It is proposed to conclude the Second Stage debate at 4 p.m.
Health (Nursing Homes) Bill, 1989: Second Stage (Resumed).
Question again proposed: "That the Bill be now read a Second Time."
I hope the Leader of the House is taking account of the number of Senators who still wish to speak on this Bill. I hope everybody will be accommodated.
We could let the debate run later than 4 p.m.
It would be all right, so long as everybody is accommodated.
Acting Chairman
I welcome the Minister. Senator Norris is in possession.
I will not delay the House very long. I have said a certain amount of what I wanted to put on the record the last time this Bill was under discussion. A most important question was raised in relation to the amendment to section 7, on page 10, to change the word "may" and replace it by the word "shall"— in other words to make the payment of a subvention to a nursing home mandatory. There is one very interesting thing about this and I am sure it will make the Minister consider it with particular care.
This amendment was supported in the House not only on this side but by a number of Senators on the Fianna Fáil benches. I remember, in particular, Senator Tras Honan urged this as a very important measure. In the time since we had this discussion I have had the unusual experience of having a number of people from the country and, particularly, for some reason from the Southern Health Board region telephoning me and asking me if I would take an interest in this because they were anxious that this amendment should pass, if at all possible. I would be very interested to hear the Minister's comments on that.
The section would repeal section 54 of the 1970 Health Board Act under which they were obliged to pay a subvention. This is now repealed. We are reverting to a position where they may if they like, but they are not obliged to.
I know the Minister has a very difficult job because he is continually under pressure to cut back, but the Department of Health is a Department with a very high spending budget. I would hate to think that this was a mean little slice being taken from the elderly. I know the Minister is a decent man in his own way and I am sure he would not wish to be party to this kind of cost cutting exercise, if that is what it is, but I would appeal to him, particularly in the light of the fact that the amendment has got support from all sides of the House, to see if it could be included.
With regard to the approval of nursing homes, again it has been brought to my attention that there are specific problems relating to certain areas of the country. In the last couple of years I have been told—perhaps it is not true but I rely on the information I get — that only one new nursing home in the southern health board region in Cork has actually been approved. I would be a little worried in case recognition or approval was again used as a kind of a filtering device to stop Exchequer funds being used in this way. Obviously, if the health boards have the power of approval and recognition and they do not want to be placed in a position of paying subvention, they may just decide not to recognise or approve of nursing homes.
I understand that there are some regulations attendent upon the Bill that may be made by the Minister. Could he give some indication as to when these regulations will be given to the House?
With regard to the question of community care, there are two arguments here. Sometimes it is in the interests of patients to be retained by the family and there should be a subvention given to them. I understand there is some provision for that. The small subvention that is made to assist when a relative looks after an elderly person does not transfer to the nursing home, if the old person is taken into a nursing home. In my view, that should be grossed as part of the income of that patient to allow him or her to go into the nursing home.
The other point is looked at from a different perspective. I could not help but be moved some months ago when I listened on the radio to a woman talking about the way in which she looked after both her parents. Her father died first. Then her mother was incapacitated with a stroke, was incontinent, and so on. She really fought with the love and devotion she felt towards her mother to keep her at home, to look after her, and to give her the care and attention that as a child she felt she owed to her mother. She also wanted to give it with love but the officials dealing with the case were unbelievably stingy. It would have been a great help if she had been able to collect a month's supply of incontinence pads, for example, but they were cheeseparing the whole time. They asked why she needed this number of incontinence pads, and so on. They were trying to reduce the number all the time, and only giving them to her in small amounts for which she had to queue. If we are serious about community care as one kind of offshoot of our interest in the aged, we have to abandon those nasty cheesepairing attitudes and give real human support to people who relieve the State of a burden.
Acting Chairman
I understand the Leader of the House wishes to speak.
It is now obvious that there are more speakers than we anticipated. With agreement from the other side of the House, we have now decided we will allow the Second Stage debate to continue until 4.30 p.m. if necessary.
Acting Chairman
Is that agreed? Agreed.
I want to welcome this Bill and congratulate the Minister on bringing forward this excellent legislation at this time. It is true to say that in practical terms it is one of the most important pieces of legislation in the medical field that has come before us. It affects each of us in some shape or form, both young and old.
The aim of the Bill is to promote the highest standards of care for dependent persons in nursing homes, to change the arrangements for subvention for persons in nursing homes and to facilitate health boards to make arrangements for the boarding out of persons who can no longer live at home. The existing legislation is almost 26 years old. It is appropriate that developments in relation to the care of dependent persons during that period are reflected in the new legislation.
At this point I would like to pay tribute to nursing homes under the aegis of the health boards and to the tremendous contribution they have made in the care of the elderly. Initially, they were looked at as being county homes which were transferred into nursing homes. A certain stigma had been attached to those homes. That was a great pity because the standard of facilities and care provided by those nursing homes is outstanding. They are totally committed and tribute must be paid to them for the marvellous work they have done. It has to be acknowledged that certain changes have taken place in society in relation to care of the elderly.
