Vol. 125 No. 13
Cibé trioblóid polaitíochta atá in aon Teach den Oireachtas is cúis an-áthais dom a bheith anseo libh ar maidin.
The main purpose of the Health (Nursing Homes) Bill, 1989 is to ensure the highest standards of care for dependent persons in nursing homes. It introduces a system of registration for nursing homes.
Can we get copies of the Minister's speech?
It is being circulated. The Bill changes the arrangements for the subvention of persons in nursing homes. It also permits health boards to board out persons who can no longer live at home. I am glad to say there was widespread support for this Bill from all parties in the Dáil. The Bill as passed by the Dáil reflects the constructive approach shown by all parties to the principles underlying it.
As Senators may be aware, the report of the working party, "The Years Ahead — A Policy for the Elderly" sets out a comprehensive framework for the development of services for the elderly into the next century. The report was presented to the Minister for Health in 1988 and its recommendations were accepted by our Government. We have allocated £5 million this year to develop services for the elderly, as recommended in this special report. Health boards have prepared detailed plans to implement the recommendations of the report. As a result of the additional funding made available by the Government, substantial progress will be made this year to improve services for the elderly.
We still do not have a copy of the Minister's address.
I am very disappointed that it has not been made available and circulated. We had it ready.
That is not a matter for the Chair.
This Bill represents another important step towards implementing the recommendations contained in The Years Ahead report.
It is an important principle of our policy towards the elderly that as far as possible they should be supported at home and remain in their community. When they are ill, elderly people should have the same access to acute medical services as younger people. If an elderly person becomes so dependent that they can no longer be cared for at home or in the community, that person should be able to avail of a high standard of nursing care in a health board institution or in a private or voluntary nursing home.
Existing legislation governing nursing homes, the Health (Homes for Incapacitated Persons) Act, 1964, is more than a quarter of a century old. It is important that developments in relation to the care of dependent persons during that period are reflected in the new legislation.
We must ensure that the public will have full confidence in the standards of care available to vulnerable people in private and voluntary nursing homes. The standards of care being provided at present are, by and large, of a high quality but there is a widespread consensus that aspects of the legislation need to be changed.
Private and voluntary nursing homes receive a considerable amount of public funds for the care of eligible patients under the Health Act, 1970. In 1986, the amount of the subsidy paid was £15 million. The existing arrangements for subventing the care of dependent persons were criticised in The Years Ahead report for a number of reasons. This Bill will ensure that scarce resources are used in the most effective way to care for dependent people.
Population projections reinforce the need to define the responsibilities of health boards and nursing homes. According to the 1986 census, there are 382,000 people over 65 years, of whom 143,000 are over 75 years old. The latest projection suggest that the number of elderly will increase slowly up to the year 2000, and then rapidly after that year.
By 2011 a population of 414,000 elderly people is forecast, an increase of nearly 10 per cent. The increase in the elderly population will not be spread evenly throughout the country. Along the western seaboard, the numbers of elderly will decrease by about 12 per cent by the year 2000 while in the grater Dublin area numbers will increase by 30 per cent. The rate of increase in those reaching advanced old age will be particularly marked. It is those reaching advanced old age who have most need of nursing care and who are least able to look after their own affairs. This Bill will ensure that the interests of the elderly in nursing homes is protected and their well being promoted.
Most of the changes proposed in this Bill were recommended in The Years Ahead report. That important report recommended a licensing system for all nursing homes. This would, in the working party's view, ensure, that standards in nursing homes are subject to more regular review and are maintained at a high level. It proposed that a health board should be able to subvent the care of eligible patients, following medical and social assessment, in nursing homes licensed by that board and that the level of subvention should reflect the patient's needs. The recommendations of the working party report reflected the views of the National Council for the Aged, which advise on policy towards the elderly, and which commissioned the first research study on nursing homes in this country.
The National Council for the Aged has also recommended that a licensing system for all nursing homes be introduced and called for changes in the method of subventing the care of elderly people in nursing homes. The National Association of Widows in Ireland at their annual conference last year called for a code of standards and regulations for nursing homes and for the registration of these homes. The Irish Private Nursing Homes Association have also made representations to the Minister for Health about the need for revised legislation on nursing homes.
This Bill addresses the main problems identified with the existing legislation, building on the recommendations of bodies with expertise in this field. It aims to ensure a high standard of care in each nursing home without interfering unduly in the management of the home. It is not our intention to put obstacles in the path of persons wishing to set up a nursing home. The Bill provides safeguards against unreasonable decisions by health boards while providing a framework within which nursing homes and health boards can each carry out their responsibility to care for dependent persons.
There are at present 332 nursing homes in operation in the country. There are 286 private nursing homes and 41 voluntary nursing homes. These nursing homes are being opened at an increasing rate. In 1989 some 20 new homes opened. The greatest concentration of nursing homes is in the Eastern Health Board area. The existing nursing homes cater for approximately 6,500 persons.
It might be helpful to Senators if I explained the existing legal situation and the problems which have been identified in the 1964 legislation. The Health (Homes for the Incapacitated Persons) Act, 1964 is the Act which governs standards in nursing homes. Voluntary nursing homes are excluded from the scope of the Act.
Under this Act, a person who proposes to set up a private nursing home must notify the relevant health board in writing one month before it is proposed to commence operating the nursing home. Regulations have been made under the Act to govern the standards of care in nursing homes. The first regulations were made in 1966 and these were revised and stengthened in 1985.
The regulations govern the standards of care, accommodation and food, the number and qualifications of staff and the description of homes among other matters. The health boards enforce these regulations. At present, the health boards inspect homes at least every six months to ensure compliance with the regulations.
Nursing homes charge their clients for the care they provide, either fully or partially. Some homes are approved for subvention under section 54 of the Health Act, 1970. In these cases, residents can avail of a subvention towards the cost of their care which is paid by their health board. The current amount of the subvention is £6.78 per day per patient.
The Eastern Health Board has made arrangements with a number of private and voluntary homes, under section 26 of the Health Act 1970, to subvent the care of dependent elderly people.
Other boards grant aid to voluntary homes under other sections of the Act.
A number of unsatisfactory elements have been identified with the present legislation. For example, a health board is given short notice, only one month, that a private nursing home is about to commence operation. A nursing home may be set up which does not in all respects comply with the regulations. The health board may, after the fact have to set about ensuring that the regulations are met. It would be better if the health board could ensure that standards were satisfactory before the home opened.
The only sanction available to a health board against a nursing home which fails to comply with the standards laid down in law is prosecution. This is a remedy which should only be used in relation to serious and intractable breaches. While the vast majority of nursing homes comply with the regulations and co-operate well with the health boards, it would be better if health boards, as the regulatory authority, had more flexibility in carrying out their functions.
Health boards should be able to ensure that a nursing home complies with the required standards before admitting its first patients. The best way to do this is to require a nursing home owner to register before opening for business. Future compliance can be encouraged by a requirement that registration be renewed on a regular basis.
The health boards are statutorily responsible for the provision of health and personal social services in their areas. We are recognising both the statutory position and the practical working arrangements in proposing that health boards will act as a regulatory and monitoring authority in relation to private nursing homes. The staff of health boards have the expertise, the local knowledge and the integrity to discharge these important functions.
There are many charitable nursing homes in operation which are not covered by the 1964 Act but which are caring for dependent persons. Many are in receipt of public funds. I agree with the recommendations of The Years Ahead report and the National Council for the Aged that all homes providing nursing care for dependent persons should be covered by the legislation. Many of these homes have in the past set the standards for the care our society gives dependent people. An obligation to register with a health board should not pose any problem for the overwhelming majority of these homes. Nursing homes already in existence on the day the Act is commenced will have a year to register with a health board. This phasing-in period will give homes time to adjust to the new legislation.
I will now outline the main provisions of this Bill. A nursing home is defined as a home caring for more than two dependent persons. The term "incapacitated person" is replaced by the term "dependent person". A dependent person under the Bill will be someone who requires assistance with the activities of daily living such as dressing, eating, walking, washing and bathing due to physical infirmity, disease, defect or mental infirmity. These are the activities which are now used in modern nursing to assess the level of dependency of a person. Most persons covered by this Bill are elderly but dependent people in younger age groups will also be included.
All homes providing nursing care for dependent persons will be included whether run for profit. Acute hospitals, health board hospitals and homes, maternity homes, psychiatric hospitals, children's homes, certain homes for members of religious communities, voluntary mental handicap homes and homes such as those of the Cheshire Foundation, are excluded from the scope of this Bill. There are good reasons these categories of homes should be excluded which, by and large, were accepted in the other Chamber. People being cared for by their families are also excluded.
This Bill as initiatied in the Dáil provided for a system of licensing nursing homes as recommended in The Years Ahead report and the National Council for the Aged. During the passasge of the Bill in that House the Minister was persuaded by the arguments in favour of registration of nursing homes rather than licensing. This Bill was so amended on Committee Stage.
The person wishing to set up a nursing home will apply to the health board for registration. The health board will have to satisfy itself that the nursing home complies with the standards laid down in regulations and that the proprietor and the person in charge of the home are fit persons to carry on or be in charge of a nursing home. This information, required by the health boards, will be requested in the application for registration. The information required will be standardised between all health boards. A registration fee will be payable by the applicants.
The duration or registration will be three years, at which stage it must be renewed. It will not be possible to open the nursing home until registration has been granted. Only a registered nursing home will be entitled to call itself a nursing home. The registered nursing home will be included on a health board register of nursing homes for the health board area. This register will be available to anyone who wishes to consult it, free of charge, at all reasonable times. It will enable anyone to obtain information on nursing homes registered by the health boards.
The detailed requirements which a nursing home will have to meet will be set out in the regulations. The 1985 regulations under the existing 1964 Act will continue to apply until new regulations take effect. Draft regulations have been circulated and there has been widespread consultation with interested groups on the contents of the regulations.
Under the provisions of this Bill, health boards will not just play a regulatory role. They will also be authorised to provide Training for nursing home staffs and to provide a range of anciliary services, such as chiropody, occupational therapy and physiotherapy to nursing homes on mutually agreed terms and conditions.
The best features of the existing regulations will be retained, such as the requirements that health boards inspect homes at least once every six months, a nurse must be on duty at all times and proper records be kept. A health board's ability to set and maintain good standards of care in nursing homes will be greatly strengthened by the proposed registration procedures.
A registered nursing home proprietor must apply for a renewal of registration at least two months ahead of all expiry dates. This gives the health boards a reasonable period in which to respond to applications for renewals. If the boards do not inform the applicants of their decisions within two months of each application, then registration will be granted automatically. This provision will encourage health boards to assess applications promptly and protect nursing homes from unnecessary delays. If a nursing home is sold during the period of registration, registration automatically lapses. The new owner must apply for registration within four weeks.
One of the amendments which the Minister for Health introduced on Committee Stage in the Dáil was to allow a prospective nursing home owner seek a declaration from a health board in advance of purchase of the home that he or she was a fit person to be a registered proprietor. This will allow a person buy a nursing home in the confidence that he or she will be registered by the health board.
A health board can only refuse to grant or renew registration or revoke registration for specific reasons. It can do so if it considers that the premises or the manner of running the nursing home does not comply with the regulations. The health board can also act if it has not been been furnished with necessary information. Finally, it can use its powers of refusal if the owner or person in charge has been convicted of an offence under nursing home legislation or of a serious offence which would render the person unfit to carry on a nursing home.
A health board will be able to attach conditions to registration at the date of issue or later. A condition could, for example, require certain improvements to be carried out to the home by a certain date. If an applicant for registration or a registered owner feels aggrieved about a health board's refusal to register or reregister the home or considers a condition attached to registration is unreasonable, he or she can ask the health board to review the decision. If still not satisfied, the proprietor may appeal the decision to the District Court.
Concern has been expressed from time to time that the title "retirement" or "rest home;" is being used to avoid the obligations of existing legislation. I am not concerned with the genuine retirement home where the residents are independent and receive no nursing care. I am concerned that a home could call itself a retirement or rest home but in practice be looking after dependent persons requiring nursing care. At present health boards have no authority to inspect such homes. Under this new Bill, they will be given power to inspect any premises where they consider dependent persons are being maintained. Heavy fines will be imposed on people found guilty or caring for dependent persons in an unregistered nursing home.
Situations have arisen when standards in a nursing home have fallen so low that urgent action is needed to protect the interests of the residents. It may be impracticable to transfer the residents to other homes. One solution which has been found to work is to allow the relevant health board assume the management of the particular home, until the problems have been resolved.
Under this Bill, a health board will have the power to assume the management of the particular home with the consent of the registered proprietor or in pursuance of an order from the District Court if a nursing home fails to comply with the standards of care in the regulations.
The period of the management order may not exceed three months or, if the board is acting on an ex parte court order, not more than two weeks. Any expenses incurred in managing the particular home during the period will be paid from the nursing home's income. The health board will be able to recover from the nursing home the salary costs of the person which the board appoints to run the home.
These provisions allow health boards to protect the welfare of dependent persons in nursing homes where the standards are such that the health of the residents is in jeopardy. It is intended as a temporary measure pending longer term action being taken, such as the transfer of patients to a more suitable location or a change of management of the home.
Technically, every person entering an approved nursing home is eligible for subvention since the extension of eligibility for care in public hospitals to the whole population in 1979 — something brought about by the Taoiseach, Deputy Haughey, then Minister for Health. Under section 54 of the Health Act, 1970, a health board may pay a subvention to a person in a home approved of by the Minister for Health. The scope of section 54 has been curbed as no new homes have been approved since 1980. Unfortunately, due to constraints on the financial resources in the health services, it was not possible to approve new homes. Senators may be interested to know that there are 78 approved homes out of 332 private and voluntary nursing homes. The present system of subvention discriminates against the many excellent modern homes which have opened since 1980.
Under the Bill, if a dependent person requires nursing care but the person is not able to pay all the costs involved, that person, or his or her relatives, will be able to apply to the health board for a subvention. Health boards will be able to contribute to the costs of maintaining a dependent person in any registered nursing home. The health board will assess the individual's level of dependency and their financial circumstances in making their decision to contribute to the costs involved.
It is important that an individual seeking a subvention is assessed before they go into a nursing home. It may be that the health board can arrange for some other form of support to solve the problem and allow the person to remain independent and in their own home. If the person is assessed as requiring nursing home care and is unable to pay the full cost, the health board will be enabled to pay a subvention. The health board will be able to vary the subvention to match the individual's dependency.
I am proposing that there would be payments for three categories of physical dependency — light, moderate and heavy dependency and possibly one category for those with severe forms of dementia. The amount of the payment will vary because the more dependent a person is, the more expensive the care. The level of payment will be fixed by regulation, following consultation with the relevant interests involved.
I wish to stress that any person in receipt of a subvention at present under section 54 of the Health Act, 1970, will not be affected by this Bill in any way. These subventions will continue to be paid as long as the person is in the particular home. However, no new applications will be accepted for section 54 subventions when the provisions of this Bill take effect.
The Minister for Health has already given an assurance in the Dáil that the overall level of financial support for people cared for in nursing homes will not diminish as a result of this Bill. This provision is not about saving money. It is about enabling health boards to target their available resources most effectively and to respond flexibly to the changing demands of dependent people for whom they have responsibility. This is the approach which the new subventions arrangements provide for.
Under a general provision of the Health Act, 1970 — section 61 — health boards may make arrangements to assist in the maintenance at home of a person who would require to be maintained otherwise than at home. These persons are frail elderly people who do not need nursing services but who require care and companionship. One of these arrangements is boarding out, which is a practical response to helping an elderly person maintain his or her independence by assisting them to live in their own community, near to their family and friends. This Bill give health boards specific legal authority to make boarding out arrangements for persons who can no longer live at home and who consent to be boarded out, subject to regulations to be made by the Minister.
Health boards will be empowered to contribute to the cost of a boarding out placement. Boarding out regulations have been drafted and discussed with interested parties. The regulations will ensure that boarded out persons are protected and that health boards supervise all placements.
It might interest Senators to know what this Bill does not do. It does not set out to limit in any way the establishment of nursing homes. The State, under the 1964 Act and the 1985 regulations, already has a statutory responsibility to ensure a minimum standard of care in nursing homes. This Bill updates the existing legislation to take account of developments in the care of dependent persons by establishing a framework for registration of nursing homes.
The Bill does not interfere with a person's right to choose nursing home care. It does not attempt to direct individuals towards particular nursing or geriatric homes. It will, in fact, widen the choice of persons entitled to a subvention from the limited number of homes with section 54 approval to all registered homes. Where someone needs financial assistance to pay for nursing home care the purpose of the assessment is to ensure that a nursing home is the most appropriate option and that the health board is directing its resources to those in need.
This Bill promotes the welfare and well being of dependent people in nursing homes. Legislation, by its nature, is concerned with minimum standards. I intend that, in partnership with the health boards and the nursing homes, we could go further and agree a code of good practice for nursing home care. A code has been drafted and a group of experts representing the interests involved has been invited to comment on the first draft. The draft code sets out the best practice to which homes should aspire and which health boards should encourage. Such a code was recommended by the National Council for the Aged and I believe it will make an important contribution to achieving high standards in all homes.
The code will reassure people that the arrangements made for the care and protection of those who can no longer care fully for themselves are the best possible. It will also encourage a uniform application of the legislation in all health boards.
Nursing homes and health boards have a complementary task of caring for the elderly. The growth of the nursing home sector has been rapid in response to the growth in the number of elderly people and their increasing income. The right of elderly people to make private arrangements for nursing care in their later years is not in question, but the nursing home sector cannot be considered in isolation from publicly organised services and the standards that should be expected from all service providers both public and private. It will be necessary to consider the role that nursing homes can play in the future in caring for dependent persons through full-time residential care, day care or respite care. We will have to be aware of how private and State funded services can work together effectively.
There is a need to explore the implications of a closer relationship between health boards and nursing homes in the future. This was an issue raised with the National Council for the Elderly which the Minister for Health appointed earlier this year. I am glad to say that the council has already commissioned research on the issue and the Minister looks forward to receiving the findings and the recommendations of the council in the near future.
The provisions of this Bill will make for a new relationship, a new partnership between nursing homes and the health boards. Both parties will have to work closely to ensure that the Bill's requirements are met. This co-operation will contribute to a clearer appreciation by each party of the other's difficulties and responsibilities. A co-ordinated approach between health boards and nursing homes and only improve the quality of care available to dependent people.
It is worth noting that only 5 per cent of our elderly are in institutional care at any time, under the care of health boards or private and voluntary nursing homes.
A much higher proportion of the elderly, 17 per cent, are being cared for at home by their families. We must do more to support these families through help at home and respite facilities. I would like to see more arrangements between health boards and nursing homes to provide day care for dependent elderly people cared for by their families or respite facilities to allow carers a break from their heavy responsibilities. The framework provided in this Bill, should encourage this kind of co-operation.
Nursing homes are an indispensable part of services for the elderly. This Bill seeks to strike the right balance between ensuring that the interests of some of the most vulnerable members of our society are protected without undue interference in the management of homes. The Bill was substantially amended in the Dáil to take account of the suggestions of the Opposition parties. I am prepared to accept the suggestions of Senators which would improve the Bill further. It is in all our interests to produce legislation which will promote the best interests of dependent people in nursing homes.
I look forward to the Senators' contributions and to bringing to conclusion this very important Bill.
This Bill, which will in substance be supported by my party — although we will be proposing amendments and teasing the Bill out on Committee Stage — must be set against the background of the whole issue of the care of the old. As the Minister pointed out at the outset, there is a tremendous escalation in the number of old people in our society at the moment. By the year 2011 there will be 414,000 old people, representing an increase of 10 per cent. When you take emigration into consideration we will have a geriatric society. There is also the very welcome development of the new status of women and their role in society, in that many women are now finding meaningful work outside the home. Most families are becoming dual income families, certainly in the cities and towns. That again contributes to the fact that we have a problem with the care of the old.
Traditionally, Ireland was a society with a tremendous commitment to its old people, where the old person was a very valued member of society. Many historians would have argued over the years that we were too gerentocratic, too committed to our old people and their welfare, often to the detriment of our youth. While one would question the kind of care that our youth may have got at times, I think a tradition of care for the old is a valuable and worthwhile one.
There are a couple of facets to the care of the old and, before I come to the specifics of the Bill, I want to look at these. Every Minister and a large number of politicians over the past 20 years have paid lip-service to the concept of community care. This is the concept where the community public health nurse, the GP, the local social services or whatever manage, in conjunction with health education people and with subsidised funding from Government, to keep people in their own homes. The concept of community care is a very noble one and is right by any criteria. It is right that an old person would live in their family unit for the greatest possible period of time. It is right that illnesses and difficulties be dealt with at that level. Truthfully, I would have to say in the House today and put it to the Minister — indeed, it can be levelled at many politicians from all sides of the political spectrum — that we have not in any sense done anything for community care; we only pay lip-service to it.
There is at the moment on a very practical level a tremendous shortage of public health nurses. It is estimated by the Irish Nurses Organisation, and indeed by more objective commentators, that 400 more public health nurses would be needed in the country at the moment to provide anything like a proper level of community care. At a time when monetarist economics are so fashionable and when cost effectiveness is so much on the lips of every legislator, often to the detriment of good health and social policy, it should not go unnoticed that community care is extremely cost effective as a method of dealing with old people and with sickness in society.
Of course, coupled with community care, which is the first area of care of the old, there is geriatric care, the traditional geriatric homes under the health boards. Because of the recent cutbacks — and I have to put this on the record of the House — there is a major problem in geriatric care. For example — and I believe this example is repeated throughout the country in a considerable way; not in every instance but quite considerably — all through last winter in St. Phelim's Geriatric Hospital in Cavan there was a tremendously long list of people waiting on admission to the hospital. It went so far that admission to the hospital was dependent on the death of a person already in the hospital, and that is a very sad state of affairs.
When we are talking about the very worthwhile report on the care of the aged, we have to address that question. As well as addressing community care, we have to address the whole issue of geriatric care in the traditional State geriatric homes. I believe that the day care centres, which have been a new phenomenon in recent years, are a most welcome development. They should be encouraged at every level.
However, the primary issue under consideration today is the one of the private nursing homes. While many private nursing homes have operated with standards of excellence in the past, there is no doubt — and I believe the Bill, though it has defects, is an essentially worthwhile response to this — that in some nursing homes there were examples of malpractice. There is no doubt there was a lack of recreational facilities, that recreation was confined to a television room, that diet could be in question, that the whole lifestyle of the homes was questionable, that people may have to get up extremely early or go to bed at a particular hour. It is also known that the level of medical back-up and medical facilities within the homes was questionable. That is why a measure which would deal with that is so important.
To go through specific aspects of the Bill, the first thing I would be concerned about in the legislation is that there will not be national standards. Under the proposed legislation each health board area will be responsible for the policing and monitoring of nursing homes in its area. I know that a code of practice, which I want to turn to later, is being negotiated or worked out but I am still concerned that subjectively and local consideration will come into play and that there will be confusion about this. I have discussed this pretty widely and I was told last night by a person in the financial sector that a number of people now are establishing nursing homes in different health board areas and that they will have a lot of problems, as actual owners of the homes. I am concerned about a lack of uniformity if it is at the discretion of the local health boards to control the homes in their area and I think we could usefully return to this on Committee Stage.
I am also very concerned about the staffing arrangements in the nursing homes, that there may not be an adequate number of qualified nursing staff. I think that is an extremely important issue. It brings up all sorts of side issues, like payment and the level of pay and remuneration. We will need to have it clearly elucidated for the House by the Minister before we could let this legislation pass that there will be qualified staff functioning in the nursing homes at all times and that there would be no question of a less than fully qualified staff operating there. That is important.
I am concerned about the code of practice because I think it is all very vague. I am honestly of the view that the legislation should have set out some broad parameters in terms of the practice of the nursing homes. I am thinking here of the amount of space per bed, of the arrangement where a very ill person who may be suffering from senile dementia might be in a room with a less ill person, for example. I am thinking of the dietary arrangements, the menues and so on, in the nursing homes. I am concerned about recreational facilities other than a television room in the nursing homes. This is an issue we do not address very often. I am thinking, of course, of staffing and of lifestyles in the homes — the time people are required to get out of bed and go to bed. Obviously, there will be individual variations here. Some people in the House may consider this a little simplistic looking at these issues but, in essence, these are the real issues. At the end of the day the real issue will be the quality of life of the individual in the nursing home, the kind of lifestyle, food and recreational facilities they will have.
I have met some people who are involved in the running of nursing homes. I visited one home in Belturbet in County Cavan, quite an excellent one, and I went through the whole thing there. I met the management, I would be the first to concede to the House that many people are ethical and quite proper and professional about their work, but we have to be very sure to deal properly with the cowboys and those less ethical. I know that is the spirit of the legislation but I am genuinely concerned that we are not very specific about it. I would like, when we get to Committee Stage, to have a very specific notion of what the requirements will be. I am concerned about the code of practice and uniformity.
I am also concerned about the inspection system of the nursing homes, and this raises a fundamental question. According to the Bill it is proposed that approximately every six months a nursing home would be inspected at local health board level by qualified personnel. I submit that one of the qualified personnel would need to be a local community nurse. I would also be of the view that there would need to be another medical person on the team of inspection. When you look at the submissions from the Irish Nurses Organisation, the IMO and other bodies in the health care area and when you look at their argument that they are understaffed, I am sincerely concerned that inspections may be very perfunctory. I am not proposing — and I do not want the Minister to misunderstand this — a plethora of bureaucracy and a plethora of irrelevant appointments and a waste of public expenditure; but I am concerned that existing situations may not allow for a totally comprehensive inspection.
