Home Help Service: Discussion with Health Service Executive

We will now have a discussion with representatives of the Health Service Executive. I am happy to welcome Ms Monica Sheehan, Mr. Michael Fitzgerald, Ms Geraldine Bermingham-Rigney and Mr. Noel Mulvihill for a discussion on the home care services.

Before I begin I would like to advise you that by virtue of section 17(2)(l) of the Defamation Act 2009, you are protected by absolute privilege in respect of the evidence you are to give this committee. If you are directed by the committee to cease giving evidence in relation to a particular matter and you continue to so do, you are entitled thereafter only to a qualified privilege in respect of your evidence. You are directed that only evidence connected with the subject matter of these proceedings is to be given and you are asked to respect the parliamentary practice to the effect that, where possible, you should not criticise nor make charges against any person(s) or entity by name or in such a way as to make him, her or it identifiable.

We are running a little late for which we apologise but momentous events are happening around us in the House today. I thank the witnesses for joining us. We have their paper, which has been circulated to members. We will deal with the executive summary of that following which members will be allowed ask a series of questions.

Mr. Noel Mulvihill

I thank the Chairman and members of the committee for the opportunity to make an opening statement. I would like to comment briefly on the home help service and update members on a number of aspects of the service. Members have been provided with a more detailed paper setting out the aspects of the service which we can discuss later.

The first issue is the context in which the service is operating and moving towards the integrated care model. The delivery of health services to older people must change for a number of significant reasons. They are, predominantly, the following: the fact that people are living longer; the population is increasing and ageing; expectations and demands are increasing; and costs are also increasing.

Government policy with regard to health services for older persons has the following two core elements: community and home-based care should be developed to maintain older people in their communities for as long as possible and to support the important role of the family and the informal carer; and, where that is not possible, high-quality residential care should be available.

The integrated care model of service delivery being developed within the HSE provides for appropriate care in appropriate settings, along a continuum from home and community-based services through acute intervention to long-term residential care, with older persons needs and preferences being central to decision-making.

In that context this report outlines the significant progress made in developing home help services and home care packages since 2006, identifying the impact in terms of people benefiting as well as the significant support to the acute hospital sector. These developments are part of an overall movement towards an integrated model of care across hospital and community, which will require continued sustained investment if the model is to be successfully implemented.

The home help service is a core community service supporting older people to remain in their own homes, preventing admission to acute services, delaying or preventing admission to continuing residential care and facilitating early discharge from the acute sector to the community.

Significant progress has been made in developing home help services since 2006, with significant impact in terms of the numbers of people benefiting as well as providing support to the acute hospital sector. In terms of numbers, this has increased from 10.8 million hours in 2006 to 11.97 million hours in 2009. The total number of people in receipt of services increased from 41,400 in January 2006 to 53,791 in December 2009.

The 2010 budget for the home help service is €211 million, which provides 11.9 million home help hours with approximately 54,500 persons in receipt of the service at any time. It is important to outline that this includes all care groups. It is not just for older people. It also applies to our mental health services, our disability service and services for children and families. The 2010 targets are the same targets as applied in 2009. This level of service, if applied equally to all clients, would equate to four hours home help per client per week.

While the resources available are substantial, they are finite. The capacity of the HSE to provide approved levels of home help service continues to be reviewed in the context of overall resources available to the HSE. Local health managers must ensure that home help services are delivered within the allocated budgets. This requires a stringent ongoing review of the application of the resources.

Levels of services provided by the home help service to individual clients are reviewed regularly to ensure they continue to support the clients' assessed care needs.

In some parts of the country, particularly in Dublin and the greater Dublin area, the home help service is provided by voluntary organisations. It is recognised that these voluntary organisations provide a valuable service. They face challenges in the future in terms of standards, and increased professionalisation of the service. Given the particular relationships that have developed, the HSE will need to provide some support to those providers in facing these challenges.

Home care packages are enhanced levels of home help services which may be provided through the home care package scheme where the assessed needs of the client indicate that such enhanced service is required. In 2010, the home care package scheme budget is €130 million, which is expected to benefit over 13,000 people. By the end of 2010, a total of just over 9,600 people will be in receipt of a home care package at any time.