I was very interested to hear both Senator Norris and Senator McGowan speaking last week in relation to the care of the elderly in the home. They approached the topic from two different points of view and in a sense both are correct. Senator Norris was praising people, and rightly so, who committed themselves to the care of elderly people, the daughter or relative who would give up a job to take care of an elderly person. That type of commitment is admirable. There was a difficulty in relation to the prescribed relative's allowance but from next October, I am glad to know, any individual who looks after an elderly person in the home will get a carer's allowance.
These people did not seek money for looking after the elderly person. It was job of work that they felt they had to do and wanted to do. They were not looking for reward; it was a labour of love. Those people are to be congratulated for the excellent manner in which they looked after an elderly relative.
Senator McGowan said there is an air of change in society that people do not want to care for old people; that they are absorbed with their jobs, their style of life and do not have the time or the inclination to look after old people. That is a pity. The extended family was a marvellous way of life, almost unique in Irish society. Few societies in the world could claim the same commitment to the elderly and the extended family perspective.
Society has been changing and for a variety of reasons that tradition is dying and there is a huge demand for nursing homes. Before the private sector became involved, the old type of county home was converted into a nursing home. The difficulty was that a number of them were situated long distances from elderly people who needed constant care and attention. Whether it was that relatives did not wish to look after them or they had no relatives to look after them, they had to be institutionalised. The tremendous difficulty was that they lost contact with their locality and their neighbours.
I want to pay tribute to voluntary groups who on their own initiative, with no profit motive, set about developing nursing homes in their localities. They have done tremendous work. I am not for one moment knocking private nursing homes. The vast majority of private nursing homes give excellent service and provide excellent facilities for the elderly. I must acknowledge the voluntary organisations who have been involved with no profit motive. They are there specifically to provide a very essential service, to look after the elderly in their community.
An important aspect in relation to old people is that their friends would have access to them. A tremendous amount of work is done voluntarily in visiting old people in hospitals and in homes but we have to acknowledge that in many cases older people may not be interested in the young people who visit them. The elderly want to take to their friends about old times and things that happened in their locality, in which younger people may not be interested.
There are approximately 340 known nursing homes in the country, It is important that this legislation be enacted as quickly as possible. The legislation spells out in definite terms the responsibilities which will attach to health boards and makes clear to those who wish to develop private nursing homes or to contribute to or continue to operate private nursing homes that they have specific responsibilities which are now part of the law and which will have to be strictly adhered to. Surveys of private nursing homes carried out in recent times show that while many homes are very professionally operated and give an excellent service there are others which leave a lot to be desired, which exploit old people for selfish gains. This type of inhumane operation could not be tolerated. There is nothing as cold-blooded or disgusting as individuals who would seek to make a profit out of the need for old people to be institutionalised. That attitude is deplorable. There have been reports of old people living in dreadful conditions in some homes and of being treated in the worst possible way.
This legislation is in the interests of the elderly and there will be a guarantee of a specific level of care and physical comfort and that conditions within private nursing homes are acceptable and suitable.
The legislation spell out where the responsibility lies for the correct management and control of nursing homes as between the owners and management and the health boards. It spells out that in the absence of proper exercise of their responsibilities the owners will suffer revocation of their licence, a withdrawal of their licence, or failure to get renewal of a licence and some very stiff financial penalties are provided for. As has been done by other speakers last week, I want to acknowledge the contribution made by The Workers' Party report, "The Years Ahead". Much background work was done on this subject and the licensing system for nursing homes was recommended by that group. That is only right and proper.
It is also important where there is a sale of a private nursing home that the new owner would have to apply for a licence. This is extremely important. An individual who set up a private nursing home and desired to provide very good service, might decide to sell the home and if a licensing law was not in existence a person who was not greatly concerned about the welfare of older people could become the owner and exploit the nursing home for profit. It is extermely important that persons buying a nursing home would have to apply for a licence and qualify in their own right.
A register would be very important so that people would be aware of the facilities available.
Another area touched on in the legislation is boarding out. I am apprehensive about the boarding out system. In theory it is an extremely good and important feature of care of the elderly, but it may provide opportunity for people to profit. An elderly person may have some finance or land or property for the transfer of which certain people would provide board. The theory would be that the elderly person would be cared for but in practice very little care would be provided. There are cases where people, for the sake of acquiring some property would agree to board out an elderly person who might then experience difficulties.
Elderly persons who find themselves in such a situation are afraid to complain. The type of pressure they can exert is limited. The alternative may be that they will be sent somewhere else. It is of prime importance to old people to be in their own locality.
It is very important that the Minister and the Department of Health would ensure that the elderly are treated in the way that would be expected. They have served their country and their families. People coming to the end of their days should have dignity. We all wish to live to be a ripe old age and hope that at that time we would be treated as we would expect the elderly to be treated today. It is extremely important to acknowledge that we may be old at some stage. We would hope when that time comes we would be treated properly. We have the responsibility now to treat older people properly.
I want to congratulate the Minister on the excellent legislation he has brought before us. A nursing home should be a home. "Home" is a very important word in this debate. A home should be properly heated and ventilated. That is extremely important where elderly people are concerned. In a nursing home there should be accommodation where the residents can chat in comfort and confidence with their friends.