I would like the Minister on Committee Stage or when replying to Second Stage to give us a clear concept of what he considers adequate inspection. What kind of personnel will carry out the inspection, and how will they be monitored? I know they will have to operate within the code of practice, which to me is still quite vague but I am concerned about the mechanisms there for inspection. I think they have to be very tight. There has to be a full team of inspectors. The embargo on the public service, which has operated over a number of years and through a number of Administrations, the shortage of nursing staff and the general pressure on the staffs of the health boards will present problems with inspection. Inspection should not be perfunctory. It certainly would not want to be announced. It would not want to be a person calling in and having a cup of coffee and a biscuit with the administrator of the home, having a chat and then leaving. It would want to be a very detailed, thorough and clinical operation carried out by qualified personnel — a whole monitoring system, right up to departmental level, even to ministerial level, of the inspection process. Again, I return to the question of uniformity, because I would feel more reassured to know — and we are all for localisation where possible — that there would be a central authority, and that the Minister's office would be in close contact with the inspector and the inspection systems ensuring uniformity of standards. I am glad to see the Minister show approval for this concept that the inspection would not want to be perfunctory. That is extraordinarily important. We all know, as practising politicians, that some inspections are less than thorough. For that reason the inspections of these nursing homes would want to be very thorough because of the critical nature of what is involved here. I am concerned about that.
That raises the question of nursing staff and community care which I addressed earlier. We have to look at this area. When you think of the cost of hospitalisation and the cost involved in the nursing homes in this area of health, I believe future analysis of health policy will fully confirm that there is a tremendous need to look more towards community care. All of us have paid too much lip service to this in the past.
I have dealt with the question of inspection of the nursing homes and unformity; now I would like to turn to the question of subvention proposed by the Minister. I welcome the concept of subvention and I also welcome the methodology that is proposed but I still think it is a bit vague to say they will assess need.
As we have successfully done in relation to higher level education grants and in other areas, I would like the standards adopted for getting medical cards, etc., to be taken into account and to look at the income ceilings and income bands where we might consider varying levels of aid. I take the point in the Minister's speech that sometimes an assessment of an individual proposing to go into a nursing home would involve a transfer of that person or a redirection of the person or of the services. I will be interested to hear the Minister's reply to this on Second Stage.
We have not heard how much of the national budget will be dedicated to subvention or how much of the health boards' budgets will be dedicated to it. There is nothing specific mentioned about it. There is nothing specific about the bands of income that will qualify people for subvention. I am genuinely concerned about that. I have no great objection to the principle of subventing a person in a private nursing home once we make sure that in no sense it is in conflict with the proper subvention and proper standards in the traditional State geriatric hospitals, but I assume that that is not the intention. That would want to be made very clear from the outset: nothing must gain precedence over funding of those in need and the poorer elements in society. The funding of their geriatric care can never take precedence over funding of better off persons. I assume that is not intention. What I am concerned about is that there is no budgetary provision, there is no estimated figure, there are no bands of income and it is very undirectional; it is a very vague commitment to the concept of subvention. Undoubtedly, we will be teasing that out further on Committee Stage.
The question of boarding out concerns me a lot. I am very interested in it. It is a good idea if we could get that to work properly. It is a good idea that people live in their own communities. It is a good idea that they would not be uprooted from the environment they have lived in over a period of years. I come from a rural society where there has been a tradition of boarding out. The tradition has been that people, often in exchange for a parcel of land or whatever, come to live with a neighbouring family in the latter end of their life. That principle is a good one, and the concept is a good one. I urge the Minister to further analyse that question and to look at it as a very real method of dealing with geriatric care which will pose so many problems in the latter end of this century and the beginning of the next. But I have worries about it.
The Minister, given the kind of constituency he comes from, and many Members of the House will be aware that in the past there have been great abuses here — although I know we never had a State system of boarding out, or not much of one anyway. We have had people in this country in the past who have taken foster children into their homes, who have taken old people into their homes, where the manipulation of the human person and the use of the human person was the source of subsidy to their home in the sense that if they had a couple of foster children, they got X amount of money for them and if they had old people in their home they got so much money for keeping them or they were paid in the form of property or liquid cash. To say "in many cases" would be slightly exaggerating the situation, but in a considerable number of cases, in a number of cases anyway, there has been abuse of this.
There are people who exploit those who are vulnerable. I would be concerned about that. I am not sure the legislation is sufficiently clear on this issue. I would like more specific information on the kind of standards that will have to pertain in the homes where the old people are to be boarded out. I would want very clear knowledge on what kind of directions will be given to those homes. That must be important. I would want a clearer definition of the inspection system. I understand from the legislation that this will be a function of the local community nurse. If we return to the Irish Nurses Organisation's point — and that of many other interested parties in the health area — that there is a shortage of 400 public health nurses in the country generally and a grave shortage of community personnel, then the question must be raised as to the effectiveness of the system of inspection of the boarding-out facilities.
I am concerned about the boarding out arrangements, first, from the point of view of there being a lack of clearly defined national criteria for boarding-out in terms of facilities such as basic food, back-up services and so on. Secondly, I would be concerned about the inspection system, as I am also concerned about the inspection system of nursing homes. We must have a clearly defined position here. Boarding-out is a good and worthwhile principle and one that we must pursue much more over the coming years. There can be no doubt it is ideal for old people to live in their own community, have no change of environment or atmosphere, if that is their wish. In so far as we can achieve that, it is a worthwhile concept, just as the day care centre which operates in their community and allows them to return home is worthwhile.
I do not object to the principle of boarding out but we will need clarification from the Minister as to what sort of criteria will exist to establish where people will be boarded out and what sort of inspection system will obtain. I do not believe the Minister is unaware of the potential for abuse here. The tragedy is that in the midst of so many good homes, very caring people and worthwhile boarding-out facilities, the few cowboys will damage a good record. That would be a tragedy.
I am concerned that there may be tremendous variation in fees for nursing homes; there is nothing in this Bill which will ensure proper price control, or control of the cost of being in a nursing home for a period. I accept and am conscious of the fact that it is very difficult to arrive at a pricing mechanism. It would be inappropriate to introduce a national pricing structure as it would be a disincentive to very good care in nursing homes but I am still concerned that there is a big variation in prices. I was conscious that this Bill was coming up and, being reasonably new to this brief, I made some inquiries as to the prices of nursing homes and found that there was a variation from £160 to £200. I would be interested in the Minister's response to that; perhaps he will suggest some mechanism that might be put in place for price control.
I know the Minister, Deputy O'Hanlon, made the point in the Dáil on this issue that the health board when assessing subventions would also become aware of prices in homes and might do something about it but I do not know if that would be adequate. It would be the function of the official to arrive at an adequate level of subvention but he does not deal with the other issue. I am concerned about the cost of nursing homes and I would like to see some price control being introduced to ensure protection for the consumer, as is the case in many other areas.
Those are the essential points I wish to raise at this stage on the Bill. The question arose during the Dáil discussion as to why the Bill's provisions were not applicable in the case of religious orders and religious communities. The attention of the Lower House was drawn to the fact that there had been a fire in recent years in a religious community in Dublin which posed many questions. I have mixed feelings about it. I see difficulties with individual religious orders in relation to the fact that they would have people in their homes who were marginally well and marginally unwell. It would be worthwhile considering extending the provisions of the Bill to those homes because it might be discriminatory against vulnerable members of religious orders who, because of their age and state of health, may not be in a position to determine their own well-being. I am concerned about that. Perhaps, the Minister will consider extending the provisions of the Bill to the religious orders and communities.
I welcome the Bill in principle. It is worthwhile, timely and appropriate legislation because it is tackling something that needed to be dealt with. However, I am concerned about the inspection system, the localised character of the system, its possible lack of uniformity, the lack of inspectors and how that whole system would function. I am also concerned about the code of practice. Perhaps I do not understand how the parliamentary draftsman operates but I cannot see why we could not have put in some of the broad principles, rather than leaving it to a code of practice. The legislation should have allowed some of the broader principles to be established therein. It is critically important that we get the issues of the code of practice and the question of uniformity right.
I am concerned also about the question of staffing of the homes, the kind of personnel and their degree of qualification. I am concerned about the staffing outside in the community which I mentioned in relation to the inspection issue. However, we will return to these issues on Committee Stage. It is not the intention of my party to obstruct the legislation because we see it as critically important to the welfare of old people who are often unable to determine their own existence and are in a very vulnerable position in homes.
I welcome the Bill. It is sad that we have to have legislation of this kind. Our country had a tradition of caring for its youth and its aged; now we are in the mainstream in relation to créches and nursing homes. That is progress and there is nothing we can do about it but we should provide the environment to ensure that our people will be well cared for. Looking after the elderly is nothing new. It was something like this that inspired Robert Burns when he wrote "Man Was Made to Mourn"; Look not alone on youthful Prime or Manhoods' boyish might. Man then is useful to his kind Supported to his right. But see him on the edge of life with Cares and Sorrows worn. The Age and Want, Oh! ill-match'd pain, show man was made to mourn. I realise he would have to say now, “person was meant to mourn”; otherwise he might be violating some rules. It is rather sad.
I hope you will repeat that later for Senator Norris.
He would not think we were capable on this side of the House.
I am very pleased that the word, "registration", rather than "licence" is being taken into account. Registration is more appropriate than licensing although when this was discussed in many places "licensing" seemed to be the operative word. However, I am pleased that the health boards will mainly be implementing this Bill, I have complete and utter confidence in them as they have done a magnificent job. I asked a number of councillors if they got many complaints about personnel in the health boards and they said they did not.
I was a member of a health board for nearly 18 years and for the last five or six years was Chairman of the Association of Health Boards. We hold a conference each year; we invite all types of politicians from the urban council up; we invite nurses, doctors, dentists, chemists and all people who care for the health of our community and I have yet to hear criticism of a health board at any of those conferences. The health boards have their finger on the pulse. At a time when there is so much talk about regionalisation it is terrible to think that anybody would contemplate having some kind of a Baile Atha Cliath board looking after the welfare of the homes.
In the tourist industry, health boards and health inspectors look after hotels, restaurants and pubs and they do it in a very sound, solid and impartial manner. They carry out their work in a very sympathetic, reasonable and sensitive manner. I know that the health boards personnel will treat this in the same reasonable, sensitive and sympathetic manner. They will be reasonable but firm — that is their motto — and understanding of the needs of the patients in the homes and the proprietor. I have no doubt they will do a very good job. I am a member of the least political county council in the country and I am pleased that this is a non-political Bill.
That is a rare bird.
That is true. Sometimes politicians may not get credit for it but across the board we do think of the individuals for whom we are catering. I am fully convinced we have in this Bill considered the patients and the Minister is to be congratulated on accepting an unprecedented number of amendments from the Opposition which he has now incorporated in the Bill.
The Bill has been well researched. I am amazed there was any criticism of community care which care is one of the best services the health boards have and are providing. The question has been often asked if the community want some of the care. We know the opposition we can get from the community when we try to do what is best for patients. We all know of instances where the community do not want services. Rather than criticising the community care dispensed by the health boards we should be asking if people are prepared to accept community care; are they prepared to accept people less well off than themselves in their midst and living within their community? This is a big problem.
The Taoiseach, when he was Minister for Health in 1977 to 1979, provided the prescribed relative's allowance for the care of the aged, free electricity allowance, free television allowance, free telephone rental, living alone allowance, a whole range of allowances for the elderly. The Government and the health boards have done great work in the community care field. I would hate to think that anyone would criticise community care or health boards because if we do we are criticising a great body of people who started out from scratch. There was no care of the elderly or community care until the health boards introduced it. The health boards have done a very good job and I know they will continue to do so. They will be able to assess patients and advise them on the best type of nursing home.
I hope there will be a range of homes because I see a need for nursing homes to cater for severely handicapped or incapacitated people. I also see the need for nursing homes to cater for people who are able to get around but who are not capable of living on their own; they need a different type of care. I do not think one small nursing home will be able to provide the sort of services of a big geriatric hospital which has different areas and a full range of personnel to cater for severely and mildly handicapped people. It is rather sad that there is a need for nursing homes but, on the other hand, if we reach old age, we can look forward to spending our days in one of those homes and there should be a wide range of homes available. It is obvious if we do not care for our fathers and mothers we cannot expect our sons and daughters to care for us.
There may also be a need for nursing homes for short-term care and people might prefer to cater for that type of patient. A person may only need short-term care when they come out of hospital following an operation. At present nursing homes cater for such persons but they are very expensive. We need somebody to go into the business of providing care for a month, two months or over a winter period.
The Bill really emanated from the health boards. They set up committees to deal with the care of the elderly and got that section of society working. As a result a health board conference was held and the Minister appointed the working party. I congratulate him on appointing the working party who produced the document, The Years Ahead — A Policy for the Elderly. They were a good group of people and they produced an excellent document, the main part of which is incorporated in this Bill. It is not something that has just been taken out of a hat. It has been well researched by people who know and understand the needs of people and who are working with the people concerned. I am very pleased that the Bill has been so well researched.
I want to comment on rural needs versus city needs. In the rural areas up to 15 per cent of the population are old people, whereas in the city it is only about 9 per cent. Many of us who are from rural areas know there are townlands where one in three people is aged 65 and over.
In those areas these are no young people to help or care for the elderly. I wish ta pay tribute to our local authorities who are so much maligned and abused at times. They provide sheltered accommodation which keeps people in their own area. There are many of them in Dublin; I have visited people in sheltered accommodation here. They have a main dining hall and sufficient accommodation to cook breakfast or to make tea for a neighbour or friend when they come to visit. This is a great system too and it is being monitored by nurses, social welfare officers and officers of the health boards.
Nobody has complained that these shelters are not being well supervised. They are being supervised for medical purposes, by the health boards.
That system means that people stay in the community a little longer, perhaps not in the townland or street in which they lived but at least near enough for neighbours and friends to visit. As we all know, there is nothing old people like better than someone to come and visit them. Loneliness is one of their greatest problems when they go to a nursing home or to sheltered accommodation. It is characteristic of Irish people to visit the elderly and to talk to them about old times and whatever is topical in their local area. They like to keep in touch and sheltered accommodation is doing a great job in this area. This system is, of course, 100 per cent funded by the Government, which is something we sometimes overlook. Our county councils deserve our congratulations for the work they are doing for the elderly and it all stems, not from officials, but from local elected representatives who make submissions at council meetings. Very often the elected representatives do not get any credit for the work they do in that regard.
I was delighted the Minister made £5 million available for elderly people in his last budget which was a great help to health boards. In any disbursement of funds we should appeal to the Minister to look closely at the mileage, the terrain, the area that has to be covered and the number of elderly in the area. He should make sufficient funds available to allow people in rural areas to have as high a standard of living and the same standard of service as those living in cities or towns. This might not be easy, having regard to the mileage, the terrain and the fact that people in rural areas live some distance from each other. However, more money should be made available to rural areas than to built up areas because people live in close proximity to each other and the inspectors have fewer miles to travel. For example, the Western Health Board area, from Malin Head to Carrick-on-Shannon is nearly half the length of Ireland. It is a large rural, mountainous area where many old people live — say, one in three in the main townlands. It is important that extra funding is provided for rural areas.
I have already mentioned nursing homes for different types of people, but I will refer to that again. In rural areas particularly when health board personnel assess somebody, they should be able to send them to a nursing home rather than to a geriatric hospital. I have no doubt that our geriatric hospitals are of grade A hotel standard and I compliment all the staff who work in those hospitals. They are working with vulnerable people; they are doing wonderful work and their care is of the highest standard. I visit many hospitals throughout the country and when I visit geriatric homes and homes for handicapped people, I see the amount of work that is done for them. Nurses lift them out of chairs, link them up and down corridors; get them out of bed against their will, cajole and coax, and sometimes mildly threaten them to get them out of bed and walking. We all know that if an old person lies in bed, he or she becomes a vegetable. Those nurses have a skill, talent and vocation in handling and caring for those patients: I would like to see this same care provided in nursing homes.
I saw an article in an English newspaper recently about the crèches in England. Some children do not speak until they are well advanced in years because, while they are excellently cared for, the nurse just puts them into a cot, leaves them there and does not talk to them.
Children need more than just cleanliness and food; they need to be talked to and to be given love and care. Those children got the care and food, but they did not get the love or anybody to talk to them.
The same can happen with old people.
"Once a man, twice a child", is an old Irish saying — perhaps I should say "Once a person" because I have been called to order at meetings a few times by women when I refer to men.
I did not say anything.
I know the Senator did not, but I am conscious of it now, "Once a person, twice a child". Old people need a lot of care, to be talked to and they need to be got out of bed to move around.
They will tell you they hated getting out of the bed, but when they got up and walked around they felt much better.
While we may have very good hygienic nursing homes, where the patients are very well cared for, we might not have the personnel to devote sufficient time to those patients. If we had a mix of nursing homes, where some would care for the chronically ill, some for the not so seriously ill, and some just rest homes, they would be able to provide super services for each type of patient. That is something that needs to be thought out. It is not enough to keep patients fed, clean and clothed; they need far more which is one of the problems facing society today. We are adopting the attitude that it is enough to feed a child but that child wants love, care and to be listened and talked to. We are getting selfish, our time is so valuable that we cannot sit and talk. That is a great pity, because old people want somebody to sit and talk to them. As was said previously, some of our greatest historians have admitted that they would not have been so successful if they had not talked to old people about what they could tell them of the past but had had to depend on computers. I would like to see nursing homes operating under those criteria, which would ensure that all patients were properly assessed and that the nursing home would be recommended to them.
I do not see a problem with the price of nursing homes. I know some are dearer than others, but the health boards will be able to cater for this because they are experts at managing money and providing a good service with scarce funds. They will negotiate and assess and will know exactly what nursing homes are charging; they will be able to keep their thumb on prices and on cowboy operators
I am pleased that this Bill will ensure that nursing home registrations are applied for three months in advance because that gives the health board an opportunity to assess the client and view the establishment. Then there will be two months before there is a decision on it. That is good because two months is a reasonable time and does not allow something to be left on the shelf for too long.
I do not envisage a problem with selling and buying nursing homes, because anyone buying or investing in a nursing home, which is a going concern, will be subject to the client being accepted as a registered owner — just as buying property is subject to getting a loan and many other conditions — and the condition of sale would be subject to the buyer obtaining registration. Therefore I do not see a problem in that regard. The important thing is that the homes would be kept to a good standard and nobody will be in a better position than the health boards to negotiate, supervise and to ensure that those standards are maintained. Religious organisations or voluntary organisations are declining in number. Vocations are getting scarce. We must pay tribute to the religious for the wonderful work they did before health boards came along and before hospitals came into existence. They were the first to care for people. They gave of their time. Indeed, these are the people who set the standards. One thing must be said for all convents and religious organisations and it is that cleanliness and neatness were their main priorities. They always kept everything very well. They do not need to be included in this Bill. They have done a very good job. There is no need to worry about them, because they do not do the work for profit. If they did not give their time and their services for nothing, there is no way those services could be provided. They are not in for the quick buck; that has never been the case. For that reason there is no need to have them included in this legislation.
I am satisfied with this Bill. It is well researched. It is the most non-political legislation that ever came before this House. There will not be any great opposition to it. There is always a danger even though the nursing homes we have at the moment are very well maintained. I have visited some nursing homes in the rural areas and found them to be excellent. I was also in one or two in Dublin. However, there is always a danger of the cowboy element coming in and that is why registration, the assistance of the health boards and the provisions in this Bill are needed. It is to protect our senior citizens: These people gave their lives to build up the country, the homes and the environment we enjoy today. I welcome the Bill.
I also welcome this Bill. It is not before its time. There was a great need for it and I would like to commend the Minister on bringing the legislation before the House. I particularly commend him for the extensive and widespread consultation he had with the various interested bodies — the National Council for the Aged, the various nursing organisations and the Irish Nursing Homes Association. I heard very high praise from all quarters for the senior officials in the Minister's Department for their handling of this legislation.
It is the test of any civilisation the way we look after the most vulnerable people in our society — the elderly, the infirm and the incapacitated. We, as legislators, have a very important duty, as far as we possibly can, to speak for those people and to defend their rights. Many of them have been in nursing homes for a very long time and some have no relatives. They depend largely on us and on this legislation to ensure that the conditions in which they are living are satisfactory. It is up to the State in any civilised society to give the very best quality support and care to such people.
As Senator Farrell said, I suppose there is some self-interest in it for all of us. We are all getting older. While we hope our families will care for us in our old age, many of us will end up in nursing homes. It is a sad fact but the more economic progress there seems to be, the more material prosperity and the more society develops, the less people tend to keep their elderly at home. Indeed, it says something for progress and what progress is. Perhaps it is a much misused word. It might be worth our while some time to think what exactly we mean when we talk about progress. There is, undoubtedly, the demise of the extended family. There is also the fact that more women go out to work. Obviously, in the past they bore the brunt of much of this caring. There is also the question of emigration and of young people going abroad, leaving their old folk behind with nobody to care for them.
I would like to support what has been said already about the overriding objective which we should have, of keeping people at home rather than having them put into institutions of any kind, or even into nursing homes. This is something to which we, rather glibly, play lip-service but if we investigate the fundamental approach to it I am not sure we are doing all we can. It may not be the remit of the Minister for Health — it may be more the remit of the Minister for Social Welfare but there are a number of anomalies. I know that if an old person, for instance, who gets quite a lot of benefits, such as free electricity and all these sorts of things while living alone, goes to live with a daughter or a son he or she loses many of these benefits. There are further problems if such a person moves into a household where there is an unemployed son because they also lose these benefits. I am not at all sure we are doing everything we could to keep people at home.
In some civilisations there is a much greater emphasis on the importance of old people or the way people value old people in society. They actually revere old people for what they can bring to young people. Important traditions can be transferred from old to young. Old people are revered for the contribution they have made to society in their day. They are respected for the wisdom which we know comes only with age. Their advice is sought, they are consulted. That is something we tend to overlook. I always feel there is great wisdom in the saying: "Old people are lonely not because they have no one to share their burden but because they have only their own burden to bear." If we bear that in mind, it would put us in a frame of mind where we could look to see in what way old people could be more integrated into society and could be given little duties to perform. I know one village I visit where the woman who runs the local library is an extremely elderly lady, way beyond what would be retiring age. She runs the library with great efficiency and she is held in great affection. There are many areas like that where old people could be given duties to perform. What we need to look at today is how people in nursing homes can be kept active and involved.
Having spoken about trying to keep people out of institutional care and out of nursing homes, I would like to emphasise another point. I do not agree altogether with the previous speaker, Senator Farrell, that community care is all he made it out to be. In many local areas, local health boards actually rate community care quite low in their priorities. When funds are limited which, of course, they invariably are, it is always the community care services that are cut back. The back-up services which are needed to help elderly people living at home — social workers, meals on wheels and services like physiotherapy and chiropody — should get more encouragement and attention from the health boards.
The Minister should put emphasis on the whole area of day care centres which people who are just about managing to keep an elderly person at home could use. An elderly person could be kept at home if the carers could send them to a day care centre even for a few days a week. Some of the carers in our society are bearing an extraordinary burden. I heard recently that the Soroptimists of Ireland, who are a magnificent organisation, had a conference called "Caring for the Carers". They did various surveys. They actually ran some practical projects where the Soroptimists went out and relieved the carers who were looking after old people. They were absolutely shocked. The facts that came out of it were quite shocking and shattering. There was a young person who had spent 29 years looking after an elderly relative, who had never been able to get out of the house. A great number of depressing statistics and facts came through from that survey. Anything that this legislation could do to put emphasis on back-up for the carers would be very well advised. Housing projects for the elderly and the subsidisation of granny flats are areas which could get much more support.
I welcome the sections of the Bill on the idea of boarding out, but I agree with previous speakers on the great need that this should be carefully monitored. The health board officials should make regular inspections to make sure that conditions are satisfactory. It is a very good way, particularly in rural areas, to deal with people with mild disability and to keep them in what must be the nearest thing to a family ambience. People who are living in very isolated areas and in poor conditions would benefit if another family in the locality could take them in; this is the opposite end from an institution. This is a section that I am very heartily in favour of. It is also making very good use of our resources.
The population projections, as outlined by the Minister, are nothing less than frightening. He told us that in 1986 there were 382,000 people over 65 years of age and that by the year 2011 this will have risen to 414,000, an increase of 10 per cent. These are figures that should be carefully considered. We should look to see whether we are making advance arrangements so that we will have in place the sort of back up which will be required to meet that ever increasing number of elderly people in our communities.
The situation in the greater Dublin area is even more alarming; I think that 30 per cent of those elderly people will be in the greater Dublin area. Any public representative in the Dublin area knows at the moment how impossible it is to get an elderly person into any sort of a nursing home or geriatric unit; it is well nigh impossible. There is no question but that we need more accommodation. The role that these private nursing homes could play when they are subvented by the health boards could ease the burden.
The number of nursing homes is rapidly increasing. They are now being opened quite obviously as business enterprises. The other day I heard of a builder who is building a nursing home purely as a business enterprise, as are many other business people. That is not something we should condemn. It is a fact of life. It is going to happen. I do not think we should put obstacles in the way, but it does mean that we want to put more emphasis on ensuring that the standards in these homes are satisfactory.
There is no doubt that the majority of nursing homes are very well run. There are, however, a few unscrupulous people who are in it just to make as much money as they can. They are running it as a business venture. They have little care or concern for the people in their care. They are the cowboys. There are some of them in every sector, in every industry and in every profession. That is why we are here today to legislate as best we can so that these commercial or business enterprises which are entered into to make money, are supervised. These people are only interested in making a profit. They have little concern for the welfare or the interests of the patients. We will see what we can do to control their activities and to maintain standards.
I welcome, in section 6, the standards which are laid out and which will, no doubt, be in the regulations which I am sure will be very detailed and comprehensive. The problem we need to bear in mind is that no matter how detailed and comprehensive the legislation or the regulations, one cannot legislate for the quality of service. In the final analysis, that depends on the kindness, the concern and the interest of the carers. It really boils down to saying it depends on the quality of the staff who are running these homes. I would hope that in the regulations there will be an obligation on every home to have a qualified nurse on duty around the clock. That is extremely important. Our nursing profession are very well trained and they are screened. If there was adequate nursing staff in these homes we would have a good chance that they would provide the quality of care we want to see. Even the best motivated, the best trained and the most caring nursing staff can do nothing if they are working in overcrowded conditions. If they are understaffed, then understandably it is difficult for them to keep up the same kindly concern for the patients.
I am glad that the rest and retirement homes where any nursing care is being provided are going to be included. This was, undoubtedly, a loophole in the previous legislation. I understand now that where any dependent person is residing in a home — dependent as described in the Bill — the home will come under the legislation. Retirement homes will be inspected regularly. There is a provision in the Act that nursing homes must be inspected once every six months. Will retirement homes also be inspected once every six months to see that they are genuine retirement homes with non-dependent persons living there who do not require nursing care? Is it the intention that retirement homes will also be visited on a regular basis to ensure that they are complying with the legislation?
