United Kingdom and United States who wish to return home in their latter years? Are they entitled to benefit from the scheme or are they excluded under the definition "ordinarily resident in the State" because they may have spent the majority of their working life abroad?

The Bill provides that where co-payment is not made, ancillary payment ceases. This will not normally be an issue. However, what about cases of hardship or other unusual circumstances? Why can co-payment not also be taken as a mortgage lien on assets in such circumstances?

What are the Minister's reasons for excluding foreign property from the list of assets? Will we have a situation where persons with a share in a second house in the State will see the value of that asset driven down year on year, but the same will not apply for those with a holiday home in Portugal or Spain? There are many people with second homes and investments abroad.

In the event of a resident dying in a nursing home, a relative must make an application within three months to be allowed to remain in the family home. This leaves all the onus on the relative to make the necessary arrangements with a short timeframe. There should be a provision whereby the Health Service Executive or the solicitor administering the will must inform the relative of the need to make this application. Many of the relatives concerned will also be elderly and some may not deal well with legislation, forms and other vehicles of authority. If such persons do not apply within the three-month timeframe, whether through lack of ability to interact or lack of knowledge and awareness, will they be put out on the street? The timeframe should be extended to at least six months and there must be provision to make some designated person responsible for ensuring the relative remaining in the house is aware of this condition and who will act to help him or her.

The Minister referred to care representatives. However, I see no mention of grandparents who may be in this position, particularly in the case of chronic brain injury.

The provision for 15 days' notice after which financial support will cease is another issue of concern. At least a month's notice should be given so that families can make alternative arrangements where the Health Service Executive intends to withdraw financial support.

The Bill provides that moneys reimbursed shall return to the Central Fund. Does this refer to the Exchequer, in which case the moneys will be for general use, or does it refer to the overall health budget or to a ring-fenced fund for the long-term nursing home care needs of the elderly? This must be clarified. My own view is that these moneys should be ring-fenced for the purpose of the provision of long-term nursing care.

In regard to the leveraging of mortgages on assets for the amount due to the Health Service Executive, will these be the same as a revenue mortgage and what will the implications be for businesses in terms of who has first call on the asset? Will it be the first or second charge? There are many examples of people living above the sweet shop with their mother. Where that mother is in a nursing home, the property value will be assessed and a 5% annual charge levied. Will this impede the child if he or she wishes to borrow money to modernise the shop? That issue must be examined.

The Bill provides that support is index linked to the consumer price index, CPI. I am concerned that this may be inadequate given that the CPI has never kept pace with medical inflation. More latitude is required in this regard.

What happens when a dispute arises with the nursing home? Although the Health Information and Quality Authority, HIQA, now has responsibility for monitoring standards in nursing homes, people remember with concern the Leas Cross case. What if there is a breach of trust and a breakdown in relations between the nursing home staff and the patient and his or her family? How easy will it be for patients to move to another facility? Will they effectively be locked into a particular nursing home?

We need more detail on the moneys provided for the scheme. The estimated cost to the Exchequer is €820 million, with an immediate cash flow cost of €103 million from deferred payments. However, the Minister has allocated only €55 million in the budget. This is a cause of concern.

My greatest concern relates to the rights of siblings. Many elderly siblings have lived together all their lives, while others return home to live with a sibling after being abroad for a long period. However, there is no provision in this Bill for such persons.

Section 53A of the Health Act 1970, as inserted by section 33(3) of this Bill states:

This section applies where in-patient services (not being long-term residential care services within the meaning of the Nursing Homes Support Scheme Act 2008) are provided to a person in a hospital for the care and treatment of patients with acute ailments (including any psychiatric ailment) and a medical practitioner designated by the Health Service Executive has certified in writing that the person in receipt of such services does not require medically acute care and treatment in respect of any such ailment.

Age Action Ireland and others have expressed concern that this arrangement may be open to abuse or misapplication in that there is no definition of acute care. As a result, one doctor may take social need into consideration while another may not, resulting in an inequity of charges.

The availability of community services is taken into consideration as part of the needs assessment, and availability should be a consideration when deciding whether to discharge a person from acute care. A study by Coughlan and O'Neill in 2001 found that almost one quarter of those requiring long-term care died in hospital awaiting placement. The report suggests that a medical practitioner designated by the Health Service Executive should make the decision that the acute care phase of a person's treatment is completed and that he or she is ready to be discharged. It is a question of independence of assessment. This decision should be made by the multidisciplinary teams. The Minister is a fan of these teams, so she should have no difficulty with that.

Another issue to which Age Action Ireland has alerted me is the possibility that a person may be double charged during his or her lifetime under the provisions of the Bill. For example, a woman whose husband was in long-term nursing home care and who dies in hospital may decide to downsize to a smaller home, in which case she will pay a 7.5% charge when she sells the jointly owned property. If she herself requires nursing home care some time later, her estate will be subject to a deferred 15% charge on her home. Couples should not be charged twice in the lifetime of either spouse but it is not clear whether this protection is contained in the Bill. It is often the case following the death of a spouse that the remaining spouse will downsize from a four-bedroom house, for example, to a two-bedroom apartment. People do so for many reasons, including security.

An extraordinary aspect of the memorandum accompanying this Bill is that in all nine examples, there is no mention of children. Clearly, children will not be catered for in the Bill. It is not uncommon for people in their 50s to take early retirement to look after a frail 72 year old mother or father only to find, God being good, that the latter lives into his or her 90s. The parent having gone into a nursing home at the age of 89, the child, now in his or her 70s, is faced with a charge for 15% of the value of the family home. That is grossly inequitable and unjust, and pays scant regard to the commitment of that daughter or son in taking care of their parent, and saving the State considerable sums of money by so doing. That is not addressed in the Bill. It is a glaring defect that will have to be addressed.

Nobody on this side of the House, at least in the Fine Gael Party, has an issue with trying to address the current, clearly unsustainable situation. However, we do not wish to discover, as we so often have previously, that a perfectly good concept in principle turns into a mire and nightmare for people in practice. I do not wish to introduce an adversarial tone to the debate but we must be mindful of what happened with the HSE. We cannot allow that type of mess to be inflicted on people.

I look forward to discussing the Bill on Committee Stage and I hope the Minister will allow us to suggest amendments. I also hope she will come forward with suitable solutions to address the issue of children and of siblings living together, of which there are many examples, the concerns of those who live on small holdings and who have perhaps farmed them all their lives, for example, two brothers and a sister, which is not uncommon, and the situation of the small shop or small business where the family home is an integral part of the building.

This legislation will be welcomed by people who have been struggling to pay nursing home bills they simply cannot afford. There are many families who have been looking forward to this legislation for a long time. However, the Labour Party has serious concerns about the legislation on a number of fronts and I propose to outline those concerns.

There is no doubt that the current situation cannot be sustained and in that regard we support the Government. However, there are aspects of the Bill that we cannot support. It is true that people who happen to live in different parts of the country or happen to be in a private rather than public nursing home are being treated differently in terms of the amount of money they must pay, even though they are in the same economic circumstances and have the same health needs. Clearly, that is unsustainable and wrong. In that regard, the Bill will improve their situation. It will alleviate the worry, concern and fear in many families.

However, this is not the legislation we were expecting after the fair deal was first announced. It still contains the elements the Labour Party signalled its concern about some time ago. Our concerns are based mainly on four aspects of the Bill. I will summarise them before discussing them in detail. The first is the removal of people's automatic right to universal health care under the Health Act 1970. Basically, people who need long-term residential care will be treated differently from the rest of the population, and most of those people will be senior citizens. The Irish Senior Citizens' Parliament and Age Action Ireland have strongly indicated their concerns in that regard. The Minister said today that this only represents one in 20 of the population. Why should that one person in 20 be treated differently from everybody else?

Age Action Ireland put the argument well when it stated that the legislation sounds the death knell of the public bed for those who need a residential nursing home bed, and that it also means the introduction, for the first time in the Irish health service, of a charge beyond the grave for essential health care services. The organisation went on to state that if this legislation is passed, it will mean that those who have conditions such as dementia and stroke will be treated differently from those who have heart attacks and cancer. We must be concerned when legislation such as this is introduced because we are, in effect, treating different elderly people differently, depending on the condition from which they suffer. The Labour Party is committed to a universal system of health care whereby everybody is treated the same irrespective of income and age. That is our first major concern about this legislation.

The second concern relates to the family home. We considered the original proposals unconstitutional because they involved the family home in the payment for long-term care. The Minister has been quite clever in this legislation in that people will be allowed to choose not to take the option of payment after the grave. However, if one does not take that option, one must come up with the money anyway. It is something of a Hobson's choice and it still means families will have to include up to 15% of the value of the family home in terms of how they are assessed for long-term care. Again, the Labour Party has a principled objection to this which I will discuss in more detail later. I will also raise questions similar to those raised by Deputy Reilly with regard to members of a family who do not fulfil the quite strict criteria outlined in page 25 of the Bill regarding the type of families that can have a deferred payment.

The third concern is the issue of the scheme being resource capped. This is a serious concern. It means, as the Minister said, that the person has an eligibility rather than an entitlement. In other words, if the money is not available, one does not get the service. This is a matter the Labour Party raised when the Disability Bill and the Education for Persons with Special Educational Needs Bill were going through the Oireachtas. It has been proved with both those legislative measures that if money is tight, the service need not be provided. That is not good enough for our senior citizens and future senior citizens.

In that context, I am particularly concerned for the future because it has been estimated that there will be more than 800,000 people over the age of 65 by 2025. Obviously, not all those people will require nursing home care; the percentages will probably be somewhat similar to the current ones. In fact, I hope they will be less because by that time I hope a great deal more money will have been put into providing care in the community and allowing people to stay in their homes. So far, however, there is no evidence of that when one sees the cutbacks in home help hours. There is no evidence that money is being put where the Minister's mouth is, if I may say so, in terms of transferring resources to community care.