Health inspection is extremely important in relation to all of this legislation. One hears of outhouses or garages being converted into nursing homes. It is extremely important that where that happens it is not glossed over. There should be specific minimum conditions laid down and a licence should not be granted unless the Department are fully satisfied that the applicant meets all the criteria. There have been cases where people tried to get away with the minimum accommodation in order to gain profit.
I congratulate the Minister on this excellent legislation. I wish him the very best of luck with it.
Like the other speakers, I welcome the placing of a statutory duty on health boards to register nursing homes, to maintain a register and also to bring nursing homes under a common system of inspection. I am glad that during the passage of the Bill through the Dáil the Minister changed the notion of licensing to registration as we would have welcomed in the Seanad.
I am worried about the change in regard to health board subventions for the maintenance of dependent persons in nursing homes at this moment. I am worried about the fact that in the Mid-west area subventions have not been paid which were due since March. There is a three month demand at the moment by the nursing home proprietors who are running businesses and need the cashflow in the same way as the health boards do. I appeal to the Minister, if it is within his power, to release funds so that the health boards can do that. Some health boards have not paid subventions at all and that is a shocking aspect. I hope this Bill will go some way towards ensuring that payments are made. I will get back to that in a moment.
The Minister last week made reference to population projections and reinforced the need for nursing care for those in most need, especially for those least able physically and financially to look after their own affairs. To refresh ourselves with figures it is interesting — although there are so many young people in the Gallery at this moment that we have a very high ageing population and it will continue to be that way as the birth rate continues to drop. The average life expectancy at birth in western Europe and North America now stands at 70. In the Republic of Ireland men of 65 can expect to live a further 12 years and women a further 15 years. That figure is expected to rise by the year 2000. The ageing of the population is not the result of living longer but of the lower birth rate so that the proportion of older to younger people is rising.
All of this is very relevant to us. Like other Senators, I worry about my own future, in relation to nursing home care. It is something that should affect everybody. I was disappointed with the level of media coverage of something which will be a problem for all of us. It seems to hit people only when they have aged parents that they must do something about it. We have always had a tradition in this country of caring for our elderly and I hoped that the Bill would get a little more coverage because it is something that we all welcome.
Looking at the projected figures for the next 15 years, the fastest growth rate will be in that group which are aged 75 and over. These people must be looked after. Between 1981 and 1990 there has been an overall increase. Eleven per cent of our population are over 65 years; over 55 per cent of those are women; 4 per cent are 75 or older and, again, the elderly are more likely to be female — 60 per cent.
It is interesting that the counties that have the greater percentage of elderly people are the counties where services would be needed, counties like Donegal, Leitrim, Sligo, Mayo and Roscommon. Obviously, because of the demographic imbalance in this country, there will be a great number of elderly people in the Dublin area where there would be a number of nursing homes. I was amazed when doing research in this to find that County Kerry had relatively few private nursing homes. County Limerick would be rather different. The figures in relation to counties like Donegal, Leitrim, Sligo, Mayo and Roscommon show that there will be many new nursing homes mushrooming in those areas. Taking all that into account, it is interesting that we still need care for our elderly at home. Only 5 per cent of our elderly live in hospices and institutions; 14 per cent live alone, which is a fairly high percentage and the proportion is 2:1 in relation to female and male.
In relation to the subvention payments, I have made reference to the Mid-Western Health Board, who have a very good record as regards their commitment of the elderly. The figure for 1988 shows that the Mid-Western Health Board paid out £1.38 million in subventive beds, which is a sizeable amount. They have to be dutifully congratulated on that because, as I said, some other health boards have not being as consistent in their commitment to the elderly.
I would appeal to the Minister — and we will be putting down amendments for Committee Stage—that the verb "may" should be changed to "shall" because it must be obligatory on health boards to meet their payments. How they balance their books is their business, but the commitment to the elderly must be a high priority.
The amount is small. I know that the Minister cannot get funds out of nowhere. A survey was done in the Limerick area, where in St. Camillus's Hospital it cost £200 a week to keep an old person. I am thinking of a small private nursing home in the county where the proprietress had to increase her fee last year from £95 to £110 per person whereas in a geriatric home like St. Camillus' it costs £200. It would be in the interests of all of us to ensure that there are new nursing homes, that they will have subventive beds and that they will be able to survive financially.
Really, £47 is a small amount but it goes a long way towards helping the already stretched budget of the proprietor. Without subventive beds, some of them would certainly close though they are caring homes, they are commercial businesses. We should ensure that old age pensioners, who have no additional financial means, can gain access to nursing homes because of the subventive payment. I applaud the Minister for saying that it is in his interests and in the health boards' interest to ensure that their meagre funds can be used for the people who most need them but there is a difficulty there which I will come to in a moment.