Regarding home help service and duties, the development of the home help service has seen the professionalisation of the service in recent years with the implementation of the national home help agreement. Home helps are now paid at care attendant rate. This has resulted in greater flexibility in service delivery and improved consistency in service quality, through training, to the benefit of service users. That has placed a greater onus on the HSE and its role as an employer and with regard to management of risk, which requires increased supervision given the numbers of high-dependent older people now supported in the community.

Home helps provide a range of services to assist people with activities of daily living based on the assessment of need undertaken by health professionals. These duties include both personal and domestic care relevant to the individual's assessed needs. The range of duties is set out in a more detailed paper which has been circulated.

Home help service training is provided on an incremental basis to facilitate changes in service provision. For example, where an older or disabled person becomes more dependent, the existing home help may need training to develop his or her skills to provide the necessary personal care. Initial training for new home helps includes induction, moving and handling, health and safety, and domestic and personal care.

Moving and handling training is a critical aspect of training, particularly where personal care tasks are involved. Moving and handling training is arranged locally in each region to address the particular requirements of each local health area. One example of the extent of training in Cork-Kerry is set out in the detailed paper already circulated.

FETAC level 5 training is available currently through arrangements with a consortium of all 33 VECs, led by the city of Dublin Vocational Education Committee. Supervisory staff may avail of the supervisor programme at FETAC level 6. In addition, FETAC programmes levels 3 and 4 are also available where appropriate, for example, if the home help requires literacy support or if English is the second language. More details on these programmes are set out in the paper circulated to the members.

The home help service has emerged over the years from what was essentially a friendly neighbour service to one that is becoming more professional and demanding as increased numbers of clients with significant and complex needs are maintained at home. Although generally the home help service is well regarded by clients there remains room for improvement and in 2010 work is under way to roll out a number of improvements that will ensure all applicants for home help services are treated in a similar way and have their application assessed in a similar way regardless of where in the country they live. Procedural guidelines for the home help service are in the process of being developed. Given the large numbers benefitting from the service it is critical that national procedural guidelines for the standardised access to and allocation of home help hours to clients are available to assist staff in managing the scheme in an equitable way across the country.

Given that the service evolved over a number of years from the old health board structure and because it is a discretionary service — there is no statutory requirement on the HSE to provide the service and no statutory entitlement for clients to receive it — different approaches to accessing the service emerged in different areas. It is a priority of the HSE to standardise access to this service so that all our clients can expect to be able to access the service using the same criteria regardless of where they live.

Procedural guidelines will assist staff in applying equitable access criteria to all applicants and in allocating home help services in a consistent way while incorporating flexibility to allow the professional staff allocating the service to take full account of the particular care needs, abilities and dependencies of the client. In this way for example a client in County Mayo and one in County Wexford can expect to be able to apply for and be assessed for the home help service in a similar way, and, subject to the limit of the resources, have appropriate services allocated to support their differing needs and dependencies. Guidelines will also help to ensure that important service is provided in an economical way while taking account of individual needs.

Another aspect of service improvement relates to draft national quality guidelines for home care support services which reflects that the needs of older persons and their carers are based on good practice, will ensure national cohesion and will support the service delivery system to minimise risk in the home care setting. The guidelines will address key issues across public, voluntary and private providers. The resource and general capacity implications will need to be considered before a strategic and operational proposal, recommending how the guidelines might be implemented across agencies in the public, private and voluntary sectors, on a phased basis within available resources, can be submitted to the HSE management team.

The HSE is committed to supporting older people to live in their own homes for as long as possible if that is their wish. Significant levels of service are available and are being provided across the country. However, as the population of older people continues to grow, the resources available to support them to remain at home must continue to expand if service provision to individual clients is to be maintained or improved.

Thank you, Mr. Mulvihill.

I welcome the delegation. We heard a great deal today about caring; both inside and outside the House but that is another story.

I have a great interest in the home help service and related matters. In early January, all Oireachtas Members representing County Galway met representatives of HSE west and were told there would be a dramatic cut in home help services for counties Galway, Roscommon and Mayo. If I understood Mr. Mulvihill, the numbers this year will be slightly higher than last year. I am not sure whether he meant numbers of people or of hours but either way he mentioned 53,000 or 54,000 as compared to 51,000 or 52,000 the previous year.