According to an article in the Health Plus section of The Irish Times, there is an estimate from the Bank of Ireland, of all places, suggesting that 10,000 new nursing home beds will have to become available over the next ten years, at an average cost of €100,000 per bed. There is, therefore, a projected large increase in the population that is likely to need long-term residential care. If the scheme is resource capped, how will we fund this? I urge the Minister to address this issue. While people might think it a good idea that they will only have to pay 80% of their income and resources to have the security of long-term care, by providing for the scheme to be resource capped, that will not be the case and many families might be squeezed out simply because the HSE runs out of money. That is a serious concern for the Labour Party.

The fourth concern is about the assessments. It is not clear from the Bill who will qualify and who will not. Age Action Ireland has also raised this point. The section on assessment is quite woolly as to how one does or does not qualify. At present, a large percentage of people in nursing homes are assessed as being medium or low dependency. I do not know if people in that category will qualify under the proposed assessment provisions. If they do qualify, will there be places for them? If they do not qualify and cannot afford to pay for care and if they do not have the supports they require in the community, what will happen to them? It seems from reading the legislation that one would have to be deemed very dependent in any assessment to qualify. There are issues with the assessment, such as the way the money is calculated, on which I will elaborate later. I wish to make clear at this stage that the Labour Party is not disposed to support the legislation on these grounds. If we can substantially amend the legislation and address these other issues our position may change, but we are not in a position to support it as it stands. I am aware the Minister will have an opportunity to reply at the end of Second Stage and I will listen carefully to her comments.

There are several other issues I wish to raise including the matter of consultation. I referred to Age Action Ireland and the Irish Senior Citizens Parliament, but there are several other bodies with concerns about the legislation. When the legislation was delayed last January, we were told the reason was to allow for consultation. However these groups told us they were not consulted. It was then further delayed for a variety of legal reasons and it is finally before the House today. The Bill is not long published. We received a very detailed submission from Age Action Ireland with which we will inform ourselves. It is important that these bodies, especially the two national organisations which represent several other affiliated organisations, have their voices heard before any final decision is made on the legislation. I presume these groups can attend on Committee Stage and I will raise this matter at the Joint Committee on Health and Children, but it is very important these organisations are heard.

The Health Information and Quality Authority, HIQA, is working on the matter of standards and I assume these will be published before the end of this year. It is important they are in place alongside the legislation to ensure a level playing field for all nursing homes. If a family is deciding on a nursing home for a loved one, they must be satisfied that it fulfils all standards including quality of care, cleanliness, and other issues of concern. Will the Minister clarify that the standards will be in place? Deputy Reilly remarked on the need for the body charged with the implementation of the standards to have teeth, given the history at Leas Cross Nursing Home and concerns raised about several other nursing homes throughout the country. I recognise the vast majority of nursing homes do a very good job. However, we must ensure those which do not are not permitted to take patients under this legislation. We must ensure the standards are in place.

I raise a concern about patients in acute beds, as it is not clear how this matter will be addressed in the legislation. There are many patients in acute hospitals in the country ready for discharge, but who cannot be discharged because there is no place for them. This is because there are no supports in place in the community or there are no places available in either a public or a private nursing home. The legislation seems to indicate that if these people are not moved out of the acute beds within a certain period of time, a charge will apply. It seems such people are treated as if they are in a private nursing home under the legislation. What happens in the case of a person who, through no fault of his or her own, cannot move from an acute bed? Such a person may be there because of a capping of the resources or because he or she cannot afford to pay for private care, but he or she is not there by choice. We all understand it would be a better use of resources if such a person is cared for at the appropriate level. However, if there is no other option to an acute bed, I wish to ensure a charge will not apply under the legislation.

It is not clear from the legislation how palliative care is catered for, and whether it is deemed different from other types of care. There are hospices throughout the country which do a wonderful job. Will the Minister ensure people in palliative care will not be subject to any additional charges, especially in the case of someone in care for an extended period of time?

I return to the four main points of my contribution, including the removal of rights under the Health Act 1970. Age Action Ireland referred to this and I expressed the concern of the Labour Party and its wish to ensure the protection of the right to health care under the Act. The withdrawal of this right amounts to treating senior citizens and others in need of long-term residential care differently from other members of the community, which is wrong. I wish to put down a marker as there is a principle involved and if it is broken with this legislation, it could be broken in other ways also.

It seems the provision of public beds will be overtaken by the provision of private beds under the legislation. There is an increasing number of private nursing homes fulfilling the demand, but there is a very good service in public institutions. Most people, including those in my area, say the level of care in public institutions is very high. There is a more intensive nursing presence in such institutions than in private nursing homes and I do not wish to see this thrown away.

There is an incentive in the legislation to reduce the number of public beds, to make fewer available in future and to depend on the private sector. I am conscious of the Minister's general position in depending on the private sector. The Labour Party fundamentally disagrees with this view, whether in respect of co-located hospitals, home care packages or whatever. The Labour Party is very concerned at the growing use of the private sector in health care. I referred to this yesterday in the debate on the cervical cancer vaccination programme. A sum of €15 million was given to a private company as part of the health repayment scheme. The work involved in sending letters to in excess of 5,000 patients who had X-rays reviewed in the north east was farmed out to a private company. Throughout the health sector there is more and more of a move from public to private service provision, to which the Labour Party fundamentally objects. We wish to ensure that in the nursing home sector public beds of a high quality will continue to be provided for senior citizens.

The matter of assessment is referred to in the document we received from the Library. I thank the library staff for the detailed research done and for the document circulated to all Deputies, which is very useful. Outlining the position on assessment and dependency, the document states that "the Interdepartmental Working Group in 2006, for instance, reported that approximately 30% of residents in long-term care were classified as medium to low dependency". What happens to such people? The document also refers to enhancing tailor-made home and community services. It quotes from a study carried out in 2006, comparing Ireland to the United Kingdom, Finland and the Netherlands. It indicates Ireland has a relatively underdeveloped and poorly co-ordinated community care service, of which we are all aware from dealing with patients in the community. My two Labour Party colleagues from County Kildare, namely, Deputies Jack Wall and Emmet Stagg, have brought to my attention on several occasions the cutbacks in the home help service in that county. The necessary level of resources are not available in the community. I acknowledge that home care packages have helped in some areas, but not others. Serious problems have been caused for patients where home care packages have taken funding from traditional home help services.

Will the Minister ensure there will be services for those who are considered of a low enough dependency that they can be catered for in the community? Otherwise, those people will be caught in the middle of this. They will not be dependent enough to qualify under this Bill, and there may not be the full service in the community that they need. The Minister has often had good ideas for the health sector, and I have supported some of them, including her wish to transfer patients from acute care to community care where possible. The reality is that the resources are not always there. When people are in the community and are assessed to be suitable for care in the community, the resources should be there for them.

I had a query about the way in which the family home is treated in the Bill. The Labour Party made clear its serious concern about including the family home in obtaining payment for this. The Minister has cleverly got around the legal issue by making it voluntary, but in effect, it is not voluntary because if a person does not have the money, then he or she will have to take this option. For up to 15% of the cost of the family home, payment can be deferred until after the death of the person concerned. It can be deferred further if the person is in a certain category outlined clearly in the Bill. The Bill lists the following people who qualify — a child of the person in respect of whom payment of ancillary State support was made, when such a child is less than 21 years; a relative of a person in respect of whom the payment of ancillary State support was made, and who is in receipt of different types of pensions and so on, and whose total income is not more than the maximum income of State pension; and other similar cases.

The query I received was from a man who lives with his elderly mother, and the letter states:

I really do not know my position vis-à-vis my elderly mother of 93 years, and would be grateful if you could enlighten me. I noted your name and comments recently concerning the fair deal nursing homes. I am a man of 59 years, living with my mother, having a joint ownership in the family home, my only home and property. Could you please inform me in simple terms my position, should my mother require nursing home care? She is in receipt of a State pension. Must the levy of 5% be incurred? I really do not know. I am a divorced man, having no interest in any other property. Any assistance or direction welcome.

That man does not have any protection under this Bill as I read it. When his mother dies — I assume she will die before him, as she is 93 and he is 59 — what happens to this man and his home?

He is protected under the Bill.

He is not under the age limit. He does not tell me his income, but if I assume his income is above the level——

He is the joint owner of the property.

——specified in the Bill, he will be liable for the repayment as I understand it.

He will not be liable when he transfers the property on.

What does that mean?

It means that the property is passed on to the next level.

That is farcical.

That is far from clear. If he is the joint owner of the property, perhaps he may be protected in some way. However, if the property belonged to his mother and he did not have joint ownership rights, for example if she had a number of sons and daughters and they all had equal rights under the Family Home Protection Act 1976, then it is far from clear what kind of rights he would have. That is of real concern. We have always said in this country that the family home is exempt from any kind of pressure when it comes to paying for services. It is ironic that foreign-owned property may not have a role in this at all, yet the family home is to be brought into the equation.

It is clear, from the mathematics done on this by my colleague, Deputy Tuffy, that a person with a mid-sized home and income will be paying for this, while the person at the bottom of the pile will be paying even more. In that sense, we are transferring resources from people who have less money to people who have more. We have very serious concerns about that.

The IFA and other farming organisations are particularly concerned that there is no cap on land. The 15% cap on the family home does not apply to land. The farm must be transferred five years before the death of the person concerned, and this is causing very serious concerns about the family farm and the viability of handing on the farm from one generation to the next. I hope the Minister addresses that issue, which was brought to my attention by Deputy Sherlock.

The Labour Party is not happy with a wide variety of issues in this Bill. We can address them by tabling amendments, and many of those amendments will relate to issues raised in the submission by Age Action Ireland and the questions raised by the Irish Senior Citizens Parliament. These issues are related to equality and fairness and are of concern to people in that age category. We had the potential to bring in a fair Bill that would address the concerns of families that are currently paying money that they cannot afford to nursing homes. We all felt it was a good idea to bring in a Bill that would address those difficulties, but this Bill does not address the four core issues identified by the Labour Party.

The first of these issues is the removal of rights under the Health Acts of the 1970s, which treat all people fairly. We should have a universal system of health care that treats all people on the basis of need, not on the basis of ability to pay. The second issue is the fact that for the first time, a means test will be applied to the family home for the provision of care to our elderly citizens. The third issue is related to the fact that the assessment may well leave out a lot of people who have no option but to be in a nursing home. The fourth and possibly the most important issue is the fact that the Bill is resource capped. In other words, whenever we run out of money, health services are slashed. An example of this was the abolition of the universal access to a medical card for the over 70s, which created a huge furore and brought thousands of senior citizens onto the streets of Dublin. While the Minister changed her mind to some extent due to the pressure of public opinion and raised the threshold for qualification, she still removed the principle of a free medical card for all over 70s. Another example was the decision to defer the introduction of the cervical cancer vaccine, for the sake of less than €10 million per annum. There are many other examples across the health service and the economy in general.

The issue of resource capping is not related to some general principle. Resource capping is a real concern because while this legislation may appear to solve problems for many families, in fact, when the money runs out people will be told they cannot have it. People have already experienced cuts in home help hours, physiotherapy and other support services.

We are not happy with this legislation, which is unfair to our senior citizens. I hope we will be able to amend it significantly, but at this point it is likely that the Labour Party will be voting against the Bill on Second Stage, unless we receive reassurances on the issues I have raised when the Minister replies to the debate.

I thought I would never see the day when I would come here to support this legislation in the House. My first encounter with the fair deal was at a meeting before the election at which I got a lot of flak from people about the scheme. At the time I defended it because, having examined it, I felt instinctively that it was a great scheme. My view has been confirmed by my experience as a Deputy since the election. Constituents seeking subventions or subvention increases are anxiously awaiting the introduction of this scheme. The assets and savings of most of them have been almost completely depleted at this stage, whereas they will now qualify for subvention as they have no money left. They want this fair deal to come in as a result of this Bill being passed into law. I am sure members of the public are telling other parties that also, which is why, although they may not be totally in favour of the legislation, the level of opposition is not the same as before.

The Bill presents an opportunity to greatly improve the nursing home system. By adopting a new scheme we can help to fix many of the problems we see daily, as elected representatives. It is great to talk about free public nursing homes but they cannot cater for everybody. In my constituency, St. Joseph's in Trim serves County Meath very well. In addition, St. Mary's in Drogheda, which used to serve part of Meath, now does a good job in serving County Louth. There are plenty of Meath people in it. The reality, however, is that such homes are not available to everyone who wishes to avail of their services and that is where the private sector comes in, although there have been difficulties with it. Some Deputies have done a good job in exposing the problems associated with certain nursing homes. By and large, however, private nursing homes I have visited are of a high standard and provide much needed employment in my constituency. The Minister visited one such extended care facility in Stamullen, County Meath, and was welcomed to the constituency on that occasion. It is a great facility and I know many of those who operate it as well as those who live there.

Our current nursing home system is broken and inconsistent. One cannot advise people with any degree of certainty what subvention they might get. There seems to be a huge discretion among the various HSE areas. I do not accept the contention that this is the first time the family home has been taken into account. Why would we be looking for valuations of family homes as things currently stand, which we regularly have to do? Why do people feel they must sell or transfer the family home, worry about their savings or throw their assets away? Nonetheless, it is happening all the time and causes much stress and strain. At my first clinic this evening after leaving the Dáil, the first person I am due to see is someone whose husband is going into a nursing home. Such homes are very important and have a major impact on the general health service.

Currently, there are 25 patients in Our Lady of Lourdes Hospital in Drogheda who should be in nursing homes. Their families do not want them to stay in hospital, but the cost of private nursing homes coupled with the lack of beds in the public sector — even though we do our best — and the uncertainty over applications are all causes for concern. When people hear the term "nursing home subvention" a lot of fear generated, which can cause delays. If the people in Our Lady of Lourdes Hospital who should be in nursing homes, many of whom I know, can get the financial certainty they need to move into the nursing home system, it would have a dramatic effect on the hospital system in the north east. That system is under pressure at the moment, although the bed managers are doing great work. However, people are there who should be in nursing homes because the hospital cannot do anything more for them. The fair deal will not only have a positive financial impact on families but also on the general health system.

Older people in need of nursing home care face vastly different costs depending on whether they are in the private or public sector. This also applies to their families. In public nursing homes they pay a flat-rate contribution regardless of affordability. In fairness, however, I would have thought most people who could afford private nursing home care are probably not in the public sector. That is my understanding, although I am open to correction. Many older people who choose to go into private nursing homes receive minimal or no financial support from the State, even though prices are rising all the time. Even those who do get help from the State often cannot afford to pay the rest because the subvention only goes so far.

There is also the question of the HSE staff's discretion in this matter. Certain people often give out about HSE staff but I do not. The HSE staff in my constituency who deal with the administration of nursing home subventions are run off their feet, so they deserve credit. The HSE is always slammed for being too fat and perhaps there are people there who, as Professor Drumm said, have nothing to do. However, the ones with whom I deal daily, whether for subvention or home help, are working hard and effectively. They are working within the resources the Government is making available to them, which are not unlimited. I am grateful to the HSE's administrative staff in my area who do great work.

No families want the stress of dealing with subvention, which is an unfair and complicated system. If we can fix the system with this legislation we can make life easier and fairer for nursing home residents and their families. People really require clarity in this regard. By now, we know that the system has to be changed and made fair and understandable. There are approximately 21,200 people in nursing homes and this figure will grow. It may be as a result of the property downturn, but there are quite a number of planning applications for nursing homes in my constituency. One of them was granted recently beside where I live and I welcome that because it will provide good quality employment for nurses, care assistants and administrative staff.

Many people moved to east Meath in their 50s when their families were reared and some of them will require nursing home care, so we must have such facilities for them. I welcome the investment that has been made in that area. In 2036, it is estimated that there will be about 44,000 patients in long-term care. It is often forgotten in the debate on our health services that people are living longer than ever before. The health service must be doing something right therefore although that is never acknowledged.

Last year, the State spent approximately €648 million on long-term care. This year alone it is projected that the Government will spend €1 billion on nursing homes. In 20 years the cost of nursing homes will treble. With this amount of money at stake, it is important to ensure it is spent wisely and goes to help those who need it. We would like to see everyone being entitled to such facilities but there is only so much money in the kitty. The Government's role is to ensure it is spent as wisely and fairly as possible. I welcome the provision in the Estimates for this nursing homes support scheme.

I understand there have been no major changes to the nursing home system in the past 40 years. The Health Act 1970 introduced serious reforms, including the right to free health care, but that is not the reality in the nursing home sector given the available resources. Public nursing homes are doing a great job but they must be supplemented by the private sector. It is more efficient for the State to do that. The public and private sectors will be treated equally under the terms of this legislation, so it is as good a deal as one could imagine without significantly increasing the tax burden to pay for it.

When passed, the Bill will ensure that all nursing home patients and their families are given a fair deal. The system will ensure that everyone's contribution will be fair, because it can be unaffordable at present. I have seen cases where, in addition to the subvention, people have to make up €300 or €400 per week on top of their parent's income, which is usually a State pension and savings. It is a difficult burden for families to bear. It involves a lot of money every week when such families are already under severe financial pressure, which is getting worse due to the downturn nationally and internationally. Under the new scheme people will only have to pay what they can afford and this is very important. People I have spoken to about the 5% to 15% annual claw-back, I do not know the official term for it, seem to be quite happy about it. I explain to people that 15% is the maximum. There are variations, such as when both members of a couple go into care. Deputy Jan O'Sullivan's query raises what appears to be a difficult situation but it seems to be covered by section 20 of the Bill, as the Minister said in her speech. We all know cases like this and they can be discussed on Committee Stage; I am sure the Minister will be open to suggested improvements to the legislation.

People will not be forced to sell their homes to pay for care under this Bill, contrary to what has been said during this debate. People are stressed and worried at the moment and many are having their family homes valued. Many old people are currently forced to sell their homes to pay for care because they only receive a certain amount of subvention. I know a constituent whose savings are running out and who is considering this option but I told him to hang on until this deal comes in. The sooner it does, the better for all. The new Bill will ensure people will not be forced to sell their homes.

Moving into a nursing home is a difficult transition for old people and they do not need the extra stress of selling their houses. Their families do not need this stress either, as it is they who usually bear the burden. This matter affects not only old people but young people too. The Minister visited the Redwood care facility in Stamullen during the summer and there is a mixture of young and old people staying there as people need long-term care for various reasons; they are covered by this Bill and that is important. St. Clare's Nursing Home is also in that area.

It is understandable that concerns about this scheme have been expressed by patients, families and Age Action Ireland. I would have expected Age Action Ireland to suggest areas for improvement. However, some of the reaction to the Bill when it was first announced was over the top and it was not given a fair hearing. It was suggested that people's houses would be taken when the reality for many residents of nursing homes was that day had already passed. It is important we ensure that people understand how the new scheme will affect them. In fairness to the Department of Health and Children, much of the documentation that was issued was very clear and self-explanatory. People understood this documentation and the concepts of 80% and 5% per annum. Technical areas cover all of the individual cases and can explain them.

Costs will go down significantly for patients and, more importantly, for families. Nobody will ever be asked to pay more than the actual cost of the care received and, for those currently receiving subventions, in most cases they will go up under the new plan. It is extremely important that the State gives all nursing home patients a fair deal and the new scheme is fair and consistent. The Nursing Homes Support Scheme Bill will ensure no pensioners in need of nursing home care will be forced to sell their homes. Passing this law will ensure that nursing home patients in Ireland are given the best care and a fair deal. The HSE has concerns about standards in some of its centres and much work must be done in this regard.

It should be noted that various studies over many years have examined how we pay for nursing home care. This issue has been debated for many years and the Library and Research Service has produced a fantastic digest for the Nursing Homes Support Scheme Bill. This has been of use to me and could be of use to Deputies across the House. There is an interesting discussion in that paper of the various approaches that have been looked at over the years and could be adopted to fund nursing home care. Various reports, including the Mercer report and that of the inter-departmental group, looked at taxation, higher pay related social insurance, PRSI, and earmark taxation, like another health levy. Estate taxes seem logical but it was felt they would not attract sufficient broad support. The scheme we have today is the equivalent of an estate tax, but it is fair and not simply a charge of the full costs of nursing home care. In many cases the charge will be a significant fraction of the full cost and I think we have achieved a good balance.

I welcome the Bill and the opportunity to speak on it. I look forward to the Minister and Ministers of State, including the Minister of State at the Department of Health and Children, Deputy Barry Andrews, working hard to pass it as soon as possible, get the scheme up and running and give security to patients and families alike.

I presume this proposal is intended to substitute for the subvention scheme and will not run in parallel with it, because this has not been made clear. Is this the case?

Is the Deputy proposing that I answer now?

It is in substitution for the subvention scheme.

Deputy James Reilly laid out the Fine Gael position on this. There are many good things in this Bill; the principle is good and the scheme proposed is better than the existing one. However, I also believe there are major flaws in the scheme and many of them have already been pointed out by Deputies James Reilly and Jan O'Sullivan.

I have personal experience of matters related to the Bill; a close member of my family is in a nursing home. I draw attention to this fact because I wish to make it clear that I have no financial interest in either the existing scheme or the proposed new scheme. My family does not benefit from subventions and will certainly not benefit from the new scheme. In case there is any speculation about my personal position, my contribution is an attempt to improve the Minister's approach and I am not advocating a scheme that will serve my family's needs.

The current position is inequitable and the subvention scheme applies unfairly. People on exactly the same level of income get different levels of subvention, depending on the institution in which they reside. By and large those fortunate enough to be in a public nursing home will pay less than those in private nursing homes, despite the fact they may be in the same circumstances with the same need of long-term care. They could have the same income yet there could be a huge variation and that is unfair and must be corrected.

Relatives of residents of private nursing homes are severely penalised under the current scheme. The subvention goes some way to meeting the cost of a nursing home but, as it is means tested, in many cases sons and daughters, who already have many financial demands due to their family commitments, must make up the balance. This is a serious imposition that the new scheme will do away with and when it replaces the existing scheme there will no longer be a call on the cash of family members. As other members said, the family home will not have to be sold to pay nursing home fees, though there will be a charge on it. This is all of benefit.

The principle begins to fall down in the area of practical application, however. This is where questions arise and we have not received satisfactory answers yet. In a Dáil question yesterday I asked the Minister what was paid out by her Department in subventions in 2007 and she kindly answered €205 million. She expects an additional €12 million to be paid out in 2008. Her first shot at a budget for the new scheme is €55 million. The current scheme cost €205 million in 2007 and the new scheme's budget is €55 million. How can the new scheme be substantially better than the old one if it costs around €150 million less? There is a problem there. Obviously, if there are deferred payments, these would make up the balance. What worries us on this side of the House is that not all those in nursing homes who are in receipt of subventions at present would qualify under the new scheme. That is key, and must be answered.

The interdepartmental committee which considered this issue when the Bill was being prepared in 2006 stated that 30% of patients in nursing homes are at a medium or lower level of dependency and the Irish private nursing homes association state that 12% of their patients are at low levels of dependency. This Bill is geared for persons who require care because they have high dependency. Therefore, on the face of it and working on the interdepartmental, Civil Service figures, the opening position is that 30% of existing patients would not qualify. What mechanism does the Department have to cover this 30% of people? They will no longer have a subvention and, in fairness, they cannot be put out in the road, so how does it work out? At the same time, the funding does not seem to be going in. Some €55 million is going in but this is in contrast to a current figure of in excess of €200 million. While there will be a loans system, ancillary support and deferred payments to be got back in the future, when one considers the profile of who is in nursing homes at present, it does not make sense.

The second issue I wish to raise is the assessment of needs. This Bill will apply to persons who are assessed to be in need of long-term care. A number of factors can be taken into account in this assessment, for example, cognitive ability, the extent of orientation, the degree of mobility, the ability to dress unaided, the ability to feed unaided, the ability to communicate, the ability to bathe unaided and the degree of continence of the person, and there are also other factors to do with social dependency and support from families and so on. This would be the normal way to assess dependency.

The first problem is that no scale is applied to any of these elements of the assessment. I listed eight elements and there are other general elements. If, for example, we gave ten points to each of the eight elements and applied 20 points to the general elements, making a total of 100 points, at what point would one qualify? Is it past point 60, 70, 80 or 20? This is not addressed in the Bill so there is a serious flaw in the assessment. It is not enough to say the Department of Health and Children or the HSE will look after that issue and that we will apply a scheme which will be fair — that is no longer the way the world works. There is a low enough level of trust in the HSE. If this is not spelled out in detail, if a weighting is not given to the different elements of the assessment and if it is not stated clearly at what point somebody will qualify, then this will not run. That is a serious matter.

The biggest problem in this section is that the Minister makes it very clear this a resource-capped scheme. Department of Health and Children schemes like the drugs refund scheme, medical cards schemes and so on are all demand-led. If there was ever a demand-led scheme, this is one. If one's mother has Alzheimer's and needs to go to a nursing home, she is entitled to the nursing home place as soon as she is assessed as needing it because she can no longer be looked after at home. However, if it is a resource-led scheme, there will be a waiting list for nursing homes of persons assessed as having very high levels of dependency who are absolutely in need of care.

This will not run, including legally. If the Minister was present, I would ask her to go back to the Attorney General. I believe it will pan out that somebody will take a case and this will be found to be unconstitutional. If a scheme is set up to assess high levels of dependency, and if the consequence of being assessed as having a high level of dependency is that one is entitled to support from the State for one's stay in a nursing home, and a Minister then says that although there are 20 vacant beds in the neighbourhood nursing home, the money is not available this year because it is a resource-capped scheme and so the person cannot go into the nursing home, there is a case in law for that person. This is particularly so if the State has already helped that person's neighbours to go to the nursing home, and others in similar circumstances, because everybody must be equal before the law in situations such as this. The HSE as the agent of State cannot be arbitrary in an assessment — it cannot choose one over the other. People in similar circumstances must be treated similarly, which is fundamental in law.

There is a serious problem here. I can see what the Department is trying to do — it is trying to cap the costs of this scheme. However, in what is essentially a demand-led scheme, the costs cannot be capped by artificially turning it into a resource-capped scheme. The Minister has gone to the trouble of writing in a section to state it will be resource-capped scheme. I do not believe it will work, so there is a serious problem.

The definition of a couple in the Bill will also give difficulty because that definition is based on sexual relationships. One is either married, a heterosexual couple living as a married couple or a gay couple living as a married couple, but what about two sisters or a sister and a brother living together? This has consequences for disposal when there is an assessment against the family home. When the person in the nursing home dies and the HSE, with the help of the Revenue Commissioners, go in to recover the 7.5% of the value of the home, plus a consumer price index add-on, what is the position of the second sister? It is quite common across the country that a sister or brother would own the home and another sister or brother would live with him or her. Why, unless someone was deliberately trying to make political mischief, would one define a couple in terms of sexual relationships rather than in terms of cohabitation, which one would have thought would be the way to deal with an issue concerning a home? This should be reconsidered because it has consequences, particularly when the loan, if I can call it that, must be collected subsequently.

The financial assessment is also curious. All net income is taken into account, which is fair enough. There is a write-off on assets of €72,000 for a couple and €36,000 for a single person. A couple could have €100,000 in savings and €72,000 would be written off, with the couple imputed to have savings of €28,000, which is €14,000 each. Some 5% of the €14,000 would be taken as income and added on to other income. That is fair enough. However, it is trickier when it comes to the assets because the family home is always included, at least for the first three years of assessment. My understanding is that all other assets at home or abroad, of any kind, are included in the assessment.

It gets very tricky at this point because this does not apply to everybody and is calculated relative to the cost of the nursing home. The level of support will be greater for people in Dublin, where nursing homes are dearer, and less for people down the country, although it depends on the nursing home. A complicated formula is contained in the Schedule but it is not that complicated. In my part of the country and in the counties surrounding Limerick, the average cost would be approximately €800 a week for a nursing home. People I know in a nursing home in Rathgar pay €60,000 a year, which is approximately €1,200 a week, so there are variations between Dublin, Limerick and elsewhere. The interdepartmental committee has supplied figures which give the range, so these are not absolute figures, but €800 a week, or roughly €40,000 a year, is the cost with which I would be familiar.

The Bill states that nobody will pay more than the cost of the nursing home, so nobody would pay more than €800 a week by way of contribution in my area, and the State will make up the balance between the imputed income and the €40,000 a year. I found this difficult to understand when I first read the Bill. We are familiar with means tests, whereby if one qualifies under the means, one gets something. This Bill provides for a reverse means test so that if one qualifies under the means, one makes a contribution. The lower the means an applicant has, the less of a contribution to be made; the higher the means, the more of a contribution to be made. It is a peculiar take on a means test as it decides what contribution a person will make rather than what he or she will get. It is the reverse of what we would be familiar with when we assist people in getting medical cards, subventions and so on.

Under the scheme everyone will pay, even those on the non-contributory old age pension who may currently have free care in a public nursing home. The budget increased the non-contributory pension to €209 per week. With this scheme, there will be a 20% discount on that, which comes to €42, leaving the recipient with €167. In my example of a weekly nursing home fee of €800, the State will come up with the difference between €167 and €800 and pay it directly to the nursing home. Under this Bill, the elderly lady or gentleman whose only income is the non-contributory pension will contribute €167 to their keep. We could have an argument about that. On the other hand, someone with an income of €800 or over will not qualify for any subvention and will have to pay the full nursing home fees.

The means test comes in at fairly low levels of income. Take the example of an individual with an imputed income of €20,000. That is not a large amount but would correspond to the pension of a garda, civil servant, teacher or nurse. Two such pensioners, a couple, would have €40,000 between them when allowing for savings and pensions. If they had a family home worth €500,000, then 5% of its value would be used, €25,000, which is a substantial amount of money. If that is added to the €20,000 then they go over the limit and receive nothing. I presume what will work out in practice is that since they do not have the money to pay, the difference between the €20,000 and the €40,000 becomes the charge on the family home at 7.5% over three years. This will, however, present problems.

When assessments of land values in the cases of farmers are taken into account, one sees how serious the problem gets. Like other property prices land prices went mad over the past several years. Take the example of a modest farm which could be worth up to €5 million. If the 5% calculation is applied to that, the couple in question would have no chance of qualifying under the scheme. All they have is an asset that they can work from which to get an income. There is no income deriving from its value. While it is clear that the 2.5% up to 7.5% charge on the value of the family home can be used as a deferred payment, it is not clear that an assessment of 5% on the value of a family farm can be used in a similar fashion. The imputed income would take such a couple well beyond the limit at which the new ancillary financial support would apply.

I am sure the Department's officials have thought all this out and have answers for it but we do not know them yet. This will have to be explained in the Minister's reply and how it will work in practice.

Another issue that needs to be examined is the tax position. The Minister for Finance in his Budget Statement said he would apply the standard rate of tax to medical rebates and nursing home fees. Form a conversation I had with him recently, I believe he is reconsidering that.

A payment to a private nursing home can be claimed against tax. Whether it is the standard or higher rate, the principle is the same. However, because of the way of assessing income under this scheme, the tax will have a variation on it. If someone pays, say, €400 of the €800 weekly nursing home fee, they are entitled to claim that against tax. Yet as income is assessed as net income, as soon as it is claimed against tax the person's income goes up, which affects the original assessment of income. When one's income goes up, one gets less from the State. When it goes down, one gets more. If the State is notionally providing half of the fees and an individual is providing the other half, he or she will claim it back on tax. However, he or she is no longer entitled to half of it because in the definition of income, the income has risen. The individual concerned will have to pay more tax and is entitled to less from the State. In the case of someone on the marginal rate of tax, one could be getting substantially more, which is a problem.

When it comes to deferred payments after three years, what is the tax position of the repayment? The Department, on behalf of the HSE, is repaying the Revenue an amount of money that was paid for nursing home fees which is claimable against tax. Take the example of the inheritor of a family home with a 7.5% charge on its value plus the CPI on that. Will he or she be able to claim that against income tax as a medical expense? I will return to these issues on Committee Stage.

I wish to share time with Deputy Niall Blaney.

Is that agreed? Agreed.

I welcome the Nursing Homes Support Scheme Bill 2008 and compliment the Minister for Health and Children, Deputy Mary Harney, and her Department for tackling a tricky and sensitive issue. It is a source of great anxiety, not only for the residents of nursing homes but for their relatives as well.

I am glad we have recognised a situation which has been extremely difficult for so many people. The Bill comes up with a practical solution which is innovative, transparent and, most importantly, completely fair. Anyone who has had any dealings with nursing homes, whether they are public or private facilities, is only too painfully aware of the very high costs associated with them, whether they are to the individual resident, their family or to the State. The issue of long-term nursing home care is fraught with heavy financial considerations, including the money which has to be laid out every week.

It also involves intense emotion and trepidation. People have told me that making the decision to admit a father or a mother, a husband or a wife, to a nursing home on a permanent basis was one of the most traumatic events in a lifetime. They tell me they are racked with guilt and remorse, feeling they have let their relatives and themselves down. They think they have condemned a parent or a spouse to an institution which is little more than a departure lounge where people sit and wait until its their turn to exit. Relatives usually feel terrible and inadequate that they were not in a position to look after a loved one in their own home. The nursing home was seen as the last option.

Years ago there was a strong tradition where elderly people were able to remain in their own home or they could move in with a son or a daughter who were only too willing to look after their every need until the end. Regrettably, we have seen a marked trend away from this pattern in recent years. It is due, in large measure, to lifestyle changes, financial demands and social conditions. As nearly every member of a household is in work, they cannot take on the added responsibility of looking after an elderly or infirm relative.

Approximately 22,750 people live in long-term residential care, either in public or private nursing homes. That represents about 5% of the over-65s population, or one in 20 people. Due to demographic factors and our high-age dependency, it is estimated that by 2036, 44,000 people will be in long-term nursing home care. The State foots the bill for two thirds of the care costs, or approximately €790 million per annum. The projected cost to the State — that is, the taxpayer — for this year is more than €1 billion. According to a survey published earlier this year by the organisation representing voluntary and private nursing homes, the weekly cost of private nursing home care can be €1,330, or almost €69,000 per annum. The average weekly cost of care in 2006 was €778. That sort of money, without subvention, would kill Samson. Not everyone has the resources to defray the full amount of these fees. The HSE reckons that private nursing home care can cost an average of €50,000 per annum and, according to the HSE, a bed in a public nursing home costs around €1,700 per week. Of course, the taxpayer bears about 90% of that charge.

At present, the State is spending €790 million to subsidise nursing home care and about half of all payments to nursing homes are in the form of subventions from the HSE. Residents in private nursing homes are means-tested and they carry approximately 60% of these care costs themselves. Where appropriate, the taxpayer subsidises the cost of this care by way of subventions from the HSE. The private and voluntary nursing home sector accounts for around 65% of all long-term places and it accommodates 18,883 residents at present. In contrast, the figure for beds in public nursing homes stands at 9,675.

It is clear that the system as it operates at present is wholly inconsistent and irrational. On the face of it, it appears to be unfair and complicated and to have little or no equitable basis. The State subvention scheme can often be inconsistent and is sometimes very arbitrary indeed. There does not appear to be much logic inherent in the current arrangements for public and private residents. The support system is blatantly unfair and unpredictable. It is ridiculous and unacceptable that there should be such a glaring difference between the public and private costs. As I understand it, the existing system for residents of public nursing homes is such that their contributions towards the costs of their care are based on a flat rate and are irrespective of their means. In contrast, State support for people who are resident in private nursing homes is means-tested. It is of course the case that many private residents receive no State support whatsoever. The existing system means that people on the same incomes can end up with vastly different care costs, which is not tenable. There is no sense to it and, in principle or in practice, it cannot be sustained in the long term.

This new scheme is entirely voluntary and nobody will be put at a disadvantage in any way. For those who wish to apply to avail of the scheme, the new proposals in this Bill confirm that from hereon all nursing home care needs will be assessed in a uniform manner by the HSE and everyone's financial circumstances will be calculated in exactly the same way. Everyone will benefit from financial support from the State if that is necessary. Furthermore, there will be an objective assessment of a person's particular medical requirements and, in a welcome departure, his or her social context, in order to see if the necessary support mechanisms can be achieved while allowing the person to remain in his or her own home and community. For many people, the nursing home option may not be ideal and it may be preferable to continue to live at home provided the necessary care and support is available locally. Under the new scheme, everyone who has assets such as savings, stocks and shares, land or property worth more than €36,000 will have to pay 5% of the value of these assets on an annual basis and for every year of his or her care in a nursing home. Naturally, the principal residence will be excluded from this assessment. Where there is a shortfall and where the individual has qualified for ancillary support, the State will pay the deficit for the duration of the person's stay in the nursing home and it will then be able to recoup that money by placing a fixed charge on the house.

As I said earlier, for all those confronted with the decision on whether to go into a nursing home or whether to consign a relative to long-term nursing home care, this matter is very distressing and the decision process is often riddled with agonising soul-searching. It is a momentous decision for anyone and, naturally, the major expense involved is a significant worry. For those faced with private nursing home care, the ongoing costs can be horrendous and are often very difficult to meet in the longer term. We are all familiar with cases in which the costs are such that the cash runs out. I for one have witnessed people being forced to sell land or other property to pay for their care. Circumstances are even more stark when one member of a couple is in a private nursing home while the other remains in the family residence. For many people there has been no choice but to sell the family home, with both members of the couple then having to reside in the nursing home. There is no doubt that such costs have placed an enormous financial burden on ordinary people and their families and the pressure is often hard to withstand. Elderly people can be vulnerable and fragile, and the escalating costs of nursing home care have placed a huge worry on them.

It is my firm belief that all those who can afford to make a contribution towards their nursing home costs should do so and it is only fair that everyone's assets and means should be assessed in accordance with common criteria to ascertain exactly how much they can reasonably afford to pay. I fully support the idea of attaching a charge to the home, and allowing that charge to be recouped from the person's estate after his or her death is a very sensible measure. Many people do not realise until they are actually in the nursing home for some time — maybe longer than they had expected — that the ongoing expenses can be astronomical. It is only when they are in the nursing home, perhaps with diminishing faculties, that they begin to experience real financial hardship. For anybody, young or old, this is a terrible torment and it must be awful to contemplate selling the family home as a last resort when the money begins to dry up. For very many people, there is no alternative.

The new proposal should give great peace of mind and reassurance to many people. They can now be comfortable in the knowledge that the family home will remain intact until after their deaths or until the estate of the surviving member of a couple is settled. From now on the State, rather than the family, will assume the task of managing the rising costs of nursing home care and will be charged with negotiating the most competitive rates with the various nursing homes. In effect, participating nursing homes will enter into a contract with the State, thereby ensuring that costs are predictable and are managed adequately. This is in everybody's interests.

The proposition essentially means that people will not be forced to come up with the necessary cash on a weekly or monthly basis. Instead, the State will move to meet the shortfall and can subsequently claim up to 5% of the value of the house every year up to a maximum ceiling of three years. Thus, the greatest proportion of the value of the house that can be secured by the State will be 15%. This is a fair and reasonable deal for everyone. Everybody will be expected to contribute according to his or her individual means and assets, no more and no less. New entrants to the scheme will be obliged to pay up to a percentage of their annual income towards the cost of their care, regardless of whether they go into a public or a private nursing home. The amount will always be less than their disposable income. If that proportion of a person's income is not sufficient to meet all costs, the State will fill the breach and pay the remainder. Overall, it is expected that the State will continue to meet two thirds of the costs of long-term care.

The current annual cost to the Exchequer of subsidising nursing home care is €790 million. The expected cost of this new scheme will be in the region of €920 million in its first year of operation and it will be accessible to everyone in need of long-term residential care, irrespective of age. The proposed legislation will alleviate much of the hardship and stress which has been visited on people and their families over the years. The need to come up with regular cash contributions will be eliminated and nobody will end up in the lamentable position of having to sell off the family home during his or her lifetime. For many people, in a nursing home or otherwise, the family home represents their last bastion of security and the thought of having to dispose of that home can be devastating.

It is important to reiterate that the new system will eliminate the anomalies and the discrepancies that prevail at present. At last, we are presented with a clear and coherent framework which will ensure that long-term care is affordable and accessible to everyone in accordance with his or her ability to pay. It is timely that we address the strain and the difficulties people have experienced as a result of high nursing home costs. Now that we are facing the prospect of ever-increasing numbers requiring long-term nursing home care, we must consider realistically the level of State support available to offset the burden of the charges. We have to take into consideration that State resources are finite in this regard. The new system is imaginative and workable and is one the State can afford. The days when we could afford to hand out money willy-nilly are gone. It is extremely difficult to justify a system which does not treat people equally and appropriately to their means.

The generality of people who are struggling to pay their nursing home expenses have welcomed this initiative. The truth is that nursing home fees have crippled many individuals and families in this country, who have had no choice but to take a place wherever it was available and pay the going rate. The fair deal represents a sound strategy which will usher in a new era for everyone, particularly the elderly, in the 21st century. Those who need financial assistance to defray the cost of their care will get that help from the State and this will ease what has been an intolerable burden on everyone for a long time. I am satisfied to commend the Bill to the House.

I thank my colleague Deputy Aylward for sharing time. It is with great pleasure I speak on the Nursing Homes Support Scheme Bill. There has been much fanfare on the opposite side of the House about this Bill and little evidence of the cross-party support which was on offer yesterday. Here we have a good news story but are still faced with negativity from the usual quarters.

We all have elderly relatives and hope we will not have to consider putting them into nursing home care. However, nobody knows what lies in the future or what disease will hit those for whom we care. Many families cannot provide the care required by their elderly, and some not so elderly, relatives. Not everybody is in a position to enjoy later life in the comfort of their family or family home. Some are struck by ill health and some have nowhere they can call home. Many of these people unfortunately also have financial constraints. All of these issues amount to a serious decision for many unfortunate families. An already difficult situation is often worsened by lack of finance, and this may be even more evident in these times.

As a nation we must look after these people in a coherent, consistent and fair manner. There have been problems in health in this country. We are trying to tease out those problems to ensure those in need of health care are catered for. Moving a relative into a nursing home is a moment dreaded by many, and the decision is often put off for longer than it should be. Many adult children feel it is their duty to return the care they received from their elderly parents, but sometimes they just cannot cope. Therefore I am glad to be associated with this Bill as it provides a way out for many families. Although economic turbulence exists, I am glad this Bill has remained a priority for this Government. This Bill will help ease upset and insecurity for many families and will provide new hope while removing the financial strain for many.

I have often been approached by constituents who are not in a position to pay for private nursing care, and public nursing care is scarce. The State provides 90% support for public nursing home care but only 40% of the cost for private nursing home care. This Bill will eliminate these discrepancies and the older person will be the outright winner. On a positive note, less than one in 20 over-65 year olds will have high dependency, that is approximately 25,000 people at present. The Bill also covers those under 65 needing long term care. This Bill is a fair deal for them. People of the same means around the country face different costs for nursing home care, which is often dependent upon where they live or whether their care providers are private or public. Unfortunately, this often led to families having to sell the family home in order to fund the care of an elderly relative and this caused undue hardship.

Irish people are renowned for the pride they have in their home. The saying "our home is our castle" is very apt in Ireland. Therefore the trauma of having possibly to sell the family home to fund nursing home care is very difficult. This Bill eliminates that worry with the introduction of ancillary State support whereby people will not have to sell their assets, such as their homes, to meet care costs. People will be able to defer contributions payable on Irish land-based assets for the duration of their lifetimes. There has been some scaremongering on this matter of late and it is necessary to put this right. This Bill will prevent people from having to sell assets to pay for care, which is sometimes the case for those in financial need. The HSE will recoup the money it pays through this ancillary State support in the event of the settlement of the person's estate. However, there will be exceptions to this, if there is a spouse or relative who depends on the assets after the death of the person who received the care.

One might argue this Bill was a long time coming but I am glad this Bill was not rushed through without capturing all the issues and addressing them. It is essential we address all issues and ensure fairness and consistency prevails. To qualify as a designated facility, care providers will have to meet stringent standards with a view to ensuring quality care. I again commend the Minister and Ministers of State involved in drawing up this Bill. I commend the Bill to the House and I am pleased finally to see it come to fruition for the betterment of those families most in need of support and care.

I welcome this Bill. It has been a long time coming. Since 2006 we have heard the Minister promising her "fair deal" but it will be late 2009 before we see any real progress with this scheme. In the meantime, many elderly people and their families have spent thousands of euro on nursing home care, and have struggled with the financial burden this has caused.

As daughters and sons, we all want what is best for our parents, grandparents and elderly family members. They have waited a long time for a fair deal on nursing home care. Now that this Bill has come up for debate, we must ensure it is in the very best interests of all our elderly people. They have paid their way and worked through the hard times, supporting this country when it was on its knees. They cared for their young families with little or no support from the State, all the while paying high taxes. They laid the foundation for prosperity and gave this small country a place on the world stage.

When it comes to the time in their lives when, for one reason or another, they can no longer care for themselves or live independently, they must pay to go into a nursing home and live in a strange environment, miles from home. Not only are they forced to pay, they have to give up their savings and, in some cases, even their home and land. These people have always paid their way and never asked for something for nothing. They are at a stage in their lives when they need help and support to live out the rest of their days with pride and dignity. They must be given the best possible care and this cannot and should not be sacrificed because of budget issues.

In my ten years in public life I have been often struck by deep upset and heart-rending anxiety felt by families who make the very hard decision for a loved one to be cared for in a nursing home. No son or daughter wants to see an elderly parent go into a nursing home but they often have no choice in the matter as they not may be in a position to properly care for their mother or father full time. When the time comes, we naturally want the best and highest standard of accommodation.

Therefore, we expect no less from the Minister for Health and Children and the Government than to implement an accessible and high quality care package and to show true respect for our elderly population. It would be nice to have a free nursing-home care package for all. It would be a small repayment for the years of service they have given to society. However, we all live in the real world and we know this is not possible. Some contribution must be made if the scheme is to work, but this must be done fairly with no unnecessary burden being placed on families.

Up to now, the scheme has had many flaws. It was difficult to get a nursing home subvention due to strict criteria and means tests. That is why I sincerely hope the new fair deal will improve the situation for our elderly population. I have read and studied the Bill to the best of my ability. I agree with some, but not all, of the measures being introduced in the legislation. I accept that people must contribute to the cost of nursing home care, but I question the requirement on patients to devote 80% of their weekly accessible income to paying for such care. They will also have to make annual payments equating to between 5% and 15% of the value of their assets, including family homes. This is excessive, especially in the case of elderly people who save a small amount every week with the intention of leaving it to their children or grandchildren after they have passed on.

My elderly next-door neighbour is in great health at the moment. When I was talking to him the other evening, he told me he is going into hospital for some tests. He is concerned about what will happen to him after he leaves hospital. If he needs to go to a nursing home, and is lucky enough to get a place, he will be asked to surrender 80% of his pension. That would leave him with less than €50 a week, which is nothing more than pocket money. What can one buy with €50? Perhaps one can afford a few cigarettes, a newspaper, some toiletries and a bottle of lemonade. Elderly people value having a few euro in their pocket because it gives them independence. My 88 year old mother, who is ailing, asks for her purse each morning when she wakes up. She needs to find her purse and make sure her money is still in it before she can get on with her day. Under the fair deal, elderly people will have to undergo care needs assessments before they go into nursing homes. What if they are not considered eligible, on foot of such assessments, because they do not meet the Minister's criteria? Who will care for them in such circumstances? Where is the fair deal in such cases?

The recent home help cuts, which shocked us all, will mean that fewer supports are available in the community. A crisis is developing in local communities as a result. I am contacted every day by elderly people whose home help hours have been reduced recently. I have received many calls telling me about the fear being experienced by elderly people who used to get two or three hours of home help, but now get just an hour. I know a girl with five children who had a stroke three years ago. She used to benefit from eight hours of home help, but that was recently reduced to two hours. I was shocked when she told me last week that her eligibility for a medical card is to be reassessed. Such cases are frightening, worrying and upsetting for everybody. Those who provide home help give generously of their time. They often stay longer than required because they have developed a good relationship with those they care for.

Families also have a caring role. We need to bear in mind that family members who are carers are on duty 24 hours a day, seven days a week. I have already mentioned my ailing mother, who is 88 years of age. Her needs have totally changed over the last three months. She needs constant care. Each member of the large family she reared is able to give some time to her. She depends primarily on my brother, who remains at home. He keeps an eye on my mother every hour of every day. He feeds, washes and dresses her. Above all, he gives her care, understanding and love, which is most important. Most people want to keep their elderly family members at home, where they feel safe and comfortable. It is important, therefore, to improve the conditions in which elderly people live. When one tries to get a local authority to do the necessary work to adapt elderly people's homes, thereby making it easier for people like my brother to cope, one encounters unacceptable delays. Last week, my brother was told by an inspector that he might have to wait eight or ten months for a new shower to be installed in my mother's bathroom. We decided last weekend to put on our boots and do the work ourselves. It took us four hours to manage to install the shower, which is easily adapted by family members. As a result, my mother will not have to wait eight or ten months — she might not be around by then — to enjoy the comfort of the shower.

The new primary care centres that have opened throughout the country, which have been promoted by the Minister, allow people to be looked after in a familiar location. They offer an ideal environment in which elderly people can be cared for without having to leave their homes. The centres ensure that people stay in the community, where they can be visited by their neighbours and friends on a regular basis. Plans for a new primary care centre in my local parish — St. Michael's in Inchicore — have recently been agreed. Fifty management units, in which people can live independently, will be provided as part of the scheme. I think it will be a real success. I thank the Minister for her inspirational vision in this instance. Similar projects should be rolled out throughout the country. As I have said, it is important to keep people alive and well in the communities with which they are familiar. I see the people who live in centres of this type on a daily basis as they go to the shops and to mass.

When elderly people are placed in pre-selected nursing homes, families do not have any alternatives. An elderly person can end up in a nursing home which is far away from his or her family members. Such people can become isolated, which puts extra pressure on family members who have to travel long distances to visit them. I have a list in my office of people who want to go into care in the Cherry Orchard institution in Ballyfermot. The facility in question is ideal. Many people from my constituency and other areas have contacted me to see if I can help them to get a care place for their elderly or infirm parents. The Cherry Orchard centre has a wonderful reputation in Ballyfermot, Inchicore and other parts of Dublin South-Central. The care people receive at the institution is beyond belief. It is an example of the HSE getting it right. Families who wish to visit their loved ones, for example, to spend time with them as they pass from this world, can come and go in a warm and friendly atmosphere.

I am concerned about the assessment of an elderly person's assets which were transferred in the five years before he or she entered nursing home care. An elderly parent may have given a family member some money to help him or her buy a house or to assist him or her at a time of debt or illness, for example. I do not agree that such moneys should be considered during the financial assessment. This provision will cause huge worry for elderly people who want to help their families but may be afraid to do so. How can money which is given in good faith, with a generous heart and without any expectation of anything in return, be assessed in such a manner? As a parent, I do not want my children to fall victim to this assessment process in the future.

I accept that a person in a nursing home should make a payment equivalent to 5% of the value of his or her home. I welcome the safeguards that are in place to allow such a person's spouse to continue living in the home. I agree that the 5% payment should be capped at 15% after three years. However, I do not agree with the decision not to impose a cap on the 5% charge on assets, including land. I have lived in the inner city all my life. When I was growing up, there was a pig farm near my home, funnily enough. It was run by a dedicated farmer who got up at 4 a.m. each day, to our annoyance, to look after his little plot of land and his pigs. An elderly farmer contacted me last week when he realised that the new criteria meant he would no longer be able to avail of the medical card to which, as a person over the age of 70, he had been entitled. Farmers who have tilled the land and worked hard all their lives should be able to pass their land on to their children without having to worry about them being assessed. This provision is grossly unfair.

The standard of nursing homes is another important issue. Up to now, there have been no regular inspections of public nursing homes. Standards must be improved in all nursing homes. Cases such as the Leas Cross scandal cannot be allowed to happen again. If we entrust our loved ones to residential care, we must be assured that they are in a clean and comfortable space and are treated with care and respect. I was recently telephoned by the mother of a 40 year old woman who is in long-term care because she has the mental ability of a two and a half year old. The harrowing stories she told me, which I confirmed with the HSE, led me to believe that there continues to be significant problems in some residential care units. Such circumstances should not be allowed to develop. I am gravely concerned that the Government will run out of money for the nursing home scheme during the current economic downturn. The scheme is currently costed at €920 million. If the Government cannot deliver the medical card scheme for people over the age of 70, what chance does it have in this instance?

Neither is the Government prepared to deliver on the cervical cancer vaccine. Cervical cancer is the worst form to suffer from according to my doctor. I had to take my daughter to see him this morning because she is sick. He was appalled to think the Government would not provide €10 million for the cervical cancer vaccine and voted against our motion last night. Even though I am a mother and a woman, I know little about this form of the disease but my doctor related harrowing stories to me earlier. In his 36 years practising, he has dealt with four women who had cervical cancer. He said it is the worst cancer to die from and he was appalled to think the Government has decided that young girls aged 12 now may have to visit his surgery when they are 18 or 19 and be told they have cervical cancer. I was shocked and horrified by his stories. There was plenty of opposition to the Government's cutback during the Private Members' debate and even a Government backbencher would not vote on it but the Government's amendment was passed.

The Minister and the Government need to listen to the issues my colleagues and I have raised because some day we will be all old and we all ask our children to support us and mind us. If this is a fair deal, it should be a fair deal for everybody.

I do not wish to share my time because I have had too much excitement this week sharing time. I welcome my friend and near neighbour, the Minister of State, who knows I would prefer to use my contribution to discuss issues of concern to him, including Tallaght Hospital. It is a major challenge to follow my fellow Dubliner, Deputy Byrne, and I compliment her on her fine address. She should not misunderstand that Government backbenchers are concerned about the issues she raised. I have also lived in Dublin all my life. She is much younger and I hail from a different era. Health has always been an issue in Dublin life and I always lament the demise of the various hospitals in the inner city, where I was raised, such as the Mercer's and Adelaide hospitals. If Governments of all persuasions had their time over again, perhaps different actions would have been taken and we would be examining this issue from a different perspective.

The Bill aims to introduce a new scheme of State support for individuals who require long-term nursing home care. It provides for a care needs assessment of individuals to ascertain whether they need to be provided with long-term residential care services and a financial assessment to determine the contribution eligible individuals may have to pay towards the cost of long-term residential care services. The Bill allows for the deferral of part of the contribution in specified circumstances and provides for a system of review and appeal.

I live in Tallaght, the third largest population centre in the State. It is a young population. I was raised in Crumlin and I often visit the area, which contrasts greatly with Tallaght. People in Tallaght, Firhouse, Greenhills, Templeogue, Brittas and Bohernabreena are ageing and that always presents a challenge. Sometimes people say one should be good to one's children because they will choose one's nursing home. In my case, my sisters have taken the initiative and they keep telling me where they will be put me. This issue will face us all, as Deputy Byrne said, and it is important that we pay attention to it. The Minister of State will be aware of the lack of significant nursing home capacity in my area. St. Brigid's nursing home in Crooksling, Brittas, County Dublin, has been around forever and it provides a brilliant service for women who need it. Kiltipper Woods is a newly established nursing home, which has gained a tremendous reputation in recent times, and it is a great place to visit.

Everyone is concerned about the conditions in nursing homes. From 1994 onwards I was a member of the Eastern Health Board and I served as chairman of the south western area health board. I sometimes lament the passing of the health boards but that is another day's work. However, as members of the health board, we had the opportunity to visit nursing homes and we did good work to ensure we were satisfied conditions were as they should be, as patients deserve that. Many of my constituents go outside the constituency because of the lack of nursing home capacity. The Cherry Orchard and Brú Caoimhín nursing homes attract many people from my constituency. Increased capacity will be required and that will be a challenge down the road.

It is important we support those who want to ensure conditions are ideal and patients are comfortable and safe. My uncle lived on Kevin Street all his life and he only moved into a nursing home in Bray when he was 92. He was lucid up to the time he died aged 93 and I recall asking him how he was getting on. He said it was a great place and it was comfortable but the only difficulty he had was it was full of old people. I always look on that story positively because he was happy. He quickly overcame the upset of his wife dying and having to leave his home in the inner city. He was happy there because he could ramble around Kevin Street, Aungier Street and Patrick Street where he was born. Suddenly he found himself in a different environment. Thankfully, because of the way the home was run and because the staff were caring and paid special attention to him, he was happy.

The best way to look after the elderly is in their own homes. When my father was sick, he lived with my sister during his latter years in Kilnamanagh before he entered St. James's Hospital. He was happy to be at home but that presents other challenges. Every family must face this scenario and not only those in the farming community. My family was no different in that regard. It is important that we continue to support these services from these benches to ensure the Department understands the need to fund all the relevant schemes year in, year out. Much is made of the pressure on home help services. The home help headquarters in my constituency is in the Tallaght Welfare Society offices on Main Street, Tallaght, and it provides services to more than 200 elderly people and others who cannot cope on their own. This means they can stay at home and it takes pressure off hospitals.

Tallaght Hospital will always face challenges, as I stated last night during the cancer debate. Its catchment area embraces not only Tallaght and Clondalkin but stretches into counties Kildare and Wicklow all to the way to Carnew on the Wexford border. In fact, I have just had a few words outside with the president of Tallaght Hospital, Archbishop Dr. John Neill. We are proud of what the hospital does.

The difficulty of people holding up beds — I do not want to use phrases that will upset people — arises in Tallaght Hospital, St. James's Hospital, St. Vincent's Hospital and in all the Dublin hospitals. It is important that we understand the challenge that presents. The Minister must understand the need to continue to create an environment, with home help and with other supports for families, where we can keep people out of hospital as much as possible. From family experience, I know hospital management will always state that the safest place to be is out of hospitals, although I know that sounds like a contradiction. Unfortunately, many elderly people go into hospital and stay longer than they really should, and that creates all sorts of other problems.

In the context of those remarks, I also want to make reference to what has already been said about the various programmes which help provide services for people who stay at home. Colleagues have echoed my experience in the South Dublin County Council area. I will not be any more critical of my council than of any other. Together with the Minister of State, Deputy Curran, and other colleagues, I would be able to tell the Minister that not a week goes when we do not make representations on behalf of families who seek approval for such services and try to get them implemented as quickly as possible. When people suddenly find themselves in need of such services they cannot get their heads around the delays caused by bureaucracy.

Public representatives should not have to get involved in these issues. When one thinks about it, TDs, and, in fairness, even councillors, get involved in these issues because the system is not working when it should work. Officials in the Departments of the Environment, Heritage and Local Government, Health and Children and in the local authorities should understand this problem. There will always be pressures at a time when there are economic challenges and there will always be choices to be made, as we heard from the Government benches last night. As far as these programmes are concerned, however, the agencies cannot have it every way. If we want to keep people out of hospital and safe in their own homes, we must try to create a situation where all of the supports, services and programmes are in place. If we provide those services, we will take the pressure off families.

I hope Deputy Catherine Byrne does not mind me mentioning her. At meetings of the Joint Oireachtas Committee on Social and Family Affairs, she often talks about her elderly mother. I bring to my own politics my life experiences and it is good to hear her doing that too, and I wish her family well. We have faced challenges in our families. We should not be afraid to speak up in the Dáil, certainly from the Government benches, and promote the ideal that necessary systems and programmes should be in place. Families who have elderly relatives to care for and get through difficult health situations need as much support as possible. The world will never be perfect, and it will always be a case of a lot done, more to do, but it is important in the context of this Bill that we would provide those supports.

Like others, I receive quite a number of representations at my clinics, through mail and calls to my office, on the issues related to this Bill — not so much this week because my office, like everybody else's, is jammed with other stuff. I do not mind people contacting me. I am always happy to receive communications. I am particularly excited when I get letters but sometimes, when matters are contrived and wound up, one wonders about the merits of those systems. My staff and I will continue to deal with these matters and where anybody makes contact with me at my Tallaght or Dáil office, I will try as far as possible to get back to them.

Many people have contacted me about this Bill, which has caused some concerns. I heard that reflected across the Chamber and it is important that we would not be afraid to face up to those issues. US President-elect Obama said last week in the midst of much else that was good that he will always listen, especially when he disagrees with the other point of view. I have been saying during the week that there is a lesson in what he says for every politician in the world and I am not afraid to take that advice.

It is important that the Minister, Deputy Harney, would also take account of the points being made on this Bill, and I suspect that she will do so. I will spring to Deputy Harney's defence, not for the sake of it but in fairness to her. I was glad to hear aspects of her work praised from the Opposition benches. Deputy Gilmore yesterday put on record — I hope he will not mind me repeating this — his admiration for aspects of her work. It is important that we acknowledge that. She does a difficult a job, and I suspect that is what people are saying on this legislation. The presence of Deputy Jan O'Sullivan reminds me that I listened to her this morning make reference to points of concern, which is fair enough. When this Bill is tweaked on Committee Stage, generally speaking it will be acceptable.

I listen to the various groups such as Age Action Ireland which have come in to joint Oireachtas committee meetings. We will certainly continue to listen to them. It is important that we would do so, reflect as far as possible the points they make to us and try to make progress on the issues of concern in any community. If one walks any street, in Clondalkin, Crumlin, Lucan, Limerick and certainly in Tallaght, that is what people will say to you.

Since the Bill was published in October 2008, people have welcomed the fact that it seeks to introduce a new scheme of State support for individuals who, as I stated earlier, require long-term nursing home care. I noted, in doing a little research for this contribution, that the Bill aims to provide for the establishment of a scheme to be known as the nursing home support scheme under which financial support may be made available to persons in respect of long-term residential care services out of resources allocated to the Health Service Executive for the purpose of the scheme. I will not bash the HSE today. There are aspects of this business about which people will be happy.

I understand also that the Bill provides for a care needs assessment to ascertain whether individuals need to be provided with long-term residential care services. I hope that process will be consumer friendly. It would be important that it would take a caring approach to the needs of families in so far as State agencies can care. On any given day here in the House we deal with all sorts of business where there is a need to take that approach. Sometimes we receive complaints about bureaucracy. It is important that we would address that. My friends in the Citizen Information Centre, CIC, system, particularly the one in Tallaght village, tell me they get such calls from people asking how to get around the system and sometimes such callers are worried when faced with officialdom.

I am also glad that the Bill provides for a financial assessment of individuals to determine the contributions they may have to pay towards the cost of long-term residential care services provided for them and also, importantly, to allow for the deferral of payment of the contribution in specified circumstances. It is important that the Minister would as far as possible continue to clarify the issues relating to the regulation. These points were raised in responses I received from people in and outside of my constituency.

It is similar to the medical cards issue which I do not want to go over again. Opposition spokespersons are entitled to keep raising it but I know from my work and involvement in my constituency that a great deal of tension, frustration and confusion was caused by people thinking from reports — I do not want to pick on the media — that they would be affected. People told me they would lose their medical cards. Without knowing their bank balances I would know enough of their circumstances from my contacts with them to know they would not be affected. However, I admit they were upset and concerned and this had to be worked through. I am glad the Government's response was positive.

It is important to emphasise that we understand this legislation will cause interest, concerns and questions to be raised. I have expressed my strong support for the Bill but questions have been raised and people are entitled to ask them. I hope the Minister will continue to deal with these issues. I look forward to supporting the Bill, which I commend to the House.

I wish to share time with Deputy Joanna Tuffy.

This Bill has been long promised and long awaited. It has major implications not only for the care of older people but also, I believe, for our entire system of health and personal social services. While the Bill clarifies much that is very unclear in terms of the care entitlements of older people at present it also introduces a complex new system that is extremely problematic. My strong objection is that I believe it effectively removes the universal eligibility for a place in a public nursing home as provided for under the Health Act 1970.

The delay in publishing this legislation has caused great concern to older people and their families and left many thousands of people in doubt about how nursing home care will be provided and paid for. I regret to say that the system put in place by the Bill is certain to give rise to new concerns and will create new forms of inequity.

We know the statutory eligibility to a bed in a public nursing home has never been vindicated in terms of the provision of the resources to make those beds available. This has led to a huge reliance on the private nursing home sector and the current complex and inequitable system of State subsidy for nursing home care. Undoubtedly this had to change but I believe that the Government, in doing so, has gone in the wrong direction.

Simply put, if a person suffers a heart attack he or she is entitled to a bed free of charge in a public hospital. However, under this Bill if a person becomes so dependent — say from the effects of a stroke — that he or she needs constant care in a nursing home, his or her entitlement to a public bed free of charge is effectively gone and he or she must pay. The Minister will argue that the places have never been there and will not be there to provide full provision for universal entitlement but I emphasise that this is not the point. A fundamental shift is taking place and the implications for the entire health service are profound.

I was alarmed to find that the Bill as published was framed without consultation with older people and older people's organisations, including Age Action Ireland. I urge the Minister to study closely Age Action Ireland's detailed submission which all Deputies and Senators have now received. This submission and the many concerns about the Bill raised by others should cause the Minister to pause and reconsider before the legislation goes to Committee Stage and I urge her to do so.

To put this debate in context I refer to the report "Care for Older People" published by the National Economic and Social Forum in 2006. This report exposed how our system of care for our senior citizens is skewed towards residential options and how there is a funding bias towards nursing home subventions. It pointed to the lack of a general model of assessment and rehabilitation.

The figures in the 2006 report, which I doubt have changed much, make stark reading. The 5% of older people who are in long-stay care account for 55% of the overall budget for care of older people of approximately €1 billion. This State ranks lowest of the EU 15, the pre-enlargement grouping, in terms of social spending per older person. We spend one third of what Denmark spends per person aged over 65.

Describing the barriers to the development of community services for older people the NESF report referred to perverse investment incentives. The report stated:

The present official funding of services is not consistent with the policy objective of encouraging community-based responses; considerable resources are invested in nursing home care responses, some of which are unnecessary and inappropriate.

To speak plainly, we all know that the worst nightmare for the vast majority of older people, and any number of us may have to face this ourselves, is to have to leave their homes and enter long-term residential care. The best option is for people to be cared for in their homes with the help of their family, friends, neighbours and the health and social services provided by the State.

The Minister claims that the Government is providing for improved support for older people in their homes but the reality is that current provision is totally inadequate. Despite the claims of the Minister and the HSE the experience on the ground is that home help hours have remained static since 2007. Frequently, we receive reports of older people's home help hours being reduced or cut off entirely. Research carried out by the Irish Association of Social Workers this year exposed the lack of adequate provision of home help across the State as well as the cutting of hours. Every Deputy can attest to cases which fit this experience within their constituencies.

The NESF report identified the weakness of community care, the poor integration between systems and between sectors, under-resourcing, lack of responsiveness to the needs of older people, poor co-ordination and the fact that care is not embedded in local communities.

Community-based care requires resources and legislation. The Bill should have been a much more comprehensive piece of rights-based legislation setting out the entitlements of older people to all forms of care, in the home, in other community-based settings and in nursing homes. At the very least, there should be parallel legislation covering the range of care other than nursing home care.

The sad reality is that the inadequacy of support for older people to spend their twilight years in their own homes means more of them must avail of expensive nursing home care. It means more of them become ill and lose their independence. This short-sighted failure of successive Governments to provide the essential resources for community care ends up costing the State enormously in providing for long-term residential care.

Cost is a major issue with this Bill. Government policy has led to a catastrophic fall in revenue. How will the provisions in the Bill be funded in 2009 and subsequently? Will we face a long delay in its commencement? Most crucially, will we see the creation of a massive waiting list for nursing home care as people are assessed as being in need of such care and then find the places are not yet available?

Age Action Ireland asked a pertinent question, namely, how would such a list work? Would it be on the basis of first come first served or on the basis of need with those most urgently requiring care being accommodated first? Has this been worked out?

Debate adjourned.
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