When we talk about nursing homes "homes" is the operative word. There are many instances, and I could give facts and figures as regards nursing homes in Limerick where discarded elderly people have been literally picked up from the wasteland of the surrounding areas and given security and care by nursing home owners at a financial loss to themselves. There is no question about that. These people are discarded by their families. It does not happen very often but when it does those nursing home proprieters have taken people in and they are running at a loss as regards the odd individual. That is something which is happening in nursing homes and in larger nursing or convalescent homes run by religious bodies. It worries me as to what will happen in the new order when there will be a certain number of beds subvented. Take a nursing home in the mid-west area which has 150 beds and of which 120 are subvented. What will happen to No. 121 where the particular person was very needy and the subvention may not come his or her way?
This is the most important aspect of the Bill. It relates to other areas of life in Ireland where there are many people in nursing homes who have the financial means to pay their way and do not. They are there, they are getting the subventive payment and there are others who are thrown in the wasteland and who have not access. I would hope that the Bill would go some way towards plugging loopholes, where the assessment of the financial circumstances or means testing may shake out anomalies. It is true that people who have neither the economic nor social need to do so will offload parents onto the taxpayer. It is a problem in many aspects of Irish life, where social welfare payments are concerned or where those who deserve them do not always get them and those who do not are able to lay their hands on them. The elderly are vulnerable. I am worried about the practicalities of more and more subventive beds if the resources are not there to provide them.
In relation to the different rates of subvention, I presume there will be more work done on that. I did not see very much in the Bill as regards the different levels of dependency, the light, the moderate and the heavy and special category for severe forms of dementia. I presume there is a committee looking into how the funding will go. Perhaps the Minister will tell us this evening the levels of subventive payments that will go to the different categories.
Again in relation to the Mid-West area, in the 37 nursing homes there are 959 beds and 17 of those have subvented beds up to 620, so you have 320 beds which are not subvented. I wonder how many of those will come on line for payment under the Bill. I have mentioned that there is a commitment by the Mid-Western Health Board to ensure that they honour their subvented bed payments. The Minister has written this into his address to us. In relation to the resources available to them, how can they most effectively respond flexibly to the changing demands of dependent people for whom they have responsibility? I wonder how the Minister proposes to do this.
Again, I want to come back to the necessity of having obligatory payments, rather than this "may" to have "shall" because it does give an out to health boards who raise their hands in the air and say "We do not have the money." It worries me. I would hope that the Bill would not be theoretical, that it could be implemented, as it is a good Bill. Most people will give to the Third World. We have the commitment and tradition always to our elderly. It is something that should get more coverage. Perhaps there should be a lobby from the public for health boards to give that commitment and prioritise their resources.
In regard to inspection area. I have a certain concern. I hope the inspectors would behave in a very caring way; I assume they would. They would be members of health boards and it would be a caring profession. They must remember the vulnerability of the people cared for in those nursing homes, allow for the little idiosyncrasies of old people. The nursing home proprietors would be in a far better position on a one to one basis. I am talking in particular about small nursing homes where there is a homely atmosphere. I would hope that the official would not come in on a day when everything would not be going so well, as can happen in any domestic establishment; that they would be sympathetic towards something which might not necessarily fit the demands of a clinical, antiseptic hospital. I would expect that when talking in terms of cleanliness, we are talking about domestic cleanliness, not necessarily antiseptic cleanliness and that there would be a sensitive approach to the inspection and that they would recognise the difference between clean and antiseptically clean.
I agree with the Minister that there should be a nurse on duty at all times and proper records should be kept. The most worrying aspect is where there is a management order, which I would accept, where standards have fallen so low that there is an urgency to protect those vulnerable people at all costs. The Minister did refer to the impracticality of transferring residents to other homes and I would consider that he is justified. You do not push people here, there and everywhere. I do not think it would be feasible. Again, think of the need for security for old people and the vulnerability of the patients in moving them around. He has the solution of allowing the health board to assume the management of the home until the problems have been resolved — and hopefully they would be resolved. First of all, the health board would have the power to assume the management of the home, secondly, the period of management would be short term for three months; and, thirdly, the expenses from the income of the nursing home would be used to pay the salaries of the officials that would run it. I find this all rather vague. In terms of financial structures and the cost effectiveness of taking it over, temporary is fine. But if you are looking at long term action — a change of management for instance — if the person has to be transferred to other premises, yes.
In law, what are the Minister's responsibilities and entitlements in relation to change of management of the home? Will the Minister assume the right to liquidate because it is a commercial premises? There might be only one case where a nursing home might have to be taken over but I would like to know the Minister's responsibility in this area. Can he liquidate that business, having regard to its long term prospects?
The Minister also referred to the present system of subvention discriminating against the many excellent modern homes which have opened since 1980. He says:
Technically every person entering an approved nursing home is eligible for subvention for care...
That applies to the entire population and is contained in section 54 of 1970 Act. Under that the health board may pay a subvention to a person in a home approved of by the Minister for Health. The scope was curbed as, he tells us, no new homes were approved since 1980 because of financial constraints in the health services. If it was not possible to approve new homes then — 78 new homes out of 322 private and voluntary nursing homes were mentioned — will there be discrimination against modern homes? How can the Minister guarantee payment? It is difficult to understand how that can be operated and how it can be put into place. It will be necessary to have a tight assessment of the financial position of people looking for subventive beds.