I have met many who now work in an official capacity as home helps for the HSE. They have enormous industrial relations type problems concerning their employment. I do not intend to examine this specific issue but there has not been a smooth transition from where these people had been employed to their present place of employment. Many would argue they got a bad deal with regard to much of the work they did.

I refer to private providers of home help. I have been told they pay their home help employees less than the HSE pays and, in some cases, their guidelines are different. Their employees appear to be allowed to do more in the home than HSE home help personnel. On occasion, HSE staff have told me they could do more for people if they were so allowed.

Generally, however, the scheme is excellent by any standards. I cannot emphasise enough that if it were only a matter of human contact, a person who calls in, it would be worth it and I acknowledge that when it is only a matter of half or three quarters of an hour a day one cannot expect miracles. Unfortunately, that is the type of division of time that pertains at present. Given the statistics he has, Mr. Mulvihall might indicate whether he can give a guarantee that for the remainder of this year and for next year, people who now get home help, at whatever level, will continue to receive it.

I apologise for the delay. I hope the delegates understand that all of us are very caught up today. Mr. Mulvihill spoke of service improvement in home help service, referred to as item 5 on page 5. He stated:

The home help service has emerged over the years from what was essentially a friendly neighbour service to one that is becoming more professional and demanding . . .Although generally the home help service is well regarded by clients there remains room for improvement and in 2010 work is under way to roll out a number of improvements that will ensure all applicants for home help services are treated in a similar way and have their application assessed in a similar way regardless of where in the country they live.

Is that code for centralisation? If so, our experience of the centralisation of medical cards does not augur well for centralising this service. It is my belief that centralisation is what is meant — in code. A person who needs a home help must telephone a number in Finglas, but judging by the medical card experience, he or she will not get a reply. I wish to know what this means.

I asked the other delegates the same question. We are upskilling everybody who helps the elderly in the community, which is great. We all know people who work in this area. However, some have told me they are upskilled in such a way that they can no longer do what they used to do. I agree that people should be taught how to lift properly in case they might put their back out and there are certain jobs people should not be expected to do. Home helps are there to help people in their home and are not domestic servants. That is not what it is about. However, on the other hand, one can take the case of a person with no family who does the domestic chores we all need to live a reasonable life. I examined the figures. Four hours a week works out at just under 30 minutes a day. A lady passes my gate every day to do home help chores. She enters a house and, I assume, takes off her coat, hangs it up and says "Hello" and "How are you?" That takes ten minutes. What is she expected to do in 30 minutes? I realise it is a vital 30 minutes and, as Deputy Connaughton correctly stated, sometimes it is merely the human contact which keeps people alive. I have no difficulty with that. I am certain I could not vacuum the front room, wash the ware left in the sink and light the fire in 30 minutes. However, I am not the greatest around the house. What can be done in 30 minutes? During the winter, the fire must be lit every day. It is not practical to do anything reasonable in 30 minutes. It is not practical to change the beds, ensure the place is clean, vacuum the bedroom and light the fire. These are the things certain people cannot do for themselves. I believe No. 5 on page 5 is code for centralisation.

I welcome Mr. Mulvihill and his delegation and I thank him for his presentation. I will deal with the last part of the presentation first. I refer to the amount of money allocated. The presentation referred to the number of home help hours in 2009 and the number of recipients. However, it does not refer to what was in the budget. What was the budget for home help in 2009 and how does it compare with the 2010 figure of €211 million?

By coincidence, a constituent, an 85 year old woman visited me yesterday with regard to home help and the review currently under way within the service. She has osteoporosis and severe arthritis. She is virtually immobile and hardly leaves the house anymore. She has two children living abroad. Therefore, the only contact she has with people during the week is from home help. Until yesterday, she was in receipt of one hour per day for five days per week. There was some flexibility attached to this and the duties were not specified. I saw the letter she received when she came to me following the review. The review has cut her help to three quarters of an hour for three days per week. The letter also specified exactly the duties of home help. For this woman, such duties included to shower her and take care of personal hygiene, to change her bed and to tidy her bathroom. This is the service for a woman who never gets to speak to anyone else during the week. I refer to the point my colleague made. We are all aware that part of the service of home help is the essential contact with an older person. There has been some debate in the national media about how the HSE is allocating time. The executive may deny it but there is only so much time for a shower, to tidy the bathroom and to change the bed. Unfortunately, this leaves no time for some conversation. I am aware from my clinic that it is unclear whether one could get in and out in a half an hour and have a chat because elderly people, by their nature, do not want that chat to end. They would stay and chat for an hour if they could do so. Sometimes that is more important than the chores highlighted, which are essential as well.