I would like to refer briefly to the section which deals with the complaints system. This is one of the most sensitive areas. In this country we have a great antipathy to complaining about anything. People go into a restaurant and are served inadequate food, but they do not complain. They think it is not a nice thing to do, or it is not the right thing to do. I would be very fearful that in nursing homes which are not up to standard, even though they are being inspected on a six monthly basis by an official of the health board, and in spite of what an official going into a nursing home can ascertain on a relatively cursory visit, patients could be treated poorly or unkindly. Is there any way it could be made easier for patients and their relatives to make complaints?
I had an experience recently where I visited an old lady in a nursing home. I went to see her on a business matter, not because I knew her. It was a home down the country and it appeared to me to be extremely well run. There were only about eight or nine old ladies in it. I went back and visited her on a second occasion and I formed the same impression of the nursing home. I spoke to some of the staff and I thought the patients were very well looked after. To my great surprise, a couple of months later when I contacted the old lady again she had gone. I contacted her at her niece's home and was told they had to take her out of the home because she was being so unkindly and badly treated. It was not anything a health board official could see. I am sure the home complied with all the regulations with regard to the size of the rooms and the adequacy of the food and bathroom facilities. There was nothing like that wrong.
I was wondering if a system could be devised, something akin to what we find in hotels where you are asked to fill out suggestions or complaints, to make it easier for people to feed back information to the health boards. It is a fact that people are rather reluctant to complain. I asked the niece of that old lady if she had done anything about it and she said, "no"; they had just taken their aunt out of the home. There are still other people in that home, probably, who have no nieces to take them out and the health board is probably none the wiser about what is going on. The whole area of monitoring is extremely important.
The Bill recommends that monitoring be done every six months. I would like to inquire whether there will be additional funding available to the health boards. As a local authority member, I know that local authorities are always being given extra burdens and extra tasks. At the moment, for instance, our local authority has a heavy responsibility to comply with the impending provisions of the Derelict Sites Bill. They have to do an enormous amount of work drawing up lists of the derelict sites in their area. All this is put on them with no extra funding for them. I would like to ask the Minister, what extra resources will be made available to health boards so that they will have the extra staff which they require if they are to carry out their monitoring obligations adequately.
I heard recently of a nursing home where no resuscitation equipment was available and it was taking people from hospitals after major operations to convalesce in the nursing home. There is well trained nursing staff there but the relatives of those people expected that there would be resusitation equipment. When I made inquiries, I was told that under the regulations they would be required to have resuscitation equipment on the premises, but in this instance they either did not have it or the cylinders were empty. That is an example of where adequate monitoring is very important in order to be certain that all these fairly detailed requirements, which will be in the regulations and which are in the Bill, will be met.
I would like to say, unlike some of the speakers here, I am happy to leave the monitoring to the health boards. It was one point on which I did agree with Senator Farrell. I believe the health boards, if they have the necessary funding, have the expertise to carry out the monitoring in a satisfactory way, and that they will do it. I am not in favour, in all instances, of having to have identical arrangements all around the country. Senator Farrell mentioned the differences there are between the requirements of patients in rural areas and in city areas. They come from different backgrounds and, understandably, they have different requirements. Some of them place a greater emphasis on one thing and some on others. A little flexibility is not a bad thing, provided that the overall general standards are being maintained.
I support the Minister in leaving this duty to the health boards. I hope there will be extra funding so that more beds will be subvented in the nursing homes. The whole system has changed now. The subventions are not going to the approved homes and non-approved homes. Every nursing home will have to have registration. The beds then will be subvented by the Department or by the health board. Unless more money is pumped into the system, we are not going to find it any easier to get geriatric or elderly people into beds in these homes. The cost of the beds, presumably, is going to rise. Understandably, many of these nursing homes which are at present in operation will simply not be able to meet or measure up to the requirements in this Bill. They will have to improve their standards and their facilities. That is going to cost money, so we can expect an escalation in the cost of beds in nursing homes. The present figure of £6.58 per day simply will no longer be adequate. It will go nowhere to meet the costs.
I would like clarification on one concern I have about the Bill. Under section 6 (2)(g) officers of the health boards can have access to records. Do I understand from this that they will have access to patients' medical records? The paragraph just says "to the records", so I am not clear whether it is to medical records or to patients' records. I would be totally opposed to that. It would break down the very long-standing confidentiality which exists between doctor and patients if a lay person from a health board had access to those records. It would be breaking a trust. Old people are, by nature, very fearful, suspicious and loath to allow people to know their business. If they felt that that was going on, they would not accept it.
Nursing homes run by religious for people from their order should not come under the provisions of this Bill. I would like, as my predecessor did, to pay a compliment to the work done by religious orders in caring for the old down through the years. In nursing homes where nuns or priests are being looked after, they continue to live in what they consider to be their home in the very same way as we have lived in our homes for a period. We would not like it if somebody was coming in to see how we were looking after somebody else. It would be the same as extending the provisions of the Bill to having somebody coming in to see how a daughter was looking after her mother — or her mother and father — in her home. There was an unfortunate fire in one such institution, but I have never heard of any other complaints. That is a hazard but I do not think that should push us into bringing religious who are looking after their own under the provisions of this Bill.
We are awaiting the arrival of the Minister.
We reconvened as agreed at 2.15 p.m. It is now ten minutes past that time and there is no sign of the Minister. I would like to put on the record our displeasure at this type of behaviour.
It may well be that the clock is incorrect. I have pointed out repeatedly that although we start promptly at 10.30 a.m. on some days and 2.30 p.m. on other days, the clock repeatedly shows at least 25 minutes to the hour. The clock must be wrong.
I welcome the Minister and call on Senator Tras Honan.
The Minister should give the House some explanation or apology as to why he kept us waiting ten minutes. It is the least we can expect from him.
I regret I am late. I had to attend another meeting to do with work in my Department. I was held up this morning for a full hour as a result of shenanigans, manipulation, discourtesy and unnecessary interruptions by the Fine Gael Party in the Dáil. I did not say anything about that. I regret that I am late. I have come to this House very often and I do my best to serve it. I have a lot of other responsibilies. I presumed that we had broken for an hour but when I was going out I discovered it was only for 45 minutes. I had given commitments that I would deal with other matters during that hour and I rushed back after the meeting. I regret that I am late.
I accept the Minister's apology but, for the record, no pair was asked for the Minister this morning. Had a pair been asked for, it would have been given.
As a result of a situation which developed here some months ago on another Bill, I took up a suggestion made by a member of the Fine Gael Party — perhaps it was Senator Manning or Senator Doyle — with my own Whip and suggested that we find common agreement. I said that there was a positive attitude among all parties for this. I presumed that once agreement had been reached it would stand and that no Minister or Minister of State, or anybody on their behalf, had to seek pairs. It was news to us that we had to seek them.
The agreement stands and the arrangement is that the Government Whip notifies the Opposition Whip as to who needs to be in the Seanad. The pair is granted automatically. We should let the matter rest at that. The Minister is paired now for the afternoon.
We will let the matter rest at this stage and continue with the debate.
I appreciate that Senator Manning is upset at the ten minutes delay. I would like to defend the Minister, Deputy Treacy in his commitment to the Seanad.
I accept that.
It is absolute. I would like to put that on record. Earlier this morning the Minister gave me a rough rundown of his schedule for the past couple of days and it was mad. That is why I feel I must defend him.
We are here this afternoon to deal with important legislation which will affect the elderly people of our nation. As they are the people who handed on so much to us, we should look after them. This Bill is of interest. It was initiated and amended in the Dáil and it is now before us as passed by Dáil Éireann. The Minister's commitment in this area is evidenced by the fact that he was prepared to amend the Bill. In fact, the Minister of State said this morning that he would be prepared to go further down the road if need be.
This morning the Minister gave a magnificent address to this House. Everything that we could want for the elderly was mentioned and I sincerely hope it will be implemented. The Minister delivered one of the finest opening addresses on a health Bill that I have heard, and I welcome that. I know the Minister amended this Bill a lot and I am quite sure it is a much better Bill as a result. One need only look at the Dáil Official Report of 6 June when many of 22 amendments were accepted. It is a healthy sign that all voices regardless of party, are listened to. I welcome that approach.
I know this Bill is warmly welcomed by nursing home proprietors and administrators. In the past nursing homes were needed and many of them had quite a good standard at a time when the overall health service was not so good — we should stitch this into the record — and we might need these old nursing homes now more than ever.
I welcome this legislation. Let us be quite clear about how important this Bill is in 1990. A number of these homes were set up using private family money. However, other people took out mortgages. Some nursing homes were owned by families who had trained nurses and some of them are still there. They fitted quite well into the general hospital situation. I understand — and nobody is prepared to accept it more than I — that the highest standard is required for these nursing homes, and not alone for our nursing homes but for all our hospitals. However, I will come to that later on in my contribution.
The Bill is intended to ensure a high standard of care in nursing homes without interfering unduly with the management of such homes and I think it will achieve this. However, the Bill is also intended to establish a common system of assessment for the payment of subventions to homes for the elderly and for nursing homes. Though the Bill will lead to a common system of assessment being established, I do not feel it will lead to payment of subvention to all those persons who qualify under the assessment system. In all cases the legislation states that the health board "may" pay subventions and this has given rise to major causes of concern. Where an elderly person meets all the criteria for payment of subvention it should be paid. Failure to do so would mean we fail in our responsibility to the elderly, particularly in the light of recent delays by health boards to sanction subvention applications. I hope I have made my mind known clearly on that one. If in a section of the Bill the word "may" has to be replaced by "shall", so be it, let us do it.
I understand that under this Bill health board personnel will be given the power to inspect any premises where persons are being cared for and that heavy fines will be imposed on those found guilty of looking after people without nursing home registration. That is fine with me, but I beg of the Minister and his Department not to carry this thing too far by bringing in another layer of bureaucracy that might damage the well-run nursing homes we have today. Again, as I have said, they have been provided by private money. A colleague of mine made reference earlier today to the fact that builders were now building nursing homes. It is a long time since people put private money into nursing homes to provide beds for elderly people.
I want to put emphasis on the inspection system. I ask the Minister to make sure, if it is the health board personnel who are involved, that the right people are put in place to do the inspections. Senator O'Reilly's concern this morning was that the inspections would be done totally and absolutely. He said it should not be somebody going into a nursing home, having a cup of tea and not doing the inspection. I do not think that is the way inspections are carried out. I am going the other way. If we have well-run nursing or geriatric homes I do not want people of the wrong make-up, people with different thinking on how nursing homes should be run, going in and doing these inspections. I do not think any of the nursing homes under the health boards fear inspection at any time.
I know the Minister has made changes in this legislation which were recommended by the working party who produced the report The Years Ahead— a Policy for the Elderly. It recommended that a registration system for nursing homes be put in place and I welcome that. There are worries about certain places not being up to the standard the Department and the people who asked for this Bill would like. I am sure that all the places not up to the standard of the majority of our nursing homes will be improved when this legislation goes through.
Reference was made earlier this morning to community care, that as a nation we should keep more of our elderly people out of institutions and that we should not need as many institutional beds, whether it be in our health board hospitals or in our private nursing homes. I would like to pay tribute here to the people engaged in community care. However, I am not as convinced as Senator Farrell, my colleague on this side of the House, that community care is as totally in place as I would like to see it. I hope it can be improved upon and further extended.
Some few years ago we talked about letting patients out of our mental hospitals into the community where the whole machinery of community care was set up. There are certainly many loopholes in the community care service. No matter whether I am in or out of Government, when talking about health, I am honest about the gaps I see in that area. In any event, I think it is wrong to politicise health; it is something I never did. I am sure my colleagues who are members of the health board where I live will speak further on this when they speak in this House. In putting forward my reservations about the gaps in community care I am adamant about paying a tribute to the nurses and doctors engaged in community care and who do provide the service.
I understand this legislation was asked for by the National Council for the Aged, by the Association of Widows of Ireland and by the Irish Private Nursing Homes Association. They want a code of standards and they see the need for revised legislation on nursing homes. There we have the people who are serving with such dedication in this field asking for this legislation and they have no worries about inspections or instructions about what their standards should be because they quite clearly have them.
I want to make reference here to the weekly cost in many of the health boards hospitals or institutions. I understand it is about £200; it may be less in some areas. The subvention under section 54 is £47. Some health boards, I understand, may make a contribution of up to £40. There is still a gap there. I would hope that, between the Minister and the Minister for Finance and their respective Departments they will make sure that those who find themselves or their family in a situation where they cannot pay in full, even with a pension and any help that is given will have the difference made up for them if there is still a gap. I made reference to that in the debate on the Finance Bill. I hope the Minister for Finance will provide this money for these people.
I wonder about the responsibilities of the health boards to administer this legislation but maybe I am wrong about this. Is it true that the responsibility for this legislation will be left totally with the health boards, or will there be somebody from the Minister's Department with the health boards to administer this legislation? The Minister will tell me, of course, that the health boards have statutory responsibility to carry out their duties and that the Minister perhaps would prefer to leave it that way, but I would feel happier — maybe the Minister has done it — if there was somebody from the Department with the health boards for the carrying out even of the initial stages of this legislation.
With regard to assessments of dependency and means, here we have doctors and family public health nurses complaining of unnecessary delay in assessments. When you serve in the field of health, and people know this and talk to you, you get information. As I say, there is a concern here that there are undue delays in assessment. This could have, and has, implications for families, when people who should be able to get a bed at a particular time have to wait and hold back. That should be looked at to see if it could be corrected and perhaps improved on. Even though at times people go down the road, when it suits them, of lashing the medical corps of our nation, nevertheless they give this country a great service. If they say that there are delays in even one or two patients getting a bed in a home or in a geriatric hospital, they do not say it lightly. It is something I would like the Minister to look at.
The perception that we have poorly run nursing homes has been lightlighted far too much. I do not know how many of them are there, but I find in this country that we highlight just the one or two bad things and most of our time forget or never highlight what is good. From my personal experience — I have served, as Senator Kennedy and Senator John Ryan know, for a long time in the area of health — I believe that this is overstated. Certainly, I have seen high standards in our nursing homes and hospitals. I will later on refer to a remark made in the Dáil — a remark which, even though I am not supposed to make reference to, I deeply resent.
Many of the homes, even those about which complaints are made, have a guestpatient situation — there is television, occupational therapy, parties, bus trips, bingo, libraries etc. If a complaint comes from one of those homes it may well be that the patient or patients, where there may be a few who complain, are not using the facilities that are in place. Like my colleagues who serve in health, this is all too familiar to us. We see the problems and the pluses. If there are complaints, they may be from patients who may well not use the facilities that are in place.
I thank the Minister and I welcome the £5 million given towards the elderly, I understand, in the budget. The care given in most of our nursing homes is, as I have stated, of a high standard.
There is so much mix-up between ourselves and the Dáil these days, I will not name TDs, but I believe that in the other House recently some TD made reference to the standard of care in one of our health board hospitals. I do not know what health board he was talking about and, even if I did, I would not make reference to it. However, I want to put it on record today that, for example, St. Joseph's Hospital, our board hospital for geriatrics in Clare, is one of the finest and the best run hospitals this nation has, with committed and dedicated staff running it. With the greatest respect to other hospitals, there is clearly a different feel in the atmosphere in St. Joseph's as against the general hospital in Ennis. I do not know why. Because that remark about a health board hospital was made by a TD in the Dáil, I must——
I did not interrupt Senator Honan because I was interested in the development of her argument, but she does tend to persist in drawing attention to the fact that she is discussing the business of the other House.
I take the Senator's point. By convention, Senator, it is not usual to draw the attention of the rules of this House to a former Cathaoirleach as it is expected that the Cathaoirleach is aware of the rules, but thank you very much for the intervention, Senator.
Thank you. He will learn by the day. I will continue, before I was so rudely interrupted. I am amazed——
I am sorry to interrupt you, but, in fairness to Senator Norris, I am most reluctant to point out that he does have a point in relation to references to the other House. I will go no further than that. Please continue.
I just said it was a TD who criticised. I took great care not to single out the constituency or to give the name of the Deputy; I would not do that. However, I took a poor view of the criticism of one of our health board hospitals. My trend throughout this contribution is that we should highlight the things that are good and then ask the Minister to correct any problems that are there. I thank Senator Norris. He is most helpful always.
Amendment No. 26 to this Bill in the Dáil was a new section proposed to be inserted by the Minister. I welcome his proposal that the provisions of the Bill will be implemented uniformly throughout the nation through the regulations and code of practice. The Minister also said on 6 June that the Government had shown their care for the elderly by the provision of £5 million in the budget, that persons at present being subvented will continue to be subvented and that a relative of a person, or a person, can apply for a new subvention if need be.
Section 7 of the Bill as passed in Dáil Éireann has the "mays" in it —"it may, if the person enters or is in a nursing home.""The Minister may, by regulations, prescribe the amounts that may be paid by health boards under this section and such amounts may be specified by reference...". There might well be room for an amendment there, that if "may" is not a strong enough word we might put in "shall" or even "must". I have two worries. First, I am concerned about any delay in assessments and, sec ondly, if there is a gap after family payments and health board contributions. I would welcome the Minister's reaction on those points. Again, I wish to pay tribute to the people who provided us with nursing homes, nursing homes which were totally kept in place by family money, by private funding and by patients paying for themselves. I am pleased that this Bill will cover some of those homes that are not getting subvention at the moment and have patients who should come into the subvention category.
I also wish to pay tribute to the religious orders and all the people who have run the magnificent residential institutions for the mentally handicapped and for the elderly. I know this first hand because I have their had their nomination in this House for the past 25 years. If we did not have the totally committed voluntary people who have, with such high standards, run those institutions for the mentally handicapped, I do not know where we would be. It is the one area where I see voluntary and statutory working together, and working well. I am a firm advocate of this because I have seen it work; I have made it work. I welcome the Bill and the whole atmosphere and attitude of all of us together to get it out there and look after the people who gave so much to us. I hope we would now do our part in making it easier for them in the end years of their lives, hoping that down the line some of our children might give us the care that we today, would pass on to the people who gave us so much.
Before I call the next speaker, for the benefit of Senators I wish to say — and I am grateful indeed to the Clerk Assistant of the Seanad who has pointed this out — that there are many references in Standing Orders as they apply to comments about the Dáil. For the information of Members, I give one or two points. Debates in or the conduct of Members of the Dáil may not be discussed and references to "another place" do not put the matter in order. Proceedings in the Dáil should not be discussed or quoted unduly and comment on same is always deprecated. It is accepted that arguments used in the Dáil may be answered and for that purpose passing reference is permissible. Therefore, Senator Honan would have been within the boundaries of the Standing Orders. It is just for the benefit of the House. Senator Ryan.
While I welcome the Bill and many of its recommendations and proposals, it is my humble opinion as a layman, someone who has been involved in the health board area for many years and as a local representative, that it is a significant development in the privatisation of geriatric services. Before I go on to the Bill, I, like the previous speaker and as someone who has served the public for 30 years, would like to pay tribute to the workers, the nurses, the doctors and all concerned with community care, who, up to 1970 under local authorities, served the people so well in nursing homes and geriatric institutions and who, since 1970 under the health boards as instituted in that year, through welfare homes and day centres have continued that tremendous work in looking after our old people. Although we have a responsibility to our young people to ensure in the years ahead they have something worthwhile to contribute to our country and something worthwhile to gain from the country, nevertheless we owe an awful lot to our older citizens. In the field of community care, we owe an awful lot to our former local authority officials, our health board officials and the many voluntary bodies who give a tremendous day to day service to people in homes and in hospitals. For that reason I would like to put on record my appreciation of the dedicated services these people have given down through the years.
The Bill as outlined followed a report of 1988 of the working party on services for the elderly. It implements the recommendation that there should be a registration system for nursing homes. However, it omits an important recommendation that fees charged by health boards to nursing homes should be proportionate to the number of beds; in section 8 of the Bill it becomes the decision of the Minister. The report also recommended that decisions of health boards on registration should be appealable to the Minister; instead, section 5 states that appeals must be directed to the District Court. Aside from the additional costs and delays, surely there must be a ministerial decision on health matters and not in the legal area already under tremendous pressures from its own business.
The report also emphasised the right of the patient to basic information, such as qualifications of staff, facilities, etc. This important element has also been omitted from the Bill despite a strong recommendation from the working party. Again, section 6 states that all such information and recommendations rest with the Minister. It would appear from section 6 of the Bill that the regulations outlined in the booklet I have here will continue to be the basis for the regulations under the new Bill. I would say to the Minister that a look at the regulations might be worth while, that in addition to the Bill being updated perhaps the regulations should be updated also. I appreciate that the Bill was amended in the other House, but it can be amended in this House also to make it an even better Bill.
I have some questions to put to the Minister on section 4. Perhaps he will give me an answer at the conclusion of Second Stage. Will these registration conditions be standardised nationally? Will they vary from one health board to another or will health boards introduce similar conditions for their own institutions? Perhaps at the conclusion of the debate the Minister will respond to that. It is very relevant. We have eight health boards in the country. What might be pertinent in Limerick may not be pertinent in Sligo or Galway. I would hope that, rather than have controversy, a nationwide guideline would be given on registrations instead of on a regional basis.
As regards the actual nursing home system itself, it has come under considerable pressure in the past couple of years — not, as a previous speaker suggested, because of increased income but as a result of serious financial cutbacks. Thousands of beds for geriatric patients have been taken out of commission and adequate post-operative convalescence is no longer available in acute hospitals, due also to the bed crisis. Thus, in the space of three to four years the number of nursing homes has increased considerably to meet the ever-increasing demands.
There is an urgent need for close surveillance and monitoring of community care services and facilities which are at present catering for people who should be the responsibility of the State. These, services are under-manned and underfinanced despite all the promises to the contrary. I wholeheartedly agree with Senator Honan; from my own experience in the mid-west region community care on paper is apparently a priority but, unfortunately, when it comes to the financing of community care it is very low on priority. The nursing homes in my area are providing a first-class service and I am happy with several which were recently built there.
My greatest concern in relation to the Bill and this area is for that section of our citizens who require such care, whose only income is perhaps an old age pension, who have neither home care nor relations and who cannot meet the maintenance costs of such homes from their meagre weekly social welfare payments. I am greatly alarmed that in section 7 there is a serious flaw in the lack of concern and commitment to the needs of those on low income. The part that concerns me reads as follows:
... the health board is of opinion that the person is in need of maintenance in a nursing home and is unable to pay any or part of its costs, it may...
Like Senator Honan, I believe that is the worst flaw and the greatest weakness in the Bill because the word "may" in that section gives the health board the opportunity to opt out of its responsibility to financially support genuine cases in their area. I have already submitted an amendment for Committee Stage to replace the word "may" with "shall". If we want to improve the Bill we should take that weakness out of it. Section 7 is the section which is most relevant to the people who are in greatest need, those on low incomes; they are the people we should be concerned about.
Over the past couple of years great emphasis has been given to a greater role for community care. Like Senator Honan, I am concerned about section 7. That section must be altered by the Minister if this Bill is to give any meaning to the people about whom I am concerned. We talk about low inflation rates, increased GNP, improved balance of payments and trading, EC summits and so on, but they have little bearing on the unfortunate pensioner who cannot get a bed in a geriatric institution in his or her health board area and who is compelled by circumstances to look for a bed in a nursing home but is not in a position to meet the costs.
I will also be putting down two other amendments on Committee Stage. I will not delay the House much longer but I will repeat again my original statement, that this is the first stage in the development of privatisation of the geriatric institutions. I will have more to say on Committee Stage.
I welcome this excellent Bill, the purpose of which is to promote a high standard of care for dependent persons in nursing homes, to change the arrangements for the subvention of persons in such homes and to facilitate health boards to make arrangements for the boarding-out of persons who can no longer live at home. I congratulate the Minister and the Department for bringing forward this comprehensive Bill. The legislation is now 26 years old and it is important that it be updated in relation to the care of old people.
Care of old people presents many problems, especially if they are sick and difficult and for this reason their nursing care is very specialised. It is only right that we should compliment the many people who have dedicated their lives to looking after the elderly. Community care was mentioned already and I would like to thank the people who are involved in community care, and I speak particularly about the Southern Health Board. In Kerry the people involved in community care are working under severe strain, especially financial strain and I would like to see extra funding being made available, even within this legislation, to them.
We have many fine nursing homes. According to the figures available there has been a continuous growth in the opening of new private nursing homes and a demand for places in them. This being so, it is important that legislation of the kind we are now discussing be enacted as quickly as possible. It sets out clearly the specific responsibilities which will apply. It also sets out clear terms of reference for people intending to open private nursing homes or continuing to operate and manage such homes. Special responsibilities are now laid down in law and they have to be strictly adhered to, and rightly so.
This legislation is in the best interests of the elderly. They will be guaranteed a level of care, physical comfort and conditions in private nursing homes that are acceptable and suitable. It will also assure relatives, friends and family members of elderly dependent people who are admitted to such homes that they are guaranteed good care. Above all, legislation spells out where the proper responsibilities lie for the correct management and control of running nursing homes, as between the owners, management and the health boards. This, in turn will lead to a clear understanding on the part of owners and management that if they fail to carry out their responsibilities their licence will be revoked or withdrawn, they will not be allowed to renew their licence or may have to pay some very stiff financial penalties which are also provided for in this legislation. The level of the penalties will strengthen the Bill in that it makes it clear to operators of private nursing homes that major infringements of the regulations and the legislation will lead to severe penalties being imposed.
Many of us have received representations from the Irish Private Nursing Homes Association and from individual nursing home owners in which they draw our attention to the word "licence". They made a distinction between a private nursing home and other establishments requiring a licence, that is — and I am referring to their terms — dog kennels and so on. They do not want to associate a licence for nursing homes with a licence for other institutions. They made particular reference to the fact that a licence must be renewed every two years. This, they consider, is a restriction on the nursing home as a business and, to some extent, would have a bearing on commercial value, particularly regarding the sale of a private nursing home. The legislation now provides that if a private nursing home changes ownership it will be essential to apply for a licence in respect of the new owner. It is correct that this should be included in the legislation, otherwise the whole thrust of the legislation in so far as it seeks to protect the dependents in the nursing home, would lose its strength. The purchaser of a nursing home with a licence might not be the type of person one would like to see operating or managing a nursing home. I welcome this provision.
It is also right that the licence should be renewed every two years. It is set out in the legislation that the applicant has very definite rights in this regard. The applicant must be notified by the health board if they are about to make a decision not to grant a licence, to revoke a licence or not to renew a licence. Under the Bill the applicant can appeal to the health board in writing and make a case as to why the licence should be granted, renewed, or should not be revoked. Even then, if the applicant is not satisfied with the decision of the health board, he can appeal to the District Court and the court can confirm either in favour of the decision, the proposed decision of the health board or, indeed, in favour of the applicant.
From some of the representations we have received, it is clear that many of the people involved in the private nursing homes business are worried. However, there are sufficient safeguards built into this Bill to ensure that they will be able to conduct their business in a fair and reasonable manner and with positive security so far as the licensing system is concerned. Those safeguards are essential, they are wide ranging and they protect the interests of all concerned. The licensing and registration of nursing homes is of the utmost importance. The public have a right to be able to check with their health board, free of charge, the total list of private nursing homes available within their health board area. For this reason, it is vital that control be exercised over the management of the institutions relative to each nursing home. Information should be available regarding fees, location, services, transport and any other essential information. In particular, information should be made available on professional staff and the commitment by the nursing home to work closer with the staff, especially the professional staff of the various health boards. This information will assist people who need to inquire about private nursing homes for themselves or a member of their family who wish to be accommodated. I would hope the Minister would ensure that this detailed information is maintained in the register and that it will be kept up-to-date at all times.
The Bill also refers to the boarding out of persons by health boards. This is a very welcome inclusion in the Bill. Health boards now take the view that instead of removing a person from the community and environment in which they have possibly lived all their lives to what for them would be an alien place, it would be better if structured arrangements could be made to allow for the boarding out of dependants living in their own local community. A number of health boards have been trying to make progress in this regard and they will welcome the inclusion of this provision in the Bill. It will be a big help to people who want to be located in their own community and they deserve a great deal of sympathy and support.
Most of us are faced with the major problem of long waiting lists for beds for geriatric patients and I hope this Bill will improve that. Section 7 enables the health board to contribute towards the cost of maintenance of deserving individuals. I hope the health boards will have sufficient funding for this purpose. I am principally concerned with the Southern Health Board. Indeed, many of the people on the waiting lists could be assisted by this type of legislation.
I would like to avail of this opportunity to congratulate all involved once again, especially in Kerry, in caring for the elderly. They are doing an excellent job but they need encouragement and further financial assistance. I hope that, as a result of this Bill, the various health boards who now have this responsibility will honour their commitments. In this Bill, the onus is on the health board to monitor all private nursing homes. There are no problems with premises that are well kept, where conditions are good and sufficient staff are available, but there will always be the few where those regulations have to be enforced; thankfully, they are very few. Should inspection of the home be deemed necessary, provision is made for it. For this reason, the records of all such homes must be up to date and available for inspection. Persons in nursing homes can be interviewed and examined, and it is good that this is specified in the Bill, but this only applies where the health board have reasonable cause to believe that a person in a home is not receiving proper treatment — this is very rare, but it is important that the provision is there. The Bill allows for inspection of nursing homes and also premises where it is believed that the work of a nursing home is being carried out. This possibility of being subject to inspection should deter persons who are tempted to abuse their position in this regard.
Also mentioned in the Bill is the proposal to provide training of nursing home staff on an agency basis. This will also help to maintain high standards of care and good relations between the homes and the boards. Section 10 of the Bill permits the assumption by the health board of management of a home on a temporary basis. This may be by consent or in pursuance of a court order. This is most important as it guarantees the welfare of dependent persons in that particular home.
The health boards inspect homes at least every six months to ensure compliance with the regulations. Nursing homes charge their clients for their care and they provide either full or partial accommodation. Mention has also been made of the fees charged by the various nursing homes. I would like to see, within this legislation, some provision to standardise fees throughout.
Some homes are approved for subvention under section 54 of the Health Act, 1970, and in those cases, residents can avail of a subvention towards the cost of their care, which is paid by their health board. However, I must point out to the Minister that this is not so with the Southern Health Board. Fatima Home in Tralee only get this subvention for six weeks in any year, while, for the patients from the other health boards areas, they are paid the subvention for the full 52 weeks. I ask the Minister to take a special interest in this case as I know that Fatima Home have taken this up directly with the Southern Health Board on a number of occasions because I believe they are being unfairly treated. They have done tremendous work over the years and because of the excellent services they provide they have a long waiting list. It is their intention to build a further ten rooms plus a sick bay. Here again, I would appeal for funding for this worthy and essential development.
One matter that comes across very clearly in the Bill is the quality of life which should at all times be maintained, and the public should have full confidence in the standards of care available to dependent people in nursing homes. I accept that the standards of care being provided at the moment are of a high standard and I wish to see this continue and, where possible, improved.
The 1986 statistics indicate that there are 382,000 people over 65 years of age, of which 143,000 are over 75 years of age. Present indications are that by the year 2011 we will have 414,000 elderly people. Those are alarming figures and for that reason, the present facilities must be substantially increased over the next few years to cater for those increased numbers. There are at present 332 nursing homes in operation, of which 286 are private, plus 41 voluntary homes. In 1989, some 20 new homes were opened but those new homes are not keeping pace with the present requirements.
I would like to thank the Government for the allocation of £5 million this year to develop services for the elderly, as recommended in the report of the working party, The Years Ahead—A Policy for the Elderly. I understand that only 5 per cent of our elderly are in institutional care while 17 per cent are being cared for by their families at home. For this reason, we must do more to support those families, financially and otherwise.
I hope this Bill will be instrumental in providing further day care for dependent elderly people cared for by their families. This would be welcomed by the carers, and I hope the Bill will encourage this development. Finally, I congratulate the Minister on the Bill. This legislation is important not only to health boards but to the elderly, dependent patients and, indeed, their families.
In a paper read to a meeting of the Private Nursing Homes Association held in April 1988, Dr. Finbarr Corkery stated:
The elderly are not a problem. Their needs can be assessed with those of their carers and coping strategies developed. It is their right to benefit from the resources of society, as much as education is for the young. It is not a charity, or an option we may choose to exercise. Inadequate provision for the care of the elderly is not the fault of the elderly, it is our fault.
It is in the context of that approach and that philosophy that I welcome the main features of this Bill in so far as it seeks to ensure high standards of care in nursing homes without interfering unduly in the management of such homes. This is a Bill, the Long Title of which describes it as an Act to make provision in relation to nursing homes for dependent persons, to provide for the registration by health boards of nursing homes and to provide for the boarding out by health boards of dependent persons. The introduction of this Bill is, indeed, timely because at present there is no effective registration system for nursing homes nor are there any minimum standards which can be effectively enforced.
In 1968 the Committee on Care of the Aged put forward what was at that time a radical opinion and belief when they said:
It is better, and probably much cheaper to help the aged to live in the community than to provide for them in hospitals or other institutions. Public and family care should be regarded as complementary and the public authority should endeavour to help the family, and not take over from it.
A significant feature of modern western society is that the majority of people will live into old age and many of them into advanced old age. A baby born in 1900 could expect to live to 50 years of age, whereas a baby born in 1990 can expect to live into their seventies. In Ireland, the demographic position of the elderly is, of course, quite complex. However, it is interesting to note that the number of persons aged 65 years and over increased from 323,000 in 1966 to 382,000 in 1986. This represents an increase of 18 per cent in a mere 20 years. Of that 382,000 people who are over 65 years of age, 143,000 are over 75 years of age.
The Bill, as the Minister has indicated, implements many of the recommendations of the report of the working party on Services for the Elderly entitled The Years Ahead—A Policy for the Elderly which was set up in 1986 and reported in 1988. In that report the working party stated:
The private and voluntary nursing home offering extended care of dependent elderly persons has a long tradition. To judge from the rapid increase in the number of private homes in recent years, there is a growing demand for the kind of care they provide. As the elderly population increases demand seems certain to rise, even allowing for the better community support for the elderly people at home. We see no reason why this trend should be discouraged since elderly people wishing to provide privately for their latter years are entitled to do so.
In spite of this, however, by and large no new homes have been recognised since 1980 except in the Eastern Health Board area. The number of subvented beds has been frozen for the past ten years. Dr. Joseph Solon, Director of Community Care with the Western Health Board said:
My own county of Galway has 54 subvented beds out of an estimated total of 340. By contrast, practically all beds in the Eastern Health Board area are subvented. Proprietors do not understand the reason for this, nor do I.
This is in spite of the fact that section 54 (3) of the Health Act, 1953 states:
It shall be the duty of a health authority ... to give to every person in their functional area who is eligible for institutional assistance such institutional assistance as appears to them to be necessary or proper in each particular case.
However, the operation of the subvention has been rendered farcical by the Minister and his predecessor in so far as no new nursing homes have been approved for subvention since 1980, not because they were not deserving, not because they did not meet certain criteria, but because there was an embargo on the funding of any new beds.
The working party in their report in 1988 recommended that the 1964 Act be amended to include the operation of nursing homes run by voluntary bodies, to include an annual licensing system for nursing homes, that section 54 of the Health Act, 1970 be amended to enable health boards to subvent the care of eligible elderly persons after assessment in nursing homes licensed by health boards and to enable the health boards to vary the level of subvention according to the needs of the patient. The working party recommended that private and voluntary nursing homes provide those services directly or on a contract basis with the health boards. They recommended that the nursing home make available to prospective residents and their families a brochure detailing the services it provides, the charges, the qualification of the staff and other information about the home. This Bill now implements a major portion of those recommendations, by placing a statutory duty on health boards to register nursing homes and to maintain a register of registered homes, to bring all nursing homes under a common system of registration and inspection, to provide for regulations governing the standard of care in nursing homes, to change the arrangements whereby health boards subvent the maintenance of dependent persons in nursing homes, to enable health boards to make boarding out arrangements for dependent persons and to repeal the Health Act, 1964, and section 54 of the Health Act, 1970.
Section 6 of the Bill empowers the Minister for Health to make regulations about the standards of care in nursing homes. Section 6, as the Minister has indicated, is broadly similar to the relevant provision in the 1964 Act, with some minor changes. The first set of regulations made under the 1964 Act were introduced in 1966. Dissatisfaction with the 1966 regulations led to the introduction of new regulations in 1985 and draft regulations for nursing homes were published on 25 May 1990. Those regulations deal with such matters as accommodation, care, quality and preparation of food, heating, bedding, staffing levels, ventilation, laundry and general hygiene. However, the standard required in all those areas is so imprecisely delineated as to be virtually unenforceable. Subjective terms such as suitable and sufficient care, adequate space, sufficient number of competent staff, suitable and sufficient accommodation, adequate day space, sufficient nutritious and varied food, are open to all kinds of interpretation. Indeed, the Eastern Health Board in a recent report observed that the regulations are too general in their requirements and too open to subjective interpretation.
It is true that those regulations are to be read in conjunction with the guidelines which have been issued by the Department of Health. However, those guidelines do not have a statutory basis. They do not provide recommended standards for all the aspects referred to in the regulations. It is essential, therefore, that detailed standards be incorporated into the new regulations and that the nursing homes concerned be given a reasonable time to comply with them. For example, in respect of accommodation standards, single bedrooms should have at least 100 square feet with a minimum ceiling height of eight feet. Shared bedrooms should have at least 80 square feet per bed. Day space should have at least 25 square feet per resident and a dining area of 25 square feet which is separate from the other areas. In this connection Anthony Lawlor, Environmental Health Officer with the Mid-Western Health Board has noted that many of the homes he has visited failed to meet those minimum standards. In one premises, single bedrooms of dimensions of 40 square feet were found and this represents less than half of the recommended standard. In practical terms, indeed, 40 square feet represents the floor area of about twice the size of a single bed. In a recent paper, Mona Horgan, superintendent public health nurse with the Eastern Health Board, made some interesting remarks. She stated:
During the course of my statutory inspections I found both high and very low standards of care, with good and bad facilities provided. I found the calibre of the person responsible for the day to day running of the home to be all important in determining the standard of care.
She also found that a difficult regulation to implement is the register of employees and the inspection of the appropriate duty roster which must be enforced. Section 10 of this Bill provides that:
The health boards may make arrangements for the boarding out of persons, who consent to such arrangements with householders, and health boards may contribute to the costs involved.
I agree with those speakers who have suggested that the word "may" is not strong enough and that it should be replaced by something more mandatory, such as the word "shall".
Health boards will be responsible for assessing the householder and the elderly person to be boarded out. The Minister for Health may make regulations in respect of standards of accommodation, care, etc. However, in the 1990 draft regulations in respect of boarding out, the same subjective terms like "suitable and sufficient" and "adequate arrangements" are used throughout the regulations. I do not believe that these regulations are strong or detailed enough to ensure that the needs of people who are boarded out are properly catered for. In regard to boarding out itself the report of the working party on services for the elderly states:
The placement of elderly people with persons willing to care for them when the elderly person can no longer live at home provides an attractive alternative to long term care in an institution.