Geriatricians cost money and need resources. In The Years Ahead — A Policy for the Elderly— I know that relates to community hospitals — the point was made: that ideally, every elderly person requiring extended care should be assessed by a consultant in geriatric medicine and the members of his or her department. There was a recommendation for the appointment of geriatricians in larger hospitals. In the mid-west there is one geriatrician serving Limerick city in St. Camillus's hospital. There is approval for another, but an approval does not mean that the appointment will be made because when Comhairle na nOspidéal advertise, the appointment can take from one to three years. There is also approval for one for the Clare area, and it is accepted there is a need for a third in the Limerick area, plus west Limerick and north Tipperary, which means more funding and resources. Comhairle na nOspidéal can designate and advertise the post but there is no guarantee of funding.
Finally, there is a need for properly regulated nursing homes because large numbers of acute beds are taken up with geriatric patients. Figures show that acute public beds have reduced from 17,000 to 13,000 over the last three to four years. Therefore long-stay patients in acute hospitals should be cared for in appropriate alternative accommodation. As other speakers have said, a special tribute should be paid to the small nursing homes serving rural areas. They answer a great community need whereby the elderly can be kept secure in their own environment and accessible to their families. I compliment the Minister for bringing forward this Bill and hope he will take into consideration the obligatory need to have "may" changed to "shall" to ensure that contributions in relation to subventive beds will go to deserving people.
I appreciate that there are a number of speakers and that we are confined to time. I will confine my contribution to a minute or two.
This Bill is overdue to some extent, but it is very welcome. In all aspects of medicine and care we are talking about community care and part and parcel of community care must be a structure other than hospitals, to look after people. A nursing home is very much part and parcel of that scenario. The nursing homes have played an important role up to now, but legislation needed to be updated.
I have always believed that at every opportunity people should be maintained at home and Senator McKenna outlined the social side of that. I have consistently supported that at health board level down through the years and in my discussions with relatives if the question of them going into care came up. However there has always been one obstacle to that, the tight guidelines which applied to the prescribed relative's allowance. It was anti-family. It was not in the interests of maintaining the family structure, to the extent that people in the rural areas knew it and, possibly, in the cities as well. For example, if a mother and son were living at home, the son could get the prescribed relative's allowance but if he married a nurse and she was at home on a full-time basis, he would immediately be disqualified from the prescribed relative's allowance. That was an anomaly and over the years, at health board level, I have highlighted this. That allowance is gone and we now have the carer's allowance and that is an important development. I do not know how the carer's allowance will work yet.
We will have to wait and see it in practice. The terms are good and I hope the regulations will give families the opportunity to avail of this allowance. The nursing homes Bill and the carer's allowance run parallel.
Another area I have a slight worry about is boarding out. Boarding out, in theory, is a good idea, but I hope the regulations are watertight and that they give authority to health board officials and the Minister's Department to at all times keep a very close eye on this. None of us want to see a neighbour, friend or constituent being neglected when boarded out. I look forward with interest to the regulations and hope that health board officials will have the authority to ensure that people who are boarded out are looked after and that no advantage is taken of them. I welcome the Bill and support it fully.
An Leas-Chathaoirleach
I have two Senators indicating they wish to speak and I understand it has been agreed that the Minister will reply at 4.20 p.m., so I ask the Senators to share their time.
I hope to maintain my tradition of being brief.
Do not name all the books.
I certainly will not. Basically, this is an enabling Bill. It repeats much of what is in the 1964 Act. What we are seeing now is a registration system when, in fact, we have a de facto registration system. The broad ideas contained in this Bill are good and I welcome them. There has been a huge growth in the number in nursing homes in recent years. That may be related to a number of factors but the primary one must be the squeeze which has been put on the health budget. That, in turn, has generated its own knock-on problems and has given rise to an increasing demand for nursing home type facilities.
It is important that clear guidelines be established in relation to what are acceptable standards in nursing homes. While the Bill does not go into the nitty gritty, it is important that the Minister sets out clear guidelines and that high standards are maintained. Those standards should apply to the training of staff and to the number of staff employed to cater for a given number of patients.
Proper standards should be maintained in relation to food, nutrition and menus. In other words, the food provided should not only be nutritious but also appetising. Standards of hygiene, heating and ventilation are vitally important as people get old. More important, however, are the standards of the recreational facilities and the general regime in the nursing homes.
It is difficult to be precise about proper standards because in many ways, it is a matter of opinion. Having said that, there is no doubt that in some homes the standards which exist are unacceptable; in some cases patients or residents have been reduced to little less than prisoners. The way to set about sorting out that problem can be very difficult, as has been mentioned by other Senators. Many old people are afraid to complain because of what they fear may happen them arising from that complaint. It is absolutely essential that the basic human dignity of all residents or patients in nursing homes be respected. That is a fundamental first priority, and in many ways I would see all the other considerations as less important.
Nursing homes should be flexible so that people are not regimented in relation to the time they go to bed etc., in other words, they should have control over their own lives. It is very important for people as they grow old to remain independent as long as possible. The independence of an old person is an important influence in determining his or her life span.