I have a problem with the review because when I discussed the matter with my secretary, it turns out that almost everyone who has come to us in receipt of home help hours who was getting one hour per day has been cut to three quarters of an hour. It seems a blanket cut of 15 minutes has been taken off everyone. The help for the woman in question was reduced from five days to three days. If this is the case, it is difficult to justify or verify the figures highlighted by the delegation, which maintains that more people will be in receipt of home help hours this year than last year and that the hours have increased from 11.97 million to 11.98 million, a marginal increase. How does the delegation square that circle? Is this the case throughout the country?

Reference was made to standardising a service. I appreciate the point that a woman with the same condition in Donegal should receive the same service as a person in Mayo. There cannot be wild differences in the service and the same argument was made for medical cards. Why was it some people could get a medical card in one county but others could not do so elsewhere? The reality for the 85 year old woman who visited me is that I am better off applying for the home care package for her, which will cost the HSE more. She is better off using that home care package to buy the essential hours she needs. We will do so. I will appeal the home help decision for this woman because it seems no consultation took place with her and the decision was part of a blanket cut. That does not constitute a review. It is a simply cost cutting exercise and it is unacceptable, especially in this case because she is a deserving case. Over the years, I have met people in receipt of home help hours who, arguably, could have done without the service. However, that is not the case in this instance. I have taken a strong view on the matter having met this woman. Were she to be left isolated and without essential contact on a daily basis, it will not end up in a happy situation for her. I call on the HSE to consider this because it is simply not acceptable.

I refer to training. The delegation remarked that the HSE is now paying the care attendant rate for people. I refer to vetting people who carry out the home help service. Everyone is conscious of the risk of abuse of elderly people and others in society. There have been cases of abuse of elderly people in the past within families. I am keen to know the level of vetting. Are there spot checks of the home help service to ensure people are in receipt of the service as intended? Can we be sure it is not simply a case that when the home help hours are appointed and the person is allocated, the matter is forgotten about until next year's assessment? This is a source of concern to many people as well. I refer to the appeal process. An appeal has been made to the change in home help hours. Have any appeals been successful to date? Is the process independent? How does the process take place? I trust the appeal in the case of my 85 year old constituent will be heard and the decision overturned when the case is shown to be genuine.

I had to watch the presentation from my office because of other pressures and for this I apologise. I wish to be associated with the welcome extended to the delegation. It is important to have this meeting. I am not always parochial but I heard others refer to their counties and so I am pleased to refer to Dublin. Mr. Mulvihill will recall that I live in Tallaght. I am a member of the board of what was the Tallaght Welfare Society which is now Trust Us, an organisation of which he is well aware. The organisation is responsible for 200 home helps and deals with more than 600 families. There is no question in my mind of the very substantial contribution it makes to keep people out of hospital and nursing homes. It is a vital element of community care. In Tallaght, there is a good deal of pressure on the hospital and on the few nursing homes in the general region.

It is important to stress, as other colleagues have done, the importance of home help. The Minister, Deputy Mary Harney, came to Tallaght some weeks ago to open a new facility for Trust Us. It faces the stadium in Tallaght. This is important because it contributes to keeping people active and away from hospital. The home help people look after the elderly and they are taken to a brand new facility, which is tremendous. I cannot wait to qualify and I do not say so in a facetious way. I look forward to the day when I need such facilities and when I can get access to them.

It is important that we stress this point to the HSE. I realise there are pressures on the executive but we should stress the need for home help. This committee will hear from delegations every other week during the coming months leading up to the budget. Everyone will have a strong case to make and we have already shown that we support what the Carers Association is trying to achieve. It will be difficult for everyone, including the Government and the HSE, to decide on the priorities and funding. As someone who has seen the system in operation, I have no hesitation in saying that home help works. Deputy Flynn made a point in this regard but I have never met anyone who did not need the help. There is a relatively small elderly community in my constituency compared with other parts of the country. There are more demands on the service at present. It is important that we stress that. As I said, I acknowledge there are a lot of pressures on the health service and the HSE budget but I have no doubt people would want us to stress the importance of home help. I am happy to be able to do that.

I hope I do not get Mr. Mulvihill into trouble but I want to acknowledge the contribution he has made in my area. His successors might not want me to say he will be missed but he made a good contribution and I was always happy to work with him.

I thank the delegates for coming before the committee and making their contributions. We all want to see people live in their own homes for as long as possible and to be supported in doing so. A lot of progress has been made over the years. On budgeting, it appears, based on the figures the HSE gave us, that the number of people benefitting has increased by 25% but the budget only increased by 10%. I have a concern about the distribution of money between hospitals and community care. If it was my money I would give more of it to community care because one would probably get better value for money. The cost of the home help service nationally appears to be some 85% of what a large Dublin hospital would get for a year. It is not an expensive service.

The HSE must examine how to ensure it is properly resourced because when there are difficulties in finding finance, a certain level of pruning takes place which is not in the interests of some of the elderly people, particularly those living alone. We all meet people in our constituencies whose number of hours has been reduced. I am aware of someone who received 10.5 hours which this person needs. I will not argue with the professionals who made the decision but I hope decisions are made on the basis of need rather than trying to save money. I fully support the Government in limiting funding to what it can afford and the HSE in living within its budget.

Having said that, as for the question of home help and the care of the elderly and those in the community with disabilities, one cannot see it in the context of a home help service on its own. One has to see it in the context of a whole range of needs and facilities which are available, such as the length of hospital stays and how people might be able to leave hospital more quickly in order to save money. We need to consider the day care facilities and voluntary facilities and supports which are available. In that context, the delegates said when the home help service started that it was a "good neighbour" support which gradually developed and was eventually taken over by the HSE. It became a career for people.

The necessary number of volunteers was not available to do the job. Now that there are more people available in the community we could consider having a more integrated voluntary State service, from which we could get much better value for money. That brings me to the review. While I am in favour of equity in the country and ensuring that everybody has equal access, the nature of the home help service is that there has to be flexibility. In the review and guidelines one cannot throw up stereotypical guidelines which affect everybody because needs are different and the needs of one individual may change from one day to the next. We have to take account of that in any review.

I have a question on the distribution of home care packages within different HSE areas. I am in the Dublin north-east area. I do not know what the up-to-date figures are but it seems most of the home care package were in the Dublin area and did not extend to the periphery. I would like to know what the current situation is.

I will be very brief. Deputy O'Hanlon mentioned people with disabilities. The delegation's presentation referred mainly to older people. Could it give us an idea of the number of younger people with disabilities with which it deals, if any? It also said that people are living longer, the population is increasing and that resources must be able to support them if the service is to be continued. Has the HSE any projections regarding demographics on older people? I am interested in what the trends are and what the demands will be over the next ten years and how many people will be looking for the service. I am also interested in the onset of dementia and how home help is involved in supporting people with that difficulty.

The delegation also mentioned the fact that it is a priority of the HSE to standardise access to the service. Deputy Lynch referred to centralisation. When does the delegation envisage that happening? Does it have a timetable or deadline for that to happen? A related question concerns the second last paragraph which deals with the draft national quality guidelines which, it is stated, will ensure national cohesion and will support the service delivery system to minimise risk. I ask for examples of what it means by "minimise risk". It also mentioned that the guidelines will address key issues. Could it give us examples of those?

The presentation said that the resource and general capacity implications will need to be considered before a strategic operational proposal recommending how the guidance can be implemented across agencies can be submitted. What does that mean? Does it mean that one cannot submit proposals until one comes up with the implications pertaining to resource and general capacity? How will that work? I understand the draft national quality guidelines are very important because we have seen all kinds of issues in other sectors and guidelines have been introduced. It appears that this has been long-fingered. I may be wrong but I would like more information because these are crucially important national guidelines.

In its opening statement the delegation referred to moving towards an integrated care model. We had a presentation earlier from the Carers Association which told us the cost of nursing home care is €800 to €1,000 per week. The delegation mentioned people moving from community-based to high-quality residential care. How is it integrated, from a financial point of view, if a certain amount of funding will be made available to have somebody looked after in high-quality residential care? A fraction of that money could keep the person concerned in his or her home for a lot longer, which is what we all want. How are the two linked? Are there any links in the system, whereby an increase in home help services for a person which would cost a fraction of what is needed to keep him or her in a nursing home could be considered? Maybe I am not making any sense but I am trying to.

It would be remiss of us not to acknowledge the work which has been done for decades by carers, a large number of whom were women. I do not know of any male carers; there may be some but not very many. I am very conscious of the number who did the work as good neighbours. They did this work for £2 per hour for many years before current pay rates were put in place. They are tremendous people who have demonstrated great humanity and support for people.

I commend the witnesses for what they are doing to introduce standardised guidelines. People are coming to me now in dire need and I wonder why they are not getting the service or why it has been reduced. I then meet people who I am amazed to discover have the service and have had it for some time. I wonder if they heard about it locally and applied for it because someone they knew had it and because there was discretion they were able to get it. I hope the medical and human needs of the person will be put at the centre of the review. If there are people who could do with less time because they are able-bodied and who are using the service as a domestic help, they should be looked at before the people with chronic conditions who obviously need support.

Professionalisation can mean two things, namely, doing what a person has been doing to a far higher standard or deciding not to do something because it is beneath his or her professional status. I fear we will enter the latter category if we are not careful because the people we are talking about need to have the fire set and cleaned out or the bathroom cleaned. A colleague recently told me about someone who came to him about an elderly couple living together. The husband was approved for home help and when the home help came in, she would only make one side of the double bed because she was only to provide care for one person. That sort of nonsense should not happen. Common sense must prevail. The providers of this care are usually people of great sense and we should not have systems in place that prevent them from operating in a sensible manner.

I assume she only put down half a fire as well.

Mr. Noel Mulvihill

I thank Deputy Connaughton for his kind comments. There were particular issues in the west because in 2009, there was over-delivery in a number of the LHOs so they had to come back on budget. The budget for 2009 is the same as the budget for 2010, with €211 million in total for home help. For those to start at the beginning of the year, there had to be a target for where that would have come from. We are watching this and we monitor the delivery of services for older persons.

In each of the four regions it is done through a performance contract. There have been difficulties obtaining data in recent months but that has changed. We now have clear figures for what is being spent in each LHO area on both home help and home care packages so we can clearly align to the original resource that was given in January. It is the same amount as in 2009.

Private provision is a growth area that has evolved in recent years. We have done a lot of work on it, particularly in terms of standardisation. We will draw up a tender and contracts. At the moment it is being worked out because we have a preferred provider list of private providers. That allows for a level of standardisation and monitoring rather than how it is currently structured.

Mr. Michael Fitzgerald

We have moved from a situation a few years ago where this work was done by the friendly neighbour to a situation where people have a specific, nationally agreed contract. Those contracts are specific about duties and hours. As part of the contract arrangements and the personnel process, all home helps are vetted through the Garda.

There was a question about home help contracts and the transition from one area to another. I was not sure what was mentioned. There was such a huge number of contracts, with various arrangements in place, that we had to work through the process over a nine to 12-month period.

It took a long time.

Mr. Michael Fitzgerald

It did. Some of that was down to staff numbers in our personnel departments to deal with it, because it was not as if we were recruiting home helps on an ongoing basis. We had all home helps to deal with and we had to provide contracts to those who did not have them previously. We are confident now about the contracts that are in place, they are nationally agreed, and arrangements are in place for the provision of contracts to any new home helps who would go into the system.

Centralisation of the home help service was mentioned. There is no sense in the document that centralisation of the service will take place. The service is locally delivered. Any person seeking a home help has his or her needs assessed by a professional, normally a public health nurse, and the allocation of time required based on that assessment is agreed and provided between that public health nurse and a home help organiser. It would be impossible for us to centralise that process.

An issue that has come up, however, is standardisation of procedures. There is a concern that insufficient care might be provided to a person because a specified length of time would be laid down and it would never change. The document makes clear what we are trying to do, to introduce standardisation whereby people with similar needs and environments receive similar levels of home help. That is down to the individual's assessed need.

Ms Monica Sheehan is the director of public health nursing in Kerry. She has operated as a provider of home help services for ten years. There is a procedure for that in the south and she will now outline that to the committee.

Ms Monica Sheehan

When the "Ageing with Confidence" strategy document for older people was published in 1999, an assessment tool was developed. It is an objective assessment tool which looks at the needs of clients and it is used predominantly by public health nurses, although occupational therapists, physiotherapists and primary care teams will also contribute to it. The general practitioners also have an opportunity to give their view. It is a comprehensive assessment tool. Much of the literature was reviewed at the time and we have used it very successfully in the south since. It looks at the environment in which the clients live, their social circumstances, and whether they are disabled or otherwise. It also looks at the capacity of their carer, if they have one close at hand, family relatives and so on. It looks at the local environment and what local voluntary groups are available to support this person to remain at home. It takes a broad approach to the needs of the particular client. Most old people have a home help service.

On the issue of how we have allocated home help services, that whole objective, ethos and philosophy was brought forward in 2002 when we started using a tool, which is probably what has gone through all the media which has misinterpreted it, for giving time so that we would continue with the objective of meeting the needs of the particular clients in a professional manner. A working group comprising the public health nurse, home help organisers and management discussed the tasks performed by our home helps. The members of the committee have mentioned various tasks such as fire lighting, serving food, making the bed, vacuuming and so on and personal care. It is broken down into personal care and domestic care. In the southern area times have been allocated. To interpret it appropriately, it takes ten minutes for this and ten minutes for that, but it is all the time the home help is in the house. One does not just go in for the half hour. It is based on the need of the individual client and on the capacity of the carer and whether they are near a day centre. We encourage older people to remain socialised, to go to satellite centres and to get involved with whatever voluntary agencies are in the area to keep them independent for as long as possible at home. This has worked well for us.

As we progressed we conducted many reviews on how the process was working for us. We have heard from the clients that no matter what level of service is provided they say it is equitable and accessible and that they get a fair deal compared with other people in, say, Midleton or Ballybunion. They are dealt with professionally. Our home helps are valued members of the multidisciplinary team and, hopefully, the training we provide enhances their skills. We provide on-the-spot training for home helps on special needs such as hoists, moving and handling or putting on special equipment. The physiotherapist, the occupational therapist, the public health nurse, or oncology nurse may assist. There is a positive approach to providing a very important service to our older people. The service is standardised and welcomed by carers and clients alike.

Mr. Michael Fitzgerald

There were a few other questions. About 85% of all home help service is delivered to older people and the balance of 15% is delivered to those with disabilities, mental health issues and some children and families who may have a requirement. Home help is provided to people with dementia and people with all types of needs who can be safely maintained in the community as much as possible. The challenge on a daily basis is to provide a sufficient and adequate level of care. Down through the years there have always been issues regarding the sufficiency of home help. Certainly in 2006 and 2007 there was an increase in funding through the home help service and home care packages. The message from our perspective is that we see it as being an important service. We are only at the beginning of the provision of that level of service if we are to successfully continue to maintain people at home who can safely remain there. The level of investment provided in 2000, 2006 and 2007 for home care packages needs to be continued. Having viewed a Scottish model the investment needs to be continued year-on-year for five years before we can begin to address and reduce the percentage of people over 65 years who have a requirement for continuing care. It is a daunting task. There will also be insufficient provision of home help and home care packages. It is a beneficial and cost-effective service and a very personal service.

To reiterate, while it is a professional service, home help services, where required, should perform domestic duties. That issue was raised in the context of professionalisation and people distancing themselves from some of those duties. Obviously when a resource is scarce one has to maximise its use. Therefore, if people's needs are to be met, many of which are personal, one has to focus in on that. That is not to say that the personal duties are not as significant.

On the provision of guidelines there was an issue concerning the long-fingering of same. No more than the guidelines that are being adopted for residential care it is a significant development for the home care service and one that should be proceeded with. Some of the items in the draft guidelines can be implemented in a short period because there are no significant costs associated with them. They merely provide more oversight on the service. However, there are issues concerning cost, some of which are in the areas of training and ensuring that everyone would reach certain standards. We must bear in mind that we have a workforce of people who have come transitionally from being the neighbour providing the service to the present day with specific contracts and training provided. That is a journey we are on.

I will take two supplementaries from Deputies Flynn and Sherlock.

I would like the question about the actual review addressed. An argument was made about the assessment tool with the involvement of GPs and carers. How can that be true if everybody who is on one hour a day automatically in a review seems to have it cut to three quarters of an hour. On the face to if, it looks like a straightforward cut. I fail to be convinced that any assessment tool is being applied. Is there an independent appeal process?

In regard to the contract to which Mr. Fitzgerald referred, he said the duties are outlined. If a woman receives a letter, as in my case, and is told her duties include three things, is there flexibility for the home help to do something else, or does the contract specify that they are the duties she has to fulfil?

I apologise for coming late to the meeting. I thank the Chairman for allowing me in and forgive me if some of my points have already been covered. In regard to the constituency I represent, Cork East, there is a deep sense that there is not a policy in respect of the delivery of home care packages. I know of nobody who is in receipt of a specific home care package, particularly in the north Cork area. The sense I have of the situation as it relates to north Cork is such that the policy isad hoc and that it is a little arbitrary in that there is no consistency for each individual. One relies on the service but one cannot be guaranteed that it will be delivered to a particular person in his or her home at a given time and it can be cut at a given time also. We want a national policy or guideline that ensures each person has a minimum right. I realise Mr. Mulvihill may have addressed that point already and if he has, I apologise but I want to record it anyway.

Mr. Noel Mulvihill

To reply to Deputy Flynn, we take her point that there appears to be a consistent reduction from one hour to three quarters of an hour. That is something we need to examine, particularly in her area. We will get back to the Deputy on that.

Mr. Noel Mulvihill

That certainly seems unusual. What we are saying is that in some areas the position arose where people were providing a service in excess of their budget. There was a requirement for them to return to their original level of service and I do not know whether that reflects some of what the Deputy is seeing on the ground. The Deputy's point is about the cut from an hour to three quarters of an hour, and that is something we must examine.

On the issue of the appeal system, we see two sides to that. First, there is a needs assessment whereby the professional determines the requirements of the person and, second, there is the provision of hours. We have in place in all areas a peer review of both sides of that. The needs assessment is reviewed by a senior manager in a profession. If it was public health nursing the assistant director of public health or a director of public health nursing would review that aspect. The provision of hours would be reviewed also by a senior manager in the system. If the Deputy provides us with the details on the case she mentioned we will pursue that.

Deputy Sherlock is right about a set of guidelines being required for home care packages. A Health Service Executive task group is completing a draft document on that issue. We will discuss it later in the month with the Department with a view to getting it signed off. We have had some issues with regard to having formal guidelines for home care packages because the question of entitlement keeps cropping up. There is an issue with regard to the legal status of the provision of home care packages and what one can assess with regard to entitlement. That has been bothersome in recent years. A standard approach to the provision of home care packages will be applied and if there are not any further delays in it, it will be rolled out in the last quarter of this year. There will be a training and roll out application form and an appeals process that will be advertised through the system. That should——

Are the means of the applicant being considered as part of that?

Mr. Noel Mulvihill

No. At this point the means of the applicant cannot be considered. That was one of the issues that bedevilled the provision of home care packages. An evaluation of home care packages was undertaken by the Department of Health and Children last year which, on a positive note, concluded that the provision of home care packages was singularly successful in supporting older people with complex needs to live at home, and in supporting acute hospital discharge. While significant issues arose to be addressed, they are being addressed, mainly in terms of the guidelines. We will roll that out during the course of the year if we get approval and following conclusion of the discussions with the Department.

Mr. Michael Fitzgerald

I make a point in connection with Deputy Flynn's area and in terms of the review. I realise it is difficult when there is a reduction in hours. It is difficult for the client and for everyone involved but we are trying to be careful to ensure that review is carried as efficiently as possible. The resource is the same as it was for last year but the demand is increasing all the time. More and more older people now want to stay at home. We have found also that with the system we have for the movement into residential care, the person is assessed and it is almost the high end, so to speak, that go into residential care. The demand on home care is much higher but there is a specific budget available. The division of that budget among that number in that given local health office area often places that demand, which means that we have to review and subsequently reduce hours in some areas where possible to give them to somebody else.

I thank the delegates for their presentation and for dealing so comprehensively with the questions. I ask members to remain while the delegates leave to deal with minutes and some housekeeping items.

The joint committee went into private session and adjourned at 6.25 p.m. until 3 p.m. on Tuesday, 29 June 2010.