Dáil Éireann díospóireacht -
Thursday, 26 Jan 2017

Vol. 936 No. 2

Nursing Home Support Scheme (Amendment) Bill 2016: Second Stage [Private Members]

Deputy Willie O'Dea

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

When talking about nursing home care and home care, we are talking about more than the elderly. Given that the elderly comprise such a large component of the people in receipt of such care, however, I will outline some statistics which demonstrate the magnitude of the problem we face. Ten years hence, it is estimated that there will be 908,000 people over 65 years of age in this country. That is one in six of the population. In the 20 years between 2006 and 2026, the number of people over the age of 75 years in the country will increase by a factor of 3.5. Every day for the next ten years, an additional seven older people in Ireland will require long-term residential care or care in the home.

The cost of caring for the elderly will increase exponentially. It will be up to approximately 2% of GDP by 2050. We are facing a spending tsunami in this regard, so it is incumbent on the Parliament and the Government to ensure the huge amount of money the taxpayer will be called upon to spend in this area is spent to best effect and that the taxpayer gets the best possible value for money, not to mention the individuals on whom the money will be spent. State policy, or at least State philosophy, is that elderly and infirm people should be cared for, in so far as possible, in the comfort and security of their own homes. However, as in so many other areas, philosophy and practice diverge. If somebody reaches a position where they are too old and infirm to take care of themselves or for their family to look after them without support, they have two choices - residential care or home care. We have legislated for residential care in nursing homes. Putting it on a statutory basis means that if somebody meets the criteria, the or she has a statutory entitlement to residential care. Of course, there is no such statutory entitlement to home care.

Another issue with home care is that it is geographically dependent, in that it depends on whether the various ingredients that comprise an appropriate home-care package are available in the locality where the patient resides. Local health officials may determine that if the necessary ingredients are not available in a locality the patient will have no choice but to opt for the fair deal scheme. Ironically, it costs the State more than three times as much, on average, to provide a fair deal package as it does to provide a home-care package.

Existing home care services are sporadic and inconsistent. They are not patient driven and there are significant geographical disparities in the availability of services. In other words, it always depends on where a person happens to live. Somebody recently described it as a postcode lottery. There is no transparency in eligible criteria and decision making. It is entirely at the discretion of the health service. In view of this, many elderly, infirm people have little choice but to opt for nursing home care at far greater cost to the Exchequer.

The ultimate solution is to have a home care system which is statutorily based, which the Minister of State is attempting to do. However, it will take time and as I said previously the elderly do not have time in abundance. In the meantime, I am proposing this as a temporary, stopgap measure. It has the capacity to assist some of those people. It will not give a general legal right to home care to everybody. However, it will give it to some, specifically those who qualify for nursing home subvention but who could be cared for at home if it would cost the State less and would not compromise the safety of the person being cared for. It would start the process of giving a universal legal right to home care. I accept the Minister of State's argument that it will take time to put in place a statutory system. If, in the meantime, we can extend it to even a small category of the population, why not do so? It would be a far better solution for the person requiring care and it would certainly be far better for the taxpayer.

The average net cost of a home care package is less than one third of the average cost of residential care and yet the HSE allocates 58% of the budget for older people to the 5% of people in nursing home care. Studies done by the Alone organisation and others show that in a clear majority of cases, older people awaiting transfer from hospital to long-term nursing home care wished to remain in their own homes. Up to 15% of older people were not involved in this decision at all. In the case of older people suffering from dementia, this figure was 45%. Ireland has 40% more people in nursing homes than the EU average and the average stay in a nursing home here, four years, is double the EU average of two years. A considerable number of these could be cared for at home.

Studies by a number of reputable organisations in this field show that 36% of people in long-stay nursing home beds have low to medium support needs. Low-dependency nursing home beds have increased by almost half in the 12 years since 2004. Medium dependency nursing home beds have increased by over one sixth in the past two years. The figure for low to medium dependency people in long-stay nursing home beds is increasing, while the figure for high to maximum dependency is decreasing. In other words, more of those in nursing homes could be adequately and more economically catered for in the home. Justin Moran of Age Action Ireland put it succinctly in a recent interview with the Irish Independent when he said there were more and more people in nursing homes in Ireland today who could be supported in the community.

When the recession kicked in, the resources for home care were slashed. Despite the fact that there has been a 25% increase in the population of over 65s since 2008, funding for community support has decreased. Expenditure is roughly at the level it was in 2008 and the number of home help hours has decreased by 18.5% or €2.3 million in the same period. While I realise home help is only one aspect of home care, the type of assistance the elderly can get from home helps has been pared back. Carers have been restricted from helping elderly people with domestic tasks such as taking out the bins, picking up shopping or cooking meals, not recognising that in many cases these domestic tasks are where the greatest need arises.

Interviewed by The Sunday Times recently, Dr. Sarah Donnelly, lecturer in social sciences at UCD, said the removal of these services was forcing people towards institutional care. "We can see there is a direct correlation between the removal of supervisory supports and the number of people with lower dependency having to go into nursing home care,” she said. The Minister of State's predecessor, former Deputy Kathleen Lynch, said in a recent interview, "It appeared to me that people expected my job was to put older people into institutions." She went on to say, "That really bothered me," which I do not doubt. This is precisely how the 2009 Act is being administered and interpreted. For every individual we can direct towards home care as opposed to into a nursing home, the taxpayer benefits in the normal course of events.

In the Bill, we have provided specifically that the option will be given only if home care will cost less. It will release resources, not to mention give people the joy, satisfaction and dignity of living at home with their families who in my experience are prepared to contribute to the care and support of their elderly relatives if there is some sort of decent home care package. I support the Minister of State in what she is doing. We need a statutory home care system. I would propose it myself but for the fact that as a humble non-Minister the rules of the House do not permit me to propose legislation which would incur a cost to the Exchequer. I will support the Minister of State in every way I can in her efforts.

The point has been made to me about the legislation opening new areas of expenditure. It does not. It will save money. If instead of going into nursing home care a person goes into home care at a lower cost to the State I do not see how it opens up avenues of expenditure. If the Bill were going to be a burden on the Exchequer I have no doubt the very resourceful people in the Bills Office would prevent our bringing it forward. The Minister has estimated that it may take two, three or more years to put a proper statutory system in place. The Minister of State can clarify this. We will all be delighted when that happens and there is no longer a need for something like this Bill. While we are waiting for nirvana, people are applying for the fair deal scheme today and in the future who could be catered for at home and would prefer to be at home. If we can bring something in which would facilitate this, would it not be the logical thing to do? I commend the Bill to the House.

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

I move amendment No. 1:

To delete all words after “That” and substitute the following:

“Dáil Éireann resolves that the Nursing Home Support Scheme (Amendment) Bill 2016 be deemed to be read a second time on this day six months, to allow the Minister of State for Mental Health and Older People to consult with the public and other key stakeholders and to examine some important issues with the Bill having regard to the fact that the Minister of State is already preparing a set of policy options for the development of a regulatory regime for home care providers in tandem with a funding model for the provision of care in the home.”

I thank Deputy Willie O'Dea for bringing forward the Bill. It allows us to open up a much wider discussion on the care of our elderly, an issue that affects many people. God willing, the one certain thing in life is that we will all get old. While statistics show we are living longer and healthier lives, we all want to ensure that if that care is needed, it is there.

As Minister of State with responsibility for older people, my priority is to ensure our older people get the best care possible. I too would be bothered if people thought my only role was to put people in residential care. For many people, care can be provided in their own homes and communities with the people they love. Home care is an increasingly important part of the supports we offer to older people and will continue to increase in importance into the future as our aging population grows.

The Deputy is correct. According to the figures, the number of people over the age of 65 will double in the coming years while the number of people over the age of 85 will treble. Currently, 11 people per day are diagnosed with dementia, and this number will only increase. It is estimated that approximately 20% of the over 65 population receive some form of community-based support service annually from the State.

The HSE's national service plan sets a target to deliver 10.57 million home help hours, 16,750 home care packages and 190 intensive home care packages for clients with more complex needs. However, home care is not currently regulated by the State and not provided on a statutory basis. I know from discussing this topic with Members and people outside the House that we are in agreement on the need to consider carefully, as a matter of urgency, the future financing and regulation of home care.