I was pleased to hear the Minister speak of having uniform standards for all health boards. While each health board will be responsible for the nursing homes in its area, I was pleased to hear the Minister say that he will lay down guidelines for each health board so that there will be uniformity across the country rather than variations in the differing attitudes of the health boards. There are also problems when it comes to the degree of disability suffered by people in nursing and I hope the Minister will make allowances for that. In particular, I hope funding will be provided to keep people of differing levels of capacity at maximum levels of welfare in these homes.
This is important legislation and we can expect it to become more relevant. As the population changes which are now taking place become clearer there will be a greater number of old people as a proportion of the total population and, therefore, a higher dependency rate. That, in turn, will be exaggerated because of the fall-off in the birth rate, emigration and other factors relating to social change. As new urban areas develop, they will create their own knock-on effects in terms of a greater burden on the community caring for older people. We have a great tradition in rural Ireland of looking after old people and in the old settled urban areas in the city of Dublin people are exceptionally concerned about old people. There are many people who do jobs for them, week in and week out, and who bring them for an outing once or twice a year. Those people deserve great praise.
Finally, in the area of health, resources are absolutely essential and it is why I am very concerned to see in the Bill that health boards "may provide" as distinct from "shall provide" money to sustain and provide for the welfare of older people. We will be introducing amendments to deal with that. I am also disturbed that the provisions of the Bill do not apply to health board establishments. That would also be a desirable alteration.
I welcome the Bill and congratulate the Minister on it, but it is not before time that it has come before this House.
On a point of order, I know no order was made this morning regarding the concluding time and that the Criminal Justice Bill took longer than anticipated but what is the position in regard to speakers? Has any order been made?
I will be happy to give some of my time to Senator Cosgrave and deal with the points raised on Committee Stage.
An Leas-Chathaoirleach
Will Senators Cosgrave and McDonald share their time?
There is no time. This is the second Bill running on which out of the blue, there has been a curtailment on time. On the Criminal Justice Bill I was allowed one and a half minutes before I was ruled out of order. I will not tolerate the same happening today.
An Leas-Chathaoirleach
My predecessor pointed out to me before I came into the Chamber that, by agreement of the House, it was agreed to terminate discussion on this at 4.30 p.m. and that the Minister would come in at 4.20 p.m.
That was not agreed this morning.
An Leas-Chathaoirleach
I know that but I understand that it was agreed across the House at approximately 3.30 p.m.
On a point of order, what time do the Senators wish? There was agreement across the floor for a 4.30 p.m. finish, and is not my intention, and I know it is not the intention of the Minister, that anybody should be excluded, but that was the arrangement. If a new arrangement is needed, what is it?
I only want a few minutes. I thank the Minister for his co-operation but Senator McDonald is before me.
In fairness, the Minister has indicated that he will share his time with speakers on the opposite side, so there is no question of curtailing the debate.
An Leas-Chathaoirleach
In the spirit of co-operation, we will try to facilitate Senators.
The Minister should be congratulated and I welcome the Bill. Many Senators have mentioned the boarding-out facility and I am sure the Minister has taken that into consideration. It is important that we look after the needs of our old people because one day we will all be old and it is nice to know that there are proper facilities for elderly people.
I do not intend to go into the Bill in depth. I am glad to see that new licensing regulations will have to be implemented. I am glad that the health boards will enforce the regulations in relation to the number and qualifications of staff, description of homes, and so on. Prior to this, if an inspection of a private nursing home was being made a big shake up would take place on the day or week before the inspection and as soon as the inspection was over, matters were allowed to deteriorate again. It is good that the health board officials will have the opportunity to carry out inspections occasionally.
While most nursing homes are being run well, some are not. Under the Bill, health boards will have to be satisfied that the home complies with the standards and the regulations laid down and that the proprietors and persons in charge are qualified to be in charge of a nursing home. Basic nursing qualifications do not guarantee suitability for management of a nursing home. Being a nurse does not mean that one would be a good manager. I am glad to see new regulations being introduced.
While many of the existing nursing homes maintain high standards, others do not. They are mismanaged and run by domestic staff who are allowed to administer drugs, change bandages and look after the needs of the patients. Domestic staff are not qualified to carry out those duties. These new regulations will have to be implemented. The proper spacing of beds will also have to be in accordance with the new regulations because at present many nursing homes seem to crowd patients into small spaces. I do not know what the distance between beds should be but surely it should be in the region of six feet? That should be stated in the Bill.
It is important to preserve the friendly atmosphere of the nursing homes in much the same way as the home environment of the patient. Many old people get up in the mornings, are washed and just sit in a room looking at four walls. Occupational therapy should be introduced to keep their minds active.
New hygenic rules will have to be implemented in nursing homes. For instance, some nursing homes use old sheets and plastic bags instead of incontinent pads to protect patients. Standards which apply to all nursing homes in the public sector will have to be implemented in the private nursing home sector. Patients will have to be bathed daily and not, as at present, once a week or once a fortnight. Hygiene in these new registered nursing homes will have to be of the highest standard. The Bill is welcome.