They recommend much greater use of boarding out in the care of frail, elderly people who can no longer live at home.
Health boards have a distinguished record in placing children in foster care. The boarding out of elderly people also presents a challenge. The rapid expansion of bed and breakfast accommodation throughout the country suggests that many householders are prepared to offer accommodation in their homes for appropriate reward. The National Council for the Aged in their 1986 study of nursing homes in the private and voluntary sector recommended:
A code of practice for residential care similar to that in Britain should be drawn up, which would set down the basic principles and standards for all residential care in this country. In view of the wide range of facilities and services provided by nursing homes and the various types of patients cared for by different nursing homes, the council recommends that each private or voluntary nursing home should be required to make available a brochure setting out in detail the relevant information about the home and the services it offers.
The council is also concerned about the shortcomings in the regulations which I have mentioned. They state:
A standard considered "adequate, suitable or sufficient" by those providing a facility or a service may not be so considered by those using the facility or in receipt of the service. The council recommends objective minimum standards are required which should be enshrined in legislation.
Almost one-fifth of the elderly people in this country live alone and over 60 per cent of those living alone report longterm illness. The working party were of the view that new developments in communications technology have considerable potential in the care of the elderly at home. This potential was explored in a study carried out by the Social Science Research Centre at the University of Limerick, it was commissioned by the Department of Health. This study concluded that an alarm system based on new radio and telephone technology, and supported by a network of relatives, neighbours and statutory bodies, would greatly increase the quality of life of many elderly people, particularly those living alone with significant medical problems. The Council for the Care of the Aged also recommended that there should be an independent complaints procedure for patients and their relatives and a general consumer input into the whole process. This is something that I believe this Bill has failed to do.
Finally, Professor David Coakley, a consultant geriatrician, in a recent paper made a number of interesting and, I believe, significant points: first, old age is not a medical condition or a nursing condition but an integral part of normal life; second, there are gradual physiological changes over the years; third, this is why it is important to respond promptly to acute illness in the older individual; fourth, the doctor should be called early and if a patient with a condition such as pneumonia is not improving on treatment at home, the family doctor, and not the administrator in a health board, should be able to admit the patient readily; fifth, the wave of enthusiasm for community care sometimes loses sight of the fact that there are situations when institutional care is, indeed, the most appropriate strategy; sixth, intermittent admissions can be a great help to families caring for an elderly and disabled relative and seventh, Professor Coakley recalled that the Royal Hospital in Kilmainham was founded by James, Duke of Ormond, who served as Lord Lieutenant under Charles II. He had a very positive approach to many things, including ageing. However, like many able politicians, he ran into difficulties with London and was recalled. He gave a farewell banquet to the officers of his army in the great hall of the Hospital. There was still fire in the old cavalier as he rose to speak: "See, gentlemen," he said. "They say at court that I am old and doting, but my hand is steady and my heart doth not fail". Then, as his officers applauded, he filled his glass to the brim, and holding it aloft he inquired if he had spilled a drop. I am sure that we all agree with the attitude of the Duke of Ormond to the process of ageing, and that this is an attitude that we, as legislators, should promote.
It is in that context that I would like to welcome this Bill.
I welcome the opportunity to say a few words on this important legislation. I compliment the Minister and his Department on the amount of consideration, study and detail that are contained in the Bill. Most people living in rural Ireland — and I am one of the representatives from a rural constituency — believe it is necessary now to examine and put in place the best possible set of regulations governing the provision of nursing homes. I have listened to the Minister today introducing the Bill. I am satisfied that quite a lot of useful consideration and study has gone into the provisions that are contained in it.
I also believe that it is nearly impossible to legislate to cover every eventual set of circumstances that can arise with an elderly person. Therefore, I am pleased that the health board in future will play a major role in the implementation and supervision of nursing homes. Recently, there has been a big increase in the number of nursing homes throughout the country. It is fair to say that some of them would not measure up to the specifications and standards in the regulations. The Bill now gives them an opportunity to examine the standards that are set down in it. The time is right for consultation between the Department, the health boards and those who have established nursing homes. I see this as quite a useful piece of legislation. Nevertheless, like other speakers I would be alarmed to see the number of nursing homes that we have increasing. We would like to feel we could be identified as a caring community.
It is tragic to see the major increase in numbers of people who now find themselves in nursing homes — people who have done their best in their lifetime to look after, maintain, educate and develop their children's future to the point where they are unloaded or dumped into nursing homes. This is the easy option and quick solution. It has to be recorded by everybody that that is not acceptable socially, nationally or any other way. It is a second best option, regardless of what the conditions in the nursing home are.
Every person in this country who has a family could find themselves in a situation where they would be ready for the nursing home. That would be tragic. I believe it would be detrimental to the whole family structure, to maintaining children, caring for children and putting everything you have into their future and education, if you knew that not too far down the road you could be a candidate for the nursing home. This is fundamental and must be said at every opportunity. I believe that the health boards' involvement here is a major part of the success that we expect from this new provision.
I welcome the regulation which allows health boards to carry out regular inspections of nursing homes. I would go a little bit further and say to the Minister at this stage that along with inspecting the conditions in the nursing homes — which is vital, welcome and necessary — that I strongly advocate that representatives of the health boards also interview those who are patients in nursing homes. I would like to see regular interviews and records being kept to prevent being left in nursing homes for the convenience of the family at home.
You could argue and debate for and against that. The good side is that health boards, institutions and welfare homes will have their financial burden eased to some extent. Therefore, it is right and proper that the health board should participate. In fact, in the long term it will be a financial saving on the State if we have more well run nursing homes to cater for the population who can contribute to their own upkeep. You could argue in favour of establishing more and more nursing homes. Commercially and economically, this would be a welcome development from the taxpayers' point of view.
I have a pathological hatred for the words "nursing home" because of what they mean for so many decent people who have devoted their lives to their children and now find themselves in a nursing home. It is sad that we have to legislate in a Christian country that believes so much in its concern for its people to have the old in nursing homes. The only thing we, as legislators can do is to make certain that those people have a voice and when they find themselves in nursing homes they are not automatically silent. The social worker or the health board representative must have consultation at least once a month with those who are in nursing homes to find out if they have any grieviances or if they have any personal messages or difficulties, or if they would like to continue or alter their position.
Most of us who are involved as public representatives in rural areas know it is a common practice to be dealing with patients who are in nursing homes who are dissatisfied but cannot be rescued. That is an important aspect of the whole nursing home/patient relationship. Once they are delivered and accepted and money changes hands the system then works to contain itself and the patient in the nursing home becomes secondary. Great care and supervision have to be applied. I am delighted to see the amount of detailed consideration which is contained in this provision. I would hope that the introduction of a measure which was necessary to bring under control the whole proliferation of nursing homes nationwide will result in supervision of such homes to see how they are working out; to see if they are working satisfactorily from the patient's point of view.
In general terms, I welcome the introduction of the Bill, and I hope we will have an opportunity to make observations on the progress of the regulations from time to time.
Like other Members of the House, I welcome the general thrust of this Bill. I find it is interesting that Senators from all parts of the House gave it a welcome but that that welcome was guarded in the sense that Members of the Government side felt it their duty to enter some reservations in detail and to suggest amendments. This is very important. In the light of the fact that the proposed amendment to section 7 was initially suggested by Senator Tras Honan from the Government side and was taken up by both Fine Gael and Labour — and I, also, will add my groat's worth of wit in support of it — I am sure this means the Government will take very seriously the possibility of amending the legislation.
I would like to remind the House that section 7 permits the health board to help to defray the maintenance cost of an elderly person where it is necessary for him or her to be held in this kind of care. I think the point that was noted by Senator Honan was that the use of the word "may" merely enables the health board. It provides the freedom to engage in this activity, whereas, generally throughout the House, there is a strong feeling that the health board ought to be placed under a direct responsibility to furnish this money. I do not imagine the sums are such as to break the Exchequer but the point is obviously sufficiently important to be taken into consideration in the light of the fact that this amendment has received universal support from all sections of the House. Certainly I will be placing my name to this amendment when it comes before the House on the next Stage of the Bill.
It is an important Bill precisely because geriatric patients are among the most vulnerable members of society and for this reason they need the special protection of legislation. I am glad to say that in this country we do not have the scandalous conditions that appear to obtain in a number of other countries, at least if the news media are to be believed, in which elderly patients are physically — sometimes, indeed, even sexually — and psychologically abused by those who are given power over them. There are also conditions, particularly in some of the larger commercial establishments in England and the United States of America, where the commercial considerations are so seriously taken into consideration by the proprietors of nursing homes that conditions become squalid and dangerous. Clearly, one of the intentions of this Bill is to ensure that this situation does not obtain in this country.
It is particularly important that this Bill receive the kind of consideration it has been receiving in the Seanad because of the particular method of election of Members of the Seanad. Since the electoral college for many Members of the Seanad is principally composed of members of county councils and so on, and since many of the Senators elected under this system are themselves members of local authorities and indeed, members of health boards, it means there is a particular expertise in the Seanad with regard to questions of health boards and nursing homes. For this reason it is particularly interesting to listen to the contributions from all sections of the House.
In his speech the Minister reviewed the situation and the defects of the 1964 Act and particularly loopholes that allowed the so-called voluntary nursing homes to evade most of the effects of any form of registration or regulation. I welcome the provision of compulsory registration and inspection. I wonder if the Minister in his reply could give some further information to people like myself who do not have direct contact with health boards and the authorities that control nursing homes with regard to the inspectorate itself? I note this is something that is assumed in the legislation. It is assumed that everybody knows how this inspectorate functions, what are the qualifications of inspectors and the guidelines under which they operate. From a reading of the Bill it is not, in fact, completely clear to me. I feel that any kind of policing of legislation under regulations like this needs to be carried out in a particularly competent manner. I would like, for my own information, a further spelling out of the qualifications. How people are appointed to the inspectorate? Who composes the inspectorate? How often do they inspect? This kind of general information would be particularly useful.
One must bear in mind that it is not merely medical matters that need to be inspected under these health board interventions. There is obviously the question of planning. Reference was made from this side of the House to situations in which there could be cramped or overcrowded facilities provided by certain nursing homes which did not live up to the high standards that one would expect. I would imagine that if this is the case, the nursing home in question is probably already breaking planning regulations. Perhaps this is an area in which there should be some briefing for the inspectors, if they do not already have it.
That other areas are fire safety — there have been a number of tragedies in these sorts of institutions abroad — sanitary conditions and the question of the actual medical care provided.
On a point of order, all those homes have to have planning permission from the local authorities and have to have satisfactory fire precautions. That applies to all nursing homes.
That is not a point of order.
It is a useful illustration and I am most grateful to Senator Farrell for making it. I can just simply tell him that there is not a building of the 18th or 19th Century in the city of Dublin that meets the fire regulations because it is quite impossible to do so. People now make every provision to comply with regulations but I very much doubt if this building would pass a fire test at the moment. In view of the inflammatory speeches that are occasionally made in this Chamber, perhaps an urgent review of the fire precautions would be in order. I take Senator Farrell's point, that there is a requirement legally, theoretically, to meet fire regulations and so on, but that is precisely why an inspectorate is necessary to monitor these things. The fact that something is printed in law does not mean it is observed. This is precisely why I feel there should be some kind of monitoring of whether these regulations are actually met. We are lucky in the sense that because we are a caring community, because we are a small community and because — and I find it in a way rather strange that I am saying this — the family is still respected in this country, there is a high and commendable level of care.
The Minister refers to the question of health boards boarding out persons who can no longer live at home. I welcome this. Perhaps I just did not hear people paying tribute to one element who have suffered very largely in silence in this area and who have really done the duty of society, that is, the children of elderly people. I know that Senator McGowan gave one side of the equation where he felt that children were rather inclined to dump their parents in homes, and so on. I am not convinced that this is actually at all widespread in this country — far from it, in fact. If I may quote a personal anecdote: my uncle was a Church of Ireland clergyman, who subsequently became an Anglican clergyman in the Church of England, and in sermons in England he consistently drew attention to Ireland as an example where old people were not dumped in homes. He was horrified by the way in which in England very often people were just simply shunted off into State-run institutions because they became troublesome and the family could not be bothered with them.
The other side of that coin, however, is something that is a very notable feature of Irish life and that is the way in which usually a daughter — and very often the eldest daughter — of a large family is kept at home with the intention of providing a kind of insurance policy for the elderly people and the talents of that particular person are never developed to the full. They are left looking after the elderly people, sometimes on a farm, sometimes in a small house in an inner city and so on. They get no chance to achieve their own full potential and by the time the parents die, they are well into their middle years, into their fifties and sixties. There is no possibility for them to go out at that stage and get employment. That is a very important point. Perhaps it has been made — and I may be over-emphasising it — but I think it is important. The Minister goes on to say it is an important principle of our policy towards the elderly that as far as possible they should be supported at home and remain in their community; admirable, as far as it goes. We would all like to think that everything was for the best in the best of all possible worlds and so on, but what about the impact of the health cutbacks?
Will the Acting Leader of the House say when it is proposed to sit again?
It is proposed to sit again at 2.30 p.m. on Wednesday, 4 July 1990.