It is the Government’s policy, as well as that of other political parties, to help older people to stay in their own homes and communities for as long as possible, with long-term nursing care seen as a last resort only after home care and other community-based supports have been fully utilised. People themselves want to stay at home and to ensure this happens we need to invest further resources into this area. Home care services provided through the HSE are provided on the basis of assessed health care need and there is no means-testing or personal contribution towards the costs involved. However, people are cared for at home under a wide variety of arrangements, both formal and informal. The HSE provides services both directly and through service agreements with private and voluntary sector providers. Traditionally, home care was viewed as providing a lower level of support than residential care, and not as an alternative to it. Increasingly, however, it is considered possible to support many people at home who would previously have gone into residential care. We have seen a decrease in the average length of stay in a nursing home from seven years to two years. To further support people remaining at home, we will require an increase in the amount and intensity of home care, as well as more effective integration with other supports, including nursing, therapies and other primary care services. We are working to provide a more viable alternative to nursing home care for a greater number of people.

Arrangements for home care provision have developed over the years with a significant local focus. While the HSE is incrementally developing a more consistent and coherent system, some legacy issues are still being worked through. Unlike the nursing homes support scheme, or the fair deal scheme as it is more commonly known, which is centrally managed in a unified way, there remains more variation than we would want to see in home care arrangements. For example, access to services can vary from place to place and at different times of the year, as Deputy O’Dea alluded to earlier.

The fair deal scheme is a coherent national system of financial support for those in need of long-term nursing home care. Participants contribute according to their means while the State pays the balance of the cost. Participants can contribute up to 75% while the overall budget for the scheme is €940 million. I believe what we need is a stand-alone statutory scheme designed for home care which recognises its particular characteristics. What we do not need is a scheme that pits home care against residential care. Both are necessary. A significant amount of detailed preparation needs to be done before final decisions are taken on the form of a home care scheme and the regulation of these services. We need to ensure this work is done as a matter of urgency.

This evening’s debate accelerates our deliberations. I acknowledge and welcome Deputy O’Dea’s intention to allow for home care services to be offered to people in place of long-term care in circumstances where these services are less costly on the State. This is my aim too but we need to ensure it is done in the correct manner and that the work I have already begun in this area is allowed to be completed.

I have discussed with Deputy O’Dea several concerns I have with this Bill, as it is currently worded and if it were to be introduced immediately. The Bill would have several unintended consequences for the operation of the national fair deal scheme and could actually jeopardise the efficient working of that scheme, in turn impacting on the wider health service. The Bill confers an entitlement to home care services. Funding made available for residential care under the fair deal scheme is not an entitlement. It is subject to available resources and a national placement list is in operation. Neither is there currently an entitlement to funding for home care which is provided on the basis of assessed need and also subject to available resources. A possible unintended consequence of the Bill is that the fair deal scheme could be overwhelmed. Inevitably, this could lead to delays in assessments and in granting approvals. Delays to the approval process have previously been shown to directly impact on the wider health services with knock-on effects of emergency presentations to acute hospitals and increased pressures in our emergency departments.

I am also concerned about one other area. Under the fair deal scheme, recipients pay 80% of their weekly income towards their care costs on the basis that they receive their food, heat and lighting. If this provision were applied to home care, older people could not survive on 20% of their income. Similarly, under the fair deal scheme, the value of a person’s home is assessed as an asset and a contribution of 7.5% per annum applies up to a maximum of three years. While this payment can be deferred, it assumes the person no longer lives in their house. Again, this is incompatible with the position of an older person who continues to live in their own house while receiving home care.

In saying that, however, let me reiterate that I agree wholeheartedly with Deputy O’Dea’s wish that care be provided to as many older people as possible in their own homes, where they are surrounded by the people and communities that they love. I know from travelling around the country and speaking to older people that this is the aspiration of so many, an aspiration which we are all working to deliver. The development of a statutory home care scheme is a priority for me and my Department. Intense efforts are now under way to make this a reality and I will bring the House up to date on these efforts.

The Department of Health is currently engaged in a detailed process which will determine what type of home care scheme is best, regarding both regulation and funding. In 2016, the Department of Health commissioned the Health Research Board to carry out an evidence review of international approaches to the regulation and financing of home care services. The examples of Sweden, Germany, the Netherlands and Scotland were used because they fit the type of model we are examining. This will be published shortly.

The Department is engaged in a mapping exercise of current service provision around the country, taking into account the scale and diversity of services funded by the HSE. This exercise is being carried out alongside future demographic projections. This work will be used to identify major policy options for a new home care scheme around the areas of regulation, financing, assessment and eligibility. Once this is complete, a public consultation will be launched to allow stakeholders, including older people themselves, their families and health care workers to express their views regarding a new home care scheme. It is my hope and intention at this stage that the consultation can be launched in May.

This debate is welcome. All Members are aware of the inconsistencies across the country in accessing home care and the need for more home care to be provided. This issue was highlighted in a touching and thought-provoking manner recently by Brendan Courtney in his documentary “We Need To Talk About Dad”, an important work on which I commend him as he is in the Gallery. All Members agree that we need more resources for home care. As I have outlined, I believe the way forward is developing a new scheme specifically designed for home care. It is important it is done as a matter of urgency. However, it is also important we recognise that the development of a funding model for home care services is a complex undertaking involving significant legislative, operational and financial resources. The Department’s intention is that regulation of the home care sector will be done in parallel with the development of such a scheme.

We all want the same outcome, namely, an affordable and sustainable home care scheme. I appreciate and warmly welcome the spirit of co-operation shown by Deputy O’Dea. On that basis, I propose that Second Stage be read again in six months’ time. This will allow the detailed work being carried out by the Department, including the consultation with stakeholders to take place. It will allow for further careful examination of several issues.

This is a priority for me and it is my intention to work with all Deputies, as well as other stakeholders, to an affordable and sustainable home care scheme for older people and future generations.

An Ceann Comhairle

I call Deputy Fiona O'Loughlin who is sharing time with Deputies John Curran and Anne Rabbitte.

Deputy Fiona O'Loughlin

Since the fair deal scheme was introduced in 2009, despite some flaws, it has helped and enhanced the lives of many who were able to avail of it to secure the necessary supports they needed in a nursing home. Good as it was, the scheme has to be altered at this point to cater for the needs and lifestyles of a growing older population, the citizens who have helped build our country. Many, however, were not just disappointed but devastated when they realised home help hours were not to be increased in the HSE’s service plan for 2017 to help alleviate problems people have at home and overcrowding in hospitals. Due to this, thousands of older people right across the country have been left without the support they need. This policy contradicts the Fine Gael Party's manifesto pledge of an additional 2.2 million home help hours over five years.

Therefore, in reality, there should have been an extra €400,000 this year. The upshot of this decision was that further pressure was put on the already stretched nursing home system and the hospital system.

In so far as possible, we all want to stay and live in our own homes, surrounded by our loved ones and by the familiar for as long as we can. I think for any of us, to be able to keep our parents, grandparents and family members with disabilities in our own homes for as long as possible is an absolute given. The Bill that my colleague, Deputy O'Dea, has put forward today has the possibility to dramatically change in a very positive way and improve the provision of care to older people and those with disabilities. I acknowledge that Government policy is that the elderly and the infirm should, in so far as possible, be able to live in their own homes. However, at present, this is not a realistic option for many. I know from listening to older people in south Kildare and those who care for them that all of them would far prefer older people to be able to stay at home. This needs to be put on a statutory basis. All health care professionals and all specialists in geriatric care say the outcomes are far better for older people if they can remain in their homes as long as possible, supported by family and home helps. In addition to adding pressure to the nursing home system, a lack of home help hours and support from the HSE at this point will ensure that older people and those with disabilities or chronic health issues will remain longer in the hospital system than is necessary.

I also make a plea for support for community care systems within this new system. We have many excellent day care systems within our communities around the country which need help and support. It is a joy to witness the terrific work Joan Kennedy does in the Rathangan Day Care Centre, providing help, support, solace, friendship and excellent food throughout the week from Nuala O'Connell and her team. This certainly helps elderly and infirm people to stay in their own homes. I have spoken here recently about the Alzheimer's group in Moore Abbey in Monasterevin and the impending decision in April as to what will happen to what is a vital service for people in south Kildare. I made the plea to the Minister of State that while we consider support for those in their homes, there needs to be support within the community as well.

I commend my colleague for bringing the Bill forward at this Stage and I plead with everybody involved to ensure this happens. It makes sense both on a financial level, since, as my colleague has pointed out, the cost would be one third of what it is for nursing home care, and it makes complete sense on a moral and supportive level.

Deputy John Curran

I support my colleague, Deputy O'Dea, in introducing this legislation. I wish to put on the record that it is not the first time we have discussed it as a party. Legislation does not just appear; Deputy O'Dea brought this to our parliamentary party for discussion before the Bill was produced. My recollection is that there was at the time widespread understanding of and support for the issue and that the legislation was brought forward with enthusiasm. Deputy O'Dea in his contribution set out clearly the issue of our ageing population. He then referred to the level of support in various nursing homes and the requirement involved. All of us in our constituencies and our families are well aware of the increased supports people require as they get older, and most of us strive in so far as possible to keep those family members in our own homes. For many people, the idea of going into residential care is a last resort. My own family is no different from many others to which I have spoken.

I am disappointed by the amendment to defer the Second Reading of the Bill by six months because, as Deputy O'Dea said, this is not a full solution but a step, and one step only. What the Bill does is afford an opportunity of choice for somebody who would qualify on medical needs and who would be assessed as being on the fair deal nursing home scheme to go into a nursing home. At that point, it gives them the option to get a level of support that would keep them in their own homes or go into residential care. I am disappointed that this cannot be progressed more rapidly. I fully support what the Minister of State said about the greater review regarding greater supports across the whole range of services but this is specific. I refer to the cohort of people whose particular aim is to go directly into the fair deal nursing home scheme. The Minister of State referred to a couple of reasons for her amendment. She said:

The Bill confers an entitlement to home care services. Funding made available for residential care under the fair deal is not an entitlement. It is subject to available resources and a national placement list is in operation.

Effectively, what Deputy O'Dea is trying to get at is that these are the same people. It is merely proposed to give them a choice. At the moment, they end up having to go into residential care because the funding model, which is, as Deputy O'Dea said, to retain people in their own homes, would be one third of the cost of a residential place. That is the crux of what we are trying to engage with.

The Minister of State went on to say the fair deal scheme could be overwhelmed. My point is that we have an ageing population. This problem, this issue, must be dealt with. If we are being overwhelmed administratively, we need to resource it, but we need to be able to give people choices. As I said, at the moment, my concern is that if the cohort of people with which we are dealing qualify for the fair deal scheme and need that level of support, the only option available to them is to take the level of support in a residential rather than a domestic setting.

The Minister of State spoke, rightly, about the aspect of the scheme about which she has a concern. She said that under the fair deal scheme, the recipient pays 80% of his or her weekly income and so on and that 20% would not be enough to live on. She further made the point about the contribution of 7.5% of the value of the home, etc., and said the fair deal scheme was not envisaged in this regard. I take these points. The purpose of debating legislation such as this on Second Stage is to make the necessary arrangements or amendments, to which we are open. Then we will be able to make this happen and facilitate as quickly as possible a group of people which we believe are going into residential care and, with this legislation in place, would have a choice. The Minister of State has raised issues that we are prepared to address on Committee Stage and in respect of which we are prepared to accept Government amendments. However, to propose a deferral of Second Stage for three months and revisit the matter then is to engage in another, different programme.

The legislation Deputy O'Dea has introduced is quite narrow and specific and is nothing more than a first step. I ask the Government to reconsider the deferral for six months. I ask the Minister of State to table on Committee Stage the relevant amendments in respect of the issues she has identified to make this happen and to give these people, who at the moment face the choice between qualifying for the fair deal and residential care only, the option of residential or domestic care with the level of medical support required.

An Ceann Comhairle

Does Deputy Rabbitte wish to share her time with Deputy Calleary?

Deputy Anne Rabbitte

Please.

An Ceann Comhairle

The floor is hers.

Deputy Anne Rabbitte

I thought I would have to wait another 20 minutes or so. I thank my colleague, Deputy O'Dea, for bringing the Bill forward. Before I begin, I extend the apologies of Deputy Mary Butler, who is our spokesperson for older persons. She is in Scotland meeting with groups dealing with dementia.

I have met with the Minister of State more than once and we have had more than one discussion regarding the fair deal scheme. I very much support what Deputy O'Dea has done in bringing forward this legislation and I fully agree with what Deputy Curran has said. What we are looking for is very narrow. The Minister of State says she needs six months and that there are elements about which she has concern. At the coalface in my constituency, I have huge concerns about how home care packages are being delivered and the criteria for assessment. That is why I would very much welcome the opportunity of having it put on a statutory footing so that everybody would be treated equally and that when one reaches a certain age, one is not placed on a scoring system by which three points are awarded to those over the age of 85 and only two points to those over 65. That does not sit well with me and it should not sit well with anyone. If people are in need of home care help, they are in need of home care help. We should seek to give them that choice of support. It should not be a question of who gets care this week or who is entitled to it after a round-table discussion.

If there is a need and requirement everybody should be treated equally. I thoroughly agree that everyone should have to contribute. People in my constituency are scrambling to get two or three hours because it is not on a statutory footing. People have the choice to say who gets what. We need to empower people to say it is a right and it should be on the same level as the fair deal scheme. The legislation governing the fair deal is a deterrent because after three years it is no longer only the house that is taken into consideration. Families whose loved one is sick in hospital and who are given the opportunity to apply for the fair deal but who do not understand its ramifications may not qualify for it. This is because their land will be over the threshold as it has not been transferred for three or five years. There are many similar issues and they get no financial gain from it. Moreover, when the five years have passed, they cannot apply for the fair deal scheme because they have applied already. They may never have drawn anything from the fair deal programme during those five years and the families may have supported and funded them throughout. The Minister of State at the Department of the Taoiseach, Deputy Regina Doherty, is looking at me. That is a fact. If a person applies for but does not qualify for fair deal that application sits on file. It is not possible to apply even if the land has been transferred for five years and the person's family has supported the person for those years. It is tied up in legislation and though the person had no financial benefit from the land, there is a case reference number attached to the person's personal public service number and that person cannot benefit from the scheme. There is a cohort of people who cannot gain from this. I endorse Deputy O'Dea's Bill and ask the Minister of State at the Department of Health, Deputy McEntee, to look more favourably on the timeframe.

Deputy Dara Calleary

I commend Deputy O'Dea on this Bill, which took 18 months to prepare. Deputies are sick of me talking about silos in government. This is one area where they are most apparent. The Department of Health is the lead Department in this scheme but the Departments of Social Protection and Housing, Planning, Community and Local Government are also involved. I got very frustrated listening to the Minister of State read her script and it was a script because it is not how she feels. She wants a six-month delay but many of the fair deal cases I deal with involve people who get a call to be told their relative needs to be moved from a general hospital but because there are no step-down facilities or there is a shortage of beds in step-down facilities, they are being presented with the unachievable task of getting that person out and dealt with. They do not have six months. They are lucky to get six days in some cases and they are putting themselves in that situation to deal with the rules in the fair deal scheme for assets and income with very little independent advice and information available. That is why the Members of this House are so expert on the fair deal scheme because we are the port of call for dealing with it. Families do not have six months.

The home care packages are non-existent. Someone looking for home help, maybe in an emergency, will not get it from the middle of September on because the budget has been allocated to current hours. Last year we found that it took until the end of November until the extra allocation that was given last July filtered down into the system and we were in a position to get extra home help hours for new clients, never mind existing clients or an expansion of the existing clients. The Government cannot say we have a proper home care system when people are ringing and begging for 45 minutes of home help a day. That is not a proper home care system in any way. It is not structured or planned. It needs to be examined. Those people who are in a queue for home help and cannot get enough time do not have six months.

There are 21-week delays for considering a carer's application. Most initial applications are turned down and have to go into the appeals process which takes approximately 18 months. If we are serious about encouraging people to remain in their homes we will deal with that. The Department of Social Protection will face up to its responsibilities to carers and particularly to emergency carers. Where people need care at relatively short notice there should be a provision.

The rules around the fair deal urgently need to be reviewed because Deputy O'Loughlin is right; when it was introduced in 2009 and 2010 it made a substantial impact as we can see from the volume of our case work. In the past 18 months I have noticed blockages in the system that were not previously there.

The rules around assets and farmland do not reflect the way society is run. Farmland cannot be sold at a minute's notice. It cannot be sold if a family is told to move their relative to a nursing home within a week. It may go back generations and an older person will not get rid of that land. Some consideration has to be given to the value of farmland. Similarly, consideration has to be given to people who are self-employed and have spent their lives building up business and assets only to be asked to make that decision quickly for him or herself or a family member. As a country and a government, in the permanent sense, we do not understand or value home care or keeping people in their homes. We talk about it but we do not have the systems and procedures in place to allow people remain in their homes at short notice or at times of crisis.

As for the idea of a further six months to enable the Minister of State to review the scheme, I have no doubt of her personal commitment to this but the system does not get it and does not want to get it. I have been ten years in this House this year and in every one of those years we have been dealing with problems with home help and fair deal and these wonderful mysterious home care packages. There is more chance of seeing sun in Ireland in July than of a home care package because I have rarely if ever seen one. Let us take the opportunity Deputy O'Dea's Bill presents and say we will do this. I have only now noticed that Brendan Courtney is in the Public Gallery. He has articulated the frustration and desperation of thousands of families who were not in a position to do that. He has articulated what we deal with every day. Let not another year pass when home help will finish in September through a lack of resources, especially not in a year when the Minister of State will not be allowed to propose a Supplementary Estimate because of the new expenditure rules. Let us take this seriously for once and for all and say that in 2017 as a republic we initiated a care system based on families that is responsible and respectful.

Deputy Caoimhghín Ó Caoláin

Sinn Féin is committed to the provision of health care services and social care services as a right, with equal access for all based on need and to the greatest extent that resources allow. This right is especially relevant for older people and the provision of support for older people is becoming increasingly important as our population ages. Ireland's elderly population is set to reach 1.4 million over the next 30 years. This obviously poses great challenges. However, I believe this should be viewed as an opportunity, with older people contributing to our society.

The issue of how we care for our elderly has been a pressing one for some time. The national positive ageing strategy was published in 2013 and one of its four national goals was to “Enable people to age with confidence, security and dignity in their own homes and communities for as long as possible”. However, this commitment and many others contained in the strategy have not been delivered on, much to the detriment of our older people and their families.

The need for this issue to be addressed as a matter of urgency was heightened recently when RTE broadcast a documentary, "We Need To Talk About Dad", which has been mentioned by a number of Deputies during this debate. In the documentary, the presenter and fashion designer Brendan Courtney shared with viewers his struggle and that of his family to care for his father, who is unable to care for himself following a stroke. I have no doubt that this programme resonated with people all over the country. In the wake of the broadcast, a poll suggested that 85% of Irish people would prefer to be cared for at home in their old age. The reality of the situation is that sufficient resources have not been provided to allow all of those who would wish to be cared for in their own homes to enjoy such supports. This is a damning indictment of successive Governments, which have made it impossible for such an entitlement to be realised due to cutbacks in home help hours, home care packages, housing adaptation grants, carers' supports and other services. As a result of the austerity policies of successive Governments, more people than necessary have had to go into long-term residential care. If one qualifies for a nursing home place under the fair deal scheme, the State is legally obliged to ensure one gets a bed. However, this is not the case for those who require home care packages. There is no legal obligation for the State to ensure such people get what they require. The provision made for them depends on the resources available. As we are all too aware, the resources are miserly.

Sinn Féin has recognised the need for additional investment for many years. In each of our alternative budgets, we have proposed costed measures that would increase home care packages and home help hours by 10%. We have committed that during a term of Government, this figure would increase by a further 10% on the baseline year in years two and three, with a resulting increase in spending of €93 million. This is the kind of investment that is needed. The system as it stands does nothing to support these people. Instead, a significant number of people are faced with no choice other than to go into residential care. I am speaking from personal experience in this regard. A greater emphasis on community-based care has the potential to reduce the number of older people requiring nursing home care, thereby drastically reducing the amount of money spent on long-term residential care. A critical element of this argument is that the provision of home care services on a statutory basis has the potential to generate huge savings and free up many valuable hospital beds. According to research conducted in Britain, when the Partnership for Older People Projects increased low-level supports to people aged 65 and over with low to moderate dependency, overnight hospital stays decreased by 47% and the use of accident and emergency departments decreased by 29%. For every extra £1 spent on the services provided by the Partnership for Older People Projects, additional savings of approximately £1.20 have been made on emergency bed days. This shows that investment in our home care services makes sense.

Ageing support is a human right. Older people have the right to choose how best they will be supported as they age. That is why we will be supporting this Bill, which gives people who have applied for the fair deal scheme a choice of home care package, as long as the cost is equal to or less than the cost of long-term residential care. We have concerns about the extension of the nursing home support scheme to include home supports. As I mentioned earlier, the nursing home support scheme was designed specifically for long-term residential care. Although home supports are inadequate and under-funded at present, they are provided free of charge to the end beneficiary based on an assessment of need. Sinn Féin believes they should continue to be provided on that basis. I understand that this Bill calls for home care services to be provided using State support from funds to be voted by the Oireachtas for the purposes of this legislation. I recognise that this Bill contributes to the debate on the need for a statutory entitlement to home care in Ireland. It merits a welcome on that basis alone. I believe family carers should be consulted on all of these matters. Their important role should be fully recognised and State supports for carers should be enhanced.

The amendment that has been proposed by the Minister of State, Deputy McEntee, calls for this Bill to "be deemed to be read a second time on this day six months, to allow the Minister of State for Mental Health and Older People to consult with the public and other key stakeholders". I would guess that this amendment has been tabled as a result of the Minister of State's announcement last week of a public consultation on the issues around home care for the elderly. I welcomed this initiative when it was announced, while noting that it has been a long time coming. We are willing to support the amendment because we believe it is important to consult the public and the key stakeholders. However, we will hold the Minister of State to the six-month deadline. There cannot be an open-ended delay. I will call for interim updates on the progress of the consultation process. Perhaps the Minister of State will indicate in her concluding remarks whether she is willing to accede to this request. Colleagues of all political views hardly need to be reminded that time is of the essence for the issue we are addressing. However, I am reminding the House of that now and I will do so again if necessary.

An Ceann Comhairle

There are eight more speakers on this Bill. If everybody takes the full ten minutes, we will have time pressure at the end. I ask Deputies to abbreviate their contributions, if possible.

Deputy Noel Rock

I assure the House that I will try to speak for less than ten minutes to give everyone a say on this most important matter. As Deputies Calleary and Rabbitte have outlined, Deputies are often the first port of call for issues relating to home care and home help. We often bear the brunt of the frustrations of many people who are aggrieved that the resources that are allocated and the systems that are put in place do not match the needs and wants of our most vulnerable citizens. I welcome the outline of the Private Members' Bill that has been proposed by Deputy O'Dea. I believe this Bill goes in a positive direction and allows for a holistic and cohesive approach to this long-running problem. Deputy Calleary mentioned that this has been a problem throughout his ten years in this House.

As the Minister of State, Deputy McEntee, has said, the Government's aim is to promote care in the community for older people so that they can continue to live in their own homes for as long as possible. This is a natural ambition and a laudable aim. I believe in the Minister of State's commitment and in her dedication to achieving this goal in the shortest possible timeframe. She has not flippantly asked for the Second Reading of this Bill to be delayed for an additional six months. She has made that request as part of a cohesive and holistic plan to ensure the systems, the architecture and the framework are in place to ensure the ambitions outlined in this Bill can be achieved in an effective way. I think that laudable ambition is worth restating.

The current level of funding of home care services is €370 million per annum. This will be expanded in 2017 with the aims of allowing people to continue to live in their own homes, freeing up hospital beds and allowing older people to be discharged from hospitals with support and greater peace of mind. The HSE's national service plan for 2017 provides for higher targets than previously, including the provision of 10.57 million home help hours to support approximately 49,000 people. I appreciate that this is too few. I accept that more can be done and that additional supports are required.

Deputy Anne Rabbitte is right to outline the commitments in our manifesto in this regard. We hope to achieve as many of these undertakings as possible and give the sector the fullest possible support. We have given a commitment to provide 16,750 home care packages under the HSE's national service plan for 2017, as well as 190 intensive home care packages for clients with complex needs. In addition, there are 1,918 short-stay beds in public residential care facilities. These provisions amount to a cohesive package, but I agree more can and must be done.

I welcome Deputy Caoimhghín Ó Caoláin's support for the Government's amendment which proposes a six-month timeframe to put the required framework and architecture in place. Everybody in the House is coming at the issue from the same angle of concern for the issues that affect older people. We can work together on a cross-party basis to achieve the objective laid out by Deputy Willie O'Dea in his Bill, but it must be done within the framework the Minister of State, Deputy Helen McEntee, has set out. The public consultation aspect is important, as there are many voices, both inside and outside this Chamber, that need to be heard. I join colleagues in welcoming Mr. Brendan Courtney to the Chamber and commending him on his documentary, "We Need to Talk About Dad". That programme represented public service broadcasting in its truest format and served to open people's eyes and minds to the issues around care of the elderly. It certainly resonated with me and many of my constituents. I support the proposal that the Private Members' Bill be given a Second Reading in six months time when the preparatory work needed to develop proposals for a statutory home care package, including appropriate regulatory provision, has been advanced. The Minister of State has emphasised that we all want the same outcome, namely, an affordable and sustainable home care scheme for all. We must all work together to achieve it.

Minister for Health (Deputy Simon Harris)

I thank Deputy Noel Rock for sharing time.

I welcome this timely debate which has shown there is a realistic view of the demographic challenge we are facing and the requirement for the Oireachtas and the Government to meet that challenge. My Department's latest "Health in Ireland - Key Trends" report highlights the growth in the number of people aged over 65 years. Each year the number in that age cohort increases by almost 20,000. Moreover, the largest proportional increases in population will be in the category of those aged 85 years and older. We all want the health needs of our older loved ones to be met in a way that supports them to enable them to stay for as long as possible in their homes and communities. It is Government policy that long-term nursing home care should be a last resort. We wish to develop home care services to provide a more viable alternative to nursing home care for a greater number of people.

We have made progress in this area. The overall funding for services for older people available to the HSE in 2017 has increased to €765 million. Home care accounts for almost 50% of this budget. Since my party returned to government in 2016, the budget for home care has increased by a further €65 million, including measures taken under the winter initiative. The number of people in receipt of home care packages will increase from 15,450 to 16,750 this year. Within hospitals, we are in the process of developing a special care pathway for older people who have to attend emergency departments. We must respect older people and treat them with dignity, not leave them waiting with everybody else. We have introduced a reduction in prescription charges for medical card holders aged over 70 years which will benefit 300,000 people. All of this is about supporting older family members, friends and neighbours, recognising the contribution they have made to our society and the generations coming after them and ensuring they receive care that is tailored to their needs.

I agree that it is unacceptable that we do not have a statutory scheme for home care, given the evidence that this is what most older people want and that it best suits the needs of a large number of people. This issue has been overlooked by all of us for many years, but that ends now. I welcome the high degree of consensus on the issue. The work my colleague, the Minister of State, Deputy Helen McEntee, is undertaking is vital. It is not enough to do this; we must do it right. We need to acknowledge the considerable differences between residential and home care. We must be careful not to pit one against the other or seek to impose arrangements for one or the other with unworkable consequences. We must respect the informal arrangements many people have made in their homes and recognise the difference between a private residence and a nursing home. We need a properly funded and organised system that will work for all older people, those who can be cared for at home and those who need and wish to receive nursing home care.

I thank Deputy Willie O'Dea for bringing forward the Bill and his constructive engagement with the Minister of State in the past week. It is about finding a way forward such that we, as an Oireachtas can say, regardless of party affiliation, that we will work together to get this done. We are all moving in the same direction, but there is frustration all around that we have not moved faster. However, we must proceed carefully on this matter. The Minister of State's step in launching a public consultation process is an important one. We need to hear older people's voices and ensure we will have a scheme that is not just designed by politicians or the Civil Service but one that will have older people at its very centre. Consulting stakeholders is not a stalling tactic. It is what one does when one wishes to treat people with dignity. We must ensure older people and those who care for them are listened to as part of this process. The Minister of State has also commissioned a review by the Health Research Board which will look at best practice in three other countries and see how we can apply it in Ireland. That will be invaluable.

I pay tribute to Mr. Brendan Courtney for his courage and that of his family in helping to ignite this important debate. He is engaging with the Minister of State and many others in this House. We will let not his family and the many families like them down. I reiterate that we are determined to do this right. I look forward to seeing this considerable work being advanced on a cross-party basis, with continued co-operation across the House, in order to deliver the best possible outcome for older people.

Deputy Michael Collins

I welcome the Bill. Supporting older people to live and age at home is undoubtedly the best option. There is widespread evidence to indicate that older people prefer to stay in their homes and communities for as long as possible. Admission to long-term, residential care should be seen as a last resort and only be availed of when it is no longer feasible for people to remain in their own communities with appropriate support. Many older people can remain at home for longer if appropriate and adequate supports and services are made available to them. Having older people remain in their communities is not just beneficial for the individual but also for the community as a whole. I am hopeful we will see an increased provision of sheltered housing to bridge the gap between people living in their own home and the move to full-time residential care.

It has been Government policy since 1960 to support older people to stay at home for as long as possible. A commitment in this regard is included in the programme for Government, the national positive ageing strategy and the HSE service plan. Unfortunately, owing to a lack of funding, this vision does not reflect the reality. The HSE's national service plan for 2017 indicates a budget of €940 million for the nursing home support scheme. In a ministerial statement the budget for home help and home care packages was put at €394 million. Home care services, where they are available, are sporadic and inconsistent. This has led to many older people being left with no option but to avail of nursing home care prematurely and at far greater cost to the Exchequer. I fully support the Bill and hope it will result in older people's preference for receiving care and support in their homes and communities being realised.

Deputy Jackie Cahill

I commend my colleague, Deputy Willie O'Dea, on bringing forward the Bill. Deputy Anne Rabbitte referred to the inadequacies of the fair deal scheme, particularly for farmers. Many people of the older generation are nervous about transferring their assets to the younger generation for various social reasons. Cognisance must be taken of this and the fair deal scheme should be modified to ensure there is fairness for all and everybody can access it.

The thrust of the Minister's comments on home care packages and the desire to have as many people as possible looked after in their own homes is where we all want to get to. If we are going to get there, we have to put serious resources in place. This is one aspect of what is envisaged in the programme for Government. In a five-year period, 2.2 million extra hours need to be provided if we are going to provide any kind of a serious home care package. As Deputies, we are faced every day with families who look for a home care package and find the hours are not there for them. There are areas of the country where workers to work these packages are not available, especially in some rural areas. Proper resources have to be put in place if a proper home care package is to work. It is a hugely desirable objective for people to be kept in their own homes and minded by their own family with State support. Economically, it would be far more advantageous for the Exchequer and it could be done far more cheaply than having people in nursing homes far sooner than they need to be.

I will make one point about home care. If home care is to work efficiently, it will need a proper GP service in all areas. This is an issue that raises its head more and more often. In my home town, a GP is retiring. The HSE has advertised his position three times and failed to get any applicants for it. In many rural areas in my county GPs are failing to take up rural practices. If a home care package is to work, the availability of a GP will be hugely important for the scheme to work efficiently. The payment of GPs by the HSE will have to be examined and talks are ongoing. Young graduates are deciding with their feet and emigrating. We have a huge shortage of young GPs going into practice. I had two GPs on the phone to me last night and they said it is no longer economically viable for them to operate. They are not performing minor operations in their surgery and this is exacerbating the accident and emergency department problem.

If a person is at home in a home care package, the availability of a GP will be hugely important. If we do not have that service, the home care package will unravel. It is essential that the ongoing talks with the HSE and the GPs come to a favourable conclusion and that a financial package is put in place to make it attractive for GPs to take up active service in this country. If this situation is not addressed it will become hugely problematic. I have had a case of a GP who was in practice for 15 years who decided to emigrate for the better financial rewards in other countries. If we are to keep these young graduates here, we have to have an economic package for GPs similar to that available in other countries. I would hate to see a proper home care package fail as a result of the lack of a GP service in urban and rural areas. This is something that needs to be addressed urgently.

As with other speakers, I fully support the home support scheme. It is an initiative that is long overdue. Unfortunately, up to now the support has not been there for families that want to care for people at home. If we can put the proper resources into this, at the end of the day the HSE's budget will benefit from it so it will be a win-win situation.

Deputy Michael Harty

I am very happy to speak on the Nursing Home Support Scheme (Amendment) Bill 2016. It is a matter close to my heart. We must keep the frail, elderly members of our community living in their and our community. It is essential that we look after our frail, elderly people. Frail is the important word. We are facing huge demographic changes in this country. I will not give the House the statistics but the number of people reaching the age of 65 has surpassed any previous decade. The number of people who are reaching the age of 85 has surpassed any previous decade. Today we have children born who will live to be 100 such are the advances of medicine. We have a huge demographic deficit to deal with and make up. There are huge numbers of single, isolated elderly people living in our communities in both our rural and urban areas. They have to be supported to stay within their communities either in their own home or in supported accommodation within their communities. We must support day services and dementia services to keep people in their home. We must support the Alzheimer Society and give it funds and support home help and home care packages to keep our people at home. Our health service cannot afford to have people in hospital beds or nursing home beds who do not have to be there and who could, with support, live in their community. We have heard about delayed discharges and there are many people in nursing homes and hospitals today who could, with support, return to their community. That is exactly what they, their relatives and society wants. We must give our elderly people the quality of life, dignity and confidence to survive within their own community.

I have spoken about the difficulties in acute services in our accident and emergency departments in the Committee on the Future of Healthcare and the Joint Committee on Health. We have been grappling with these problems for the past number of months and we can see that the only future for our health service is to transfer hospital centred care to community centred care. We are not talking about transferring or taking away funds from our hospital service but we must put funds into our community-based services.

There are many options which we can engage in to look after our elderly. If people cannot be looked after in their own homes, they can be looked after in low-support housing. A former Member of this House, Dr. Jerry Cowley, has a fantastic community service in his home town of Mulranny in County Mayo where he takes people in isolated communities who cannot live on their own. I do not like to use the phrase "congregated setting"; he brings them into a community, low-support setting where they can live out their lives independently but with huge levels of support. When they lose their independence they can move into a higher support setting within the same community. They can live out the end of their lives in a very secure and supported fashion. These incentives and supports should be encouraged throughout the country.

Inspired by what Jerry Cowley did, we have a similar, but perhaps not as advanced system in our own village in Kilmihil in County Clare. We have taken people out of nursing homes and hospitals and we have brought in homeless people. People look after each other. There is a huge community spirit. Communities are very receptive to looking after their elderly people if they are given support. We must face up to the challenge of looking after our elderly people because it makes no common sense to warehouse people in nursing homes. People must go in if it is a last resort but placing people in them unnecessarily is unacceptable and is also very costly.

If we are going to support our elderly people within their community, we cannot simply just put them in the community and leave them without any services. There must be a primary care team who can look after them. There must be occupational therapists, physiotherapists, adaptation to their homes and an increase in public health nurses, community intervention teams and GP services. All these components go to supporting our elderly people in our communities. It is important that if home help is put on a statutory footing, which I hope it will be when the consultative process is finished, we resource primary care and provide the services to assist people to live in their own communities. That is what we want.

Of course, people become acutely ill and there is no avoiding it. If somebody has a catastrophic illness and can be rehabilitated to a level of independence, they should be brought back into their communities and not be put into nursing homes.

In general terms there is a continuum of care and we must identify our frail elderly within the community to intervene very early. We cannot let them come to a stage where home help must be provided in an emergency. We must anticipate people becoming frail, giving them a limited amount of support and gradually increasing it to the maximum level to keep them living within their own communities. Early intervention in the decline of the frail elderly is very important. We must have more community geriatricians who can give expert advice on how people can be maintained medically in an independent fashion at home.

As I stated, part of the work of the Oireachtas Committee on Health and the Committee on the Future of Healthcare is to examine these issues. Yesterday we spent many hours examining how our accident and emergency departments are overcrowded, mainly with frail, elderly people who could be moved from those departments once their acute treatment is completed to bring them back to the community. The Committee on the Future of Healthcare hopes to produce a report at the end of April on a ten-year vision for our health service. The service needs to plan not year to year basis and from crisis to crisis but rather with a ten-year vision. There must be an apolitical plan that does not change every time a Government or Minister changes. It should be a framework for how we see a fair and equitable health service in future.

I commend the Minister of State on starting a consultative process on introducing a statutory home help scheme. I will certainly support her in that. However, that consultation must be finite and we must have a date for starting to trigger this change. It will be one of the fundamental changes in supporting our health service so it should not be put on the long finger or tied up in rationing or bureaucracy. The process must be fair and equitable. It is not common sense to do otherwise.

Deputy Mattie McGrath

I am also pleased to be able to speak to the Bill and I compliment an Teachta O'Dea on putting forward the Bill and the research he has done. The Minister, Deputy Harris, has just left but I thank him for earlier receiving a deputation of a powerful group of enablers in Tipperary, some of whom are recovering cancer survivors. They have put in much passion and energy into providing a new, state-of-the-art cancer care centre in Tipperary called Circle of Friends. I thank the Minister for engaging with them. Those people will show the way for the Health Service Executive, HSE, in many areas related to this issue. It is about community, what we can do and ní neart go chur le chéile. Not everything can be done by the HSE and the Department. That is why the Bill is very timely and understanding. Deputy O'Dea has demonstrated he is aware of the major logjams that exist. We must also thank Mr. Brendan Courtney and his family for giving oxygen to this major issue, which all of us, including the Minister of State and her backbenchers, face every day in our clinics.

We must support people and families in the home as long as we can. There is a right to homes, water and everything else, but surely a person has the right to be able to stay in his or her home for as long as possible. There is nurturing and bonding within a family with a sense of pride, love and satisfaction when somebody moves on, regardless of whether those involved are siblings, husbands, wives or grandchildren. It is very important that grandchildren can engage and everybody is involved with the care. Apart from the care aspect, these people will not be in rooms in nursing homes. I have nothing against nursing homes. I have seen stickers on the back of cars stating, "Be nice to your children, they choose your nursing homes." It is a nice, catchy slogan but I do not like it. Families in all communities like to be able to care and it is a much better experience. Outcomes are much better also and people often recover. People who are kept at home with supports often recover.

I salute from the bottom of my heart the legion of home help and home care people and the work they do. At times they have been diminished and they rush to and fro and from place to place. It may sound like there is no compassion in the administration but I know there is. The likes of the home help co-ordinator, Ms Brigid Farrell, in Tipperary do their best but there are limited resources and time. These people are so unhappy to go in for 20 minutes or half an hour as they are hardly in the door when they have to go. They go beyond the call of duty by going back to the families in their own time. They stay longer and they work harder. They love the work and they should be supported.

Figures have been mentioned relating to home care packages. There is €940 million in the current budget run for the fair deal nursing home scheme but there is a third of that, less than €350 million, for home care packages. That balance must shift as it is the natural course of action and it would help everybody. Patients will recover and families will have extra help. There are new groups like Home Instead Senior Care that must be brought into this area. I am not diminishing the work of home help workers but there are private companies that offer these services, and they should be allowed to be funded and paid by the State, albeit with a modicum of restraint.

I cannot say enough about family carers. I cannot say enough about Councillor Richie Molloy, who is a manager in south Tipperary, and his team. I should also mention the Alzheimer's disease and other support groups. Like the group I met today, these people come together on a voluntary basis. Some of the people have been sick themselves but they give much time and energy to sufferers and allow them to get involved with so many therapies and meeting other people. Whether it is knitting, reading, walking or the many counselling services they provide, it is done voluntarily. They want to help the HSE but we need more understanding from it and the Department. There is a six-month consultation promised and I hope these people will see serious engagement. They are the carers and groups helping sufferers of Alzheimer's and Parkinson's disease as well as others. I hope they will be consulted and treated with the respect they deserve as they have much to offer.

Deputy Harty spoke about a former Member, Dr. Jerry Cowley, and what he did in Mulranny, as well as what Deputy Harty did in Clare. In my village we have a wonderful voluntary housing scheme and although we have not yet got into the caring, the process could be expanded and the energy is there to do it so people could be treated when sick. If these people are sick now in my area, unfortunately, they must go to hospital. The accident and emergency department crisis could be eased considerably if people had a place to go to. There are not enough step-down beds and we know about the row we had about the hospital in Cashel that was closed some years. We spent €22.4 million on it but there is not a bed in it. Although it has no surgical equipment, we have the best facilities in the form of modern offices, tables, chairs, desks and computers. It is a scandal and I am delighted that Deputy Kelly and I agreed for once and the Committee of Public Accounts will investigate it. Such issues should not exist. If small amounts of that money were put into enabling the enablers - those who do the caring, such as the Carers Association - we would have a great country and great care for people.

We must support our GPs, who are the front line for a sick person. If any of us get sick at night, a GP is the first person called. I have a GP in Cappawhite who is not in great health and he is weary from the cumbersome system. The Minister, Deputy Harris, was in Clonmel visiting two private doctor centres where the doctors have come together. They are Mary Street Medical and Western Road Medical Centre. They have the capacity, equipment and expertise, above all. They are linked with universities. They are offering diagnostic services that could reduce the numbers attending accident and emergency departments. We must think outside the box and support our GPs.

With Tipperary GPs, I might be part of the last group standing that is opposed to free medical care for children under six. What has it done but clog up surgeries even more? If the care is rolled out for those under 16, it will do the same. We will all be nursing home candidates some day, some perhaps sooner than others, but we need a bit of imagination to support community-based services. This Bill is excellent and timely.

It is great for the communities. The sense of satisfaction and pride they get is extraordinary. I see them at Christmas. I visit many nursing homes and day care centres. I see the satisfaction not only from the clients but from the family members, providers, volunteers and staff who work there. It is good for everyone psychologically; there is a feel good factor for everyone. We must look after step-down facilities and we must put money into them.

Farmers are self-employed. I am not suggesting that it only applies to farmers, it applies to the self-employed as well. They are seriously discriminated against by the fair deal scheme. These people want to pay. As Deputy Cahill noted earlier, major issues arise with transferable land and changes of ownership. I am dealing with such situations in my constituency as well. There is considerable room for recovery.

This Bill is timely. I hope that meaningful consultation will take place. I also hope the Government will listen and engage with all the providers to ensure they are facilitated. I met representatives of a cancer support service today. We see such people in every county. There is a vast amount of voluntary energy. This group has raised €600,000. It needs €800,000 to build new premises. That model can be transferred to this context in order to develop community care centres and supports for various initiatives already in the community. I have in mind Sr. Celestine from north Cork, the area from which the Minister for Agriculture, Food and the Marine, Deputy Creed, comes. Sr. Celestine is doing great work providing sheltered housing and step-down facilities. Many groups throughout the country do similar work. There is a wonderful place in the old convent in Naas. The Minister of State should visit it to see what goes on there. Similar work is going on in other constituencies. Although the name eludes me, the facility is a powerful hub of community endeavour.

All we want is a little support from the Government - "a little help from our friends", to use the phrase from the advertisement on television. Moreover, we need less red tape and bureaucracy. I mean no disrespect to the officials in the Chamber but we have to get rid of half of the officialdom in the HSE. We need to get common sense back. Unfortunately, there is a major imbalance and a lack of common sense. That is why I have said balance is important.

There is a need for balance with home care. Some people need nursing home care and they cannot manage anywhere else, but it is not necessary for many others and these people should not be in nursing homes. We must allow the enablers, families and communities a little help to care for these people by providing more home help hours and allowing more home care packages. We should cut out the bureaucracy and the serious delays and the frustrations therein. We need to support general practitioners as well.

Deputy Alan Kelly

I welcome the Bill and I thank Deputy O'Dea for putting it forward. It is timely. I had a brief opportunity to speak to Deputy O'Dea about the Bill yesterday. In fairness, I thank the Minister of State as well for the time she gave me this week to discuss the matter.

The legislation is timely because of the situation in which we find ourselves. We need a comprehensive plan. I am rather taken by what everyone else has said. There is unanimity on the need for a plan, something that does not happen often in this House. We are heading over the cliff in a demographic sense. We are going to have 1.5 million in the elderly bracket in the not-too-distant future. There is going to be a serious bubble in our demographics. We need to prepare for this and quickly. Whatever the duration of this Dáil, I believe this is something the Minister of State can put her stamp on and put in place a plan. That is why I am pleased we have reached some consensus on a way forward. That is what we need.

A statutory scheme for home care is necessary. Once we agree that, we can have a debate afterwards on the terms of the scheme and how it should work. A considerable amount of nitty-gritty needs to be sorted out. Considerable legal issues arise. Certainly, comprehensive regulatory issues arise and I have particular views and concerns on these. They are not easily addressed; they are particularly tricky. We cannot have the same regulatory processes for a home, which is a completely different setting to a nursing home. This is virgin territory; we have not been here before. We need to work this through. That is why I am glad we will have time to consult the relevant people. During the consultation period, perhaps we should work in parallel with some of the very capable individuals on the regulatory side within the Department to determine how it would work. I know that people will, through the consultation process, express their views on how the scheme should work and emphasise a need for the scheme. Perhaps the last aspect will not get as much focus. I call on the Minister of State to focus on this element because it might trip us up when we make decisions. I am referring to the status of the home, which is not just a normal building. I wonder what status the home will have and how it will be managed, how the regulatory framework will work, the type of regulatory framework and what standards will pertain. I do not think we can be definitive about this matter. We will have to customise some rules to make a statutory scheme work.

I have been very much taken by the comments made by many of my colleagues. Let us suppose that in six months' time we reach the point of making a decision on this initiative. I genuinely hope that we reach that point. We need a plan to ensure that we have community capacity to support the initiative. Without such support, the initiative will have been a waste of time.

Like Deputy Harty, I am a member of the excellent Committee on the Future of Healthcare. We have made significant progress because everyone has left their political baggage outside of the committee room door. The work is not easy. It is tough and we need to be thorough, but we will get there. I was very much taken by a submission made by Professor Colette Cowan. She is the regional chief executive of the University of Limerick hospitals group and the network of hospitals in the mid-west. She is under severe pressure working in one of the most difficult working environments that I have ever seen. When she made her presentation to the committee, she told us that the best way to prevent her having to tackle the current crisis in emergency care is to take a whole block of her funding and, over a period, invest it in the community to prevent people ending up in hospital in the first instance. I know this lady for some time. She started off as a normal nurse and worked her way up through the HSE. Therefore, she knows all strands and knows what is needed at every level of the hospitals of which he is in charge. I take what she says very seriously. In parallel with this plan, we need to ensure that the community intervention teams, primary care centres, geriatricians, occupational therapists and physiotherapists are all in place.

We all have constituencies. By way of example, what operates in north Tipperary is very different from what operates in the south of the county and there is no standard or commonality. Community intervention teams work different hours. Beyond Thurles, the teams work different hours. There are major gaps in service. All of this relates to the issue of GPs and the new GP contract. In rural areas, in particular, the new GP contract has become a major problem. Deputy Harty and I are trying to deal with GP issues in east Clare. I take an interest in east Clare because I live close by. There are significant problems with the GP issue in the area. If we do not have GPs working in these areas, then we will not be able to implement this plan. Certainly, we need a variation of what Deputy O'Dea has proposed, and it must be supported by the Minister of State and this House. All of the issues that I have outlined are interlinked. We need to sort out the GP issue. We need to ensure that we have community funding. We need to ensure that all positions are filled. If the services are not interlinked, we will not solve this critical issue.

Where are we going with this? I believe the proposal made by Deputy O'Dea is sincere. I also believe that the views of the Minister of State should be taken into account and that she has made sincere statements. She will have the energy to push this initiative. However, in six months' time we should revisit this matter. On the basis of what I have said, the Bill proposed by the Deputy is a good starting point. However, it needs tweaking.

Having said that, we can get there.

I believe that the process by which we will put this in place needs a huge volume of consideration. In the intervening time, I ask that we not alone open up and take on board all the consultations but also that we tease it out with the Minister of State's office, the Department of Health and, in particular, the HSE in order that in six months' time we are not then starting at the base line of teasing out the community requirements. Hopefully we will have made progress on the GP contract and on the issue of how we are going to manage the regulatory process. If we have done all that in six months' time, I will be delighted and this House will have done a service. On that basis, the Labour Party and I will be supporting the compromise that has been reached. We will review it in six months' time on the condition that all that happens. I will certainly play my part in supporting that in any way I can.

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

I thank all the Deputies who have contributed to this debate, in particular Deputy O'Dea for bringing forward this Bill and not simply allowing for this debate to take place, but for helping to move things on as well. On Deputy Calleary's reference that I have a script, we all have our notes and everything else, but these are my words, sentiments and intentions. This is very much my commitment to the House. We all want a scheme and system for home help that is fair, equitable and sustainable, but also affordable.

I would stress that it cannot be to the detriment or at the expense of the nursing home support scheme. I would agree that it is not perfect. I know that Deputies have made reference to the scheme needing to be changed. We had a review that was finalised last year that recommended a number of changes, many of which have been made or are in the process of being made, some of which require legislative change and some of which we have decided are not needed. That is ongoing and will be an ongoing process. It is a scheme that supports 26,000 people. It has a budget of €940 million. It is a very sensitive scheme. We have seen in recent times, when funding was taken away, that our waiting lists went from four weeks to up to 20 weeks. We know the effect that has on our emergency departments, our respites and on everything else and the knock-on effect that has. However, it is also a very highly-regulated scheme and I believe that is extremely important. While I support the spirit of this Bill and what it is proposing, I would have concerns that it will have a knock-on effect on a scheme that has taken seven years to put in place.

I wish to make it clear that we are not going to spend seven years on my watch putting together a home care scheme. This is something that is of vital importance. There certainly needs to be a timescale put on this. However, we need to make sure that the voices, not just of ourselves, but of our older people and of the representative groups that look after them are heard. That is why I am proposing that we have the next step, which is our consultative forum or engagement. There will, I hope, be a set time of six weeks to it. I envisage that many of the organisations have an idea at this stage what they want to say and what they will be proposing.

I agree with Deputy Kelly that it is not just about home help and putting forward a scheme for that. This needs to be an approach that we take across the board. Our national strategy on positive ageing in Ireland looks at not just the Department of Health. I suppose that is a difficulty that I have as a Minister of State at the Department of Health in that I do not have charge of anybody else's budget. The national positive ageing strategy takes a whole-of-Government approach to how we can support people to remain within their homes and communities for as long as possible by looking at transport, their environment and their financial situations. All this work needs to be done.

All that work is in conjunction with The Irish Longitudinal Study on Ageing, TILDA, which took ten years to complete and takes on the views, expertise and knowledge of the older people in our society. It is also in conjunction with the Healthy and Positive Ageing Initiative, HaPAI, which again takes on board the views of our older people. This is what I am asking for. I again thank Deputy O'Dea for his co-operation. We must allow the older people and those who want to have a say in this have their say. We must progress this scheme and ensure it is successful, affordable and sustainable. I reiterate that I look forward to working with all Deputies in the House on progressing this scheme. I look forward to coming back in six months' time and hopefully having a significant amount of work done on this, having taking into account the views and voices of the older people and every person in this country.

Deputy Willie O'Dea

I thank all the Deputies who contributed today. It was remiss of me not to welcome Mr. Brendan Courtney to the Visitors Gallery and to compliment him on his outstanding documentary. Rarely have I seen a television programme that engendered such a public reaction, particularly in the Limerick area that I am familiar with. I am sure that has been replicated all over the country. He has certainly done us all an enormous service. I want to thank Deputies Caoimhghín Ó Caoláin, Michael Collins, Mattie McGrath, Alan Kelly, Noel Rock and all the other speakers who supported the principle of this Bill.

The elderly people of this country are not bed blockers or demographic time bombs. They are the people who worked, paid their way, made sacrifices and built up this country. It is incumbent on us as a Parliament and on any Government that is democratically elected by the Irish people to look after them and do all that is necessary to ensure that they can live out their declining years with dignity.

In her initial response, the Minister of State made three arguments against the Bill as currently drafted. She said that the Bill confers an entitlement to home care services and that there is no such entitlement under the fair deal scheme. I appreciate that the Minister of State used her own words, but I have been in her position in the past. Sometimes a Minister gets a script from the Department. I felt when I was in government as well as now that people put across arguments just as fillers to say that they have arguments 1, 2, 3 and 4. The fact of the matter is that there is a statutory entitlement to the fair deal scheme. It is demand-led. If one satisfies the criteria, one has an entitlement. One might not be able to get it because the money is not there, but ultimately one will get it if one lives long enough. The same applies if one substitutes home care for the fair deal scheme. Therefore, that is really a non-argument.

The Minister of State mentioned that an unintended consequence of the Bill was that the fair deal scheme could be overwhelmed. I cannot see why. There is a team of experts who assess a person's eligibility for residential care. They are people who know the situation of the patient; they will have just assessed him or her under the nursing home scheme. They will also have access to the home care services. They will know what home care services are available in the area. They have people to advise them on the cost. I cannot see for one moment how the extra consideration that would need to be given to offer a home care package would overwhelm the fair deal scheme. God help us if it could. I do not accept that.

The Minister of State made a point on cost. Under the residential care scheme and the nursing home scheme, people have to pay if they have assets. Their assets are assessed, etc. When a statutory home care scheme is introduced in this country, whether or not there will be a payment element in it is a matter for the Government that drafts the legislation. I will make the point that when I say that the residential scheme costs almost four times as much as a home care package, I am talking in net terms, exclusive of what the contribution is from the people who are availing of the fair deal scheme. The net cost to the State is still on average about three to four times what a home care package would cost. I take Deputy Ó Caoláin's point on this as I think he makes a good point. If we introduced a system of charging for home care, we would find almost invariably that when people are being cared for in their own homes among their own families and if there is a decent package in place, the families will be making their own contribution also. They will be contributing. It will lessen their capacity to contribute if they have to contribute in addition to the HSE.

The Government amendment proposes the Bill be read a Second Time on this day six months. I am informed by people who are better at calendars than myself that this day six months is the 26 July. I thought the Ceann Comhairle would have to work that out but I have it worked out for him. I was wondering about it because I do not anticipate that the Dáil will be sitting on 26 July, so can I take it that if the Dáil has gone into recess before the 26 July Members will return here? I would be ready to come back.

An Ceann Comhairle

Or we could arrange that we would stay here.

Deputy Willie O'Dea

Well, that might be the Ceann Comhairle's preference but it would not be mine.

Deputy Alan Kelly

With reformed family friendly hours?

Deputy Willie O'Dea

We may very well still be sitting on the 26 July but if we have adjourned in the meantime we must come back. We will certainly be demanding that because it is part of what is contained in the amendment we are agreeing this evening.

I thank my Fianna Fáil colleagues for their outstanding contributions also, in case they thought I was forgetting about them. We have taken a first step today. I am not happy that we are waiting for six months to elapse. We are talking about elderly people and six months is a very long time when one is old or ill.

I wish the Minister of State well in her consultation process. Fianna Fáil will be making a contribution to it and I hope it gets underway as quickly as possible because time is something the elderly do not have in abundance. I am reassured, from what I have heard this evening from the Minister of State and the Minister that the Government is fully committed to introducing a full statutory scheme for home care and that they are in the process of putting that in place without delay. On that basis, and thanking people for the support for the Bill, we are prepared to accept the Government amendment.

Amendment agreed to.

Motion, as amended, agreed to.

An Ceann Comhairle

The Bill will be read a Second Time six months from this date.

The Dáil adjourned at 6.05 p.m. until 2 p.m. on Tuesday, 31 January 2017.