I welcome the Bill and compliment the Minister for introducing it. The boarding out of children is nothing new and has been going on for many years. There are some very good foster homes but others left a lot to be desired, especially in the earlier years. We have the same tendency starting now with the health boards but, unfortunately, it is a cost cutting procedure. I hope that through the powers of this Bill the Minister will be able to put in place significant rules and regulations to ensure that dependent persons will be looked after, that they will be given the due care and attention they deserve and that the dignity of the person will at all times be guaranteed and respected. From that point of view it is important that the Minister and the health boards will undertake to guarantee that a great number of people will not move into the area of catering for boarded out elderly or disabled persons for the sole reason of making a fast buck. That would be deplorable.
While fees are mentioned in the subsections of section 4, it is not clear whether the health boards will attempt to regulate the charges for nursing homes. I assume that health boards will offer a capitation grant or fee which will supplement the person's old age or disability pension. It is important in taking into consideration the capitation grant and the person's pension that the dependent person would be guaranteed a minimum sum of disposable income each week. As in our geriatric and district hospitals there should be a very strict register and account kept of the elderly people's pensions and money.
There should be some regulation as to the ratio of staff and residents and there should be training for staff. Nurses will have training but nurses' aides would need an understanding of the ways of the elderly — especially if they are a little doddery — and of their problems and pecularities. People in their declining years should live in an environment which is as near as possible to their own home and extended family. In relation to boarding out where the rules and regulations or registered nursing homes do not apply, some regulations need to be implemented to ensure that minimum facilities, such as accommodation and day rooms, are provided. There should be more than one day room for these people to sit around in or live in because if there are four, five or a number of people living together the tendency is that they will have disagreements or get on one another's nerves. They must be able to move from one place to another.
The quality of life must be guaranteed for those people in the Bill. The health boards and the Department of Health, have long experience of boarding out children so it should not be a great problem, but to extend it to people who are moving into their second childhood is much more complex. There is another problem in our health board area and it occurs when people are accommodated with the assistance of the health board. When people get ill and there is a difficulty acquiring beds in public hospitals there should be a greater liaison to ensure that they — they may have been shoved aside by the health board for economic reasons — are taken in and given the proper medical and nursing care to get them back on their feet again.
Many of the provisions of the Bill are of great importance. Indeed, I am not happy with the policy of the Department of Health who are seeking to make considerable reductions in public expenditure by opting to give small contributions to people who take disabled or elderly people into their families. The idea of the extended family is a Christian one and people who apply to be part of this scheme must be fairly closely vetted. They must be offered some training and be subject to regular inspection by qualified persons employed by the various health boards. The location of these homes is of crucial importance. In rural areas I hope there will be a policy whereby those homes are situated close to shops and churches to ensure that people can retain their independence and are able to toddle off either to pray or to the shops. I know that the ideas enshrined in the Bill are largely in operation in many counties. I hope the experience health boards have gained over the last two or three years will be reflected in this Bill because, obviously, instead of having several hundred people in geriatric homes around the country we are going to try to get back to the extended family tradition which is a very laudable ideal in itself.
While a high percentage of people will apply to be part of this wonderful scheme there will, inevitably, be a number of people who will be in this business, and I think mistakenly, for the cash. That is why it is going to be very difficult to police the standards. It is going to be difficult to have an inspectorate who will be able to monitor the scheme from house to house. Section 10, for that reason, is of great importance and I hope that the size of the houses, the number of rooms and so on, will be of a high standard. In one's daily movement around a health board area one hears a lot of complaints but the people who are boarded out are not in a position to complain. From that point of view we need a very dedicated body of nurses to inspect the homes, to assess conditions for themselves and recommend the course of action to be taken.
The big problem is that, looking at the last census and the demographic projection for this decade, it is quite clear that the health boards and the Department of Health will not be in a position to accommodate the number of retired and elderly persons here. I do not think we should be endeavouring to meet that deficiency by shoving the problem over to the public. The State has an obligation to provide for the elderly, for people who are in need of care. That is an obligation that should be met. I hope we will not be setting out on a road where is will be done on the cheap. It would be ideal, of course, to have people in retirement, especially those living alone, supported by the State and kept out of a hospital ward. A very simple support system could accommodate those people in their own community.
I do not think the Bill has sharp enough teeth to control everything. In addition, the Minister is taking, or proposing to make, most of the big decisions by regulation. The definition section refers to physical infirmity, physical injury, defect or disease or mental infirmity. We have in every health board area quite a number of psycho-geriatric patients being accommodated in hospitals, many of them unsupervised full-time. That again is getting a very mixed response from the public. I do not know whether it is less expensive than the system we had before under which patients were maintained in large psychiatric institutions. It remains to be seen whether or not it will represent an improvement. It does not appear to be a great improvement for the people who are being accommodated but perhaps from now on many people will not be taken into institutions long-term or become institutionalised.
This is a most important Bill and I hope the House will take a long and serious look at its implications across the whole spectrum of care for the individual, the nursing homes and those being boarded out. They are three very important aspects of life, especially in rural Ireland. I hope we will be able to get assurances from the Minister that the many fears expressed by people will be allayed. I look forward to a more detailed discussion on some sections on next Stage.
I shall be brief and make a few points in relation to the Bill. It would not have been necessary to curtail the debate if some Members were not so longwinded and repetitive earlier. The Bill is long overdue and I welcome it and what the Minister is trying to achieve in it. We are all aware of the problems involved — geriatric care and looking after our old people. It is fair to say that people on average are living longer. They deserve to be looked after when they retire or fall into poor health and do not have relatives to look after them. They should be looked after properly after having spent many years working hard.
Pension schemes and benefits should be looked at to see how they all tie up. Unfortunately, what is happening is that people do not have adequate finance. In relation to the provision of nursing home care, there are some very good nursing homes. We are all aware of the well qualified people who run them and how the patients are well looked after, but unfortunately, there are the cowboy operators out for the quick buck. They are the people the Minister is going to nail under this Bill and, if necessary, close them down unless they improve.
Some nursing homes are glorified, converted semi-detached houses and the patients live in overcrowded conditions. In some cases the staff are not qualified. I suggest that there should be a sufficient number of qualified persons, nurses and so on, to so many patients. It should not be possible for nursing homes to go for cheap labour. There should be qualified doctors available at all times.
We are all aware of the expensive fees charged by nursing homes. Obviously, people cannot be expected to run them without making some profit but it should not be case of profit first and the health and welfare of the people in the nursing home second. We have to monitor what is happening and ensure that patients are being looked after, that people are not being left in bed all day and developing bed sores. Their relatives may live too far away and may be unable to check up on them.
I support the principle of the Bill and I should like to ask the Minister on Committee Stage to deal with the monitoring and policing of the provisions. Obviously, there will be a need for policing in relation to the registration period. Beyond that, what will happen? It is grand introducing a Bill and passing it into law but will it bring about changes? There should be stricter guidelines from the Department as exist in relation to fire brigades. I hope the Minister will be able to look at the suitability of facilities, staffing, etc., and see to it that nursing homes are designed properly with sufficient fire exits.
The Minister should consult with his colleague, the Minister for the Environment, in relation to schemes for senior citizens. Many of these people can do a lot for themselves and only need a little assistance. We have had two successful schemes promoted by Dún Laoghaire Corporation in Beaufort and Kilbegnet Close where there are between 30 and 40 units and help available. In those centres people live their lives with a certain sense of independence and dignity.
Another problem that has been touched on was the position of an eldest or youngest daughter ending up looking after an elderly parent or relative. For far too long these people were taken for granted. Certain moves were made in the Finance Bill in relation to them but the dependent relative allowance remained at £100 or £120 for many years.
I welcome the Bill and I look forward to the Minister dealing with the points I raised on Committee Stage.
I am pleased that there is a broad consensus in the Seanad in support of this Bill. We all have an interest in ensuring that we have the highest standards for our elderly people in the community. While it is not possible to deal with every issue raised during the debate I will come back to a number of the points on Committee Stage. I will try to answer some of the questions raised on particular sections of the Bill. There was some confusion during the debate about the status of religious homes under the Bill. It might help the House to explain the provisions of the Bill regarding these homes. The Bill distinguishes between nursing homes run by religious orders where the majority of patients are lay people, homes run by religious orders where the majority of patients are priests or members of a religious order and religious communities caring for their own members and nursing homes run by religious orders where the majority of dependent persons are lay people. The latter will be brought within the scope of the legislation. They were excluded under existing legislation.
The Bill, as introduced in the Dáil, excluded all religious homes where priests or members of a religious order constituted the majority of those being cared for. On Report Stage I introduced an amendment which will allow homes where the elderly religious are being looked after by their own order to come under the scope of the Bill and qualify for subvention. Of course, if they do come under the scope of the Bill they will have to live within the regulations laid down under it. Everybody will accept that it would not, for example, be right to insist that a monastery of Carmelite nuns who have taken a vow of poverty be obliged to comply with the standards of comfort laid down in the new regulations. For that reason all religious orders were not included in the Bill originally.
The issue of price control was raised by Senator O'Reilly, and others, who suggest that the fees be regulated. I do not think that is necessary because there is no restriction on the number of nursing homes that can be established. With the competition between nursing homes I believe there will be sufficient control to ensure that nursing homes charges are not exorbitant. Indeed, the health boards will be monitoring the nursing homes because the health boards will not pay a rate above that necessary for places in nursing homes.
Senator Hederman raised the issue of retirement homes. The Bill is not concerned with genuine retirement homes such as special housing complexes for the elderly, or lodging houses. We are concerned that somebody does not try to circumvent the legislation by having a nursing home and calling it a retirement home. We have to make sure that that will not happen. Indeed, the Bill provides for fines of up to £50,000 for people who operate or open unregistered homes. A number of Senators raised the issue of consistency. Of course, there will be very close liaison between officials of my Department and the health boards in the implementation of this legislation, and there will be standarisation in regard to the implementation of the provisions. Health boards must have a little flexibility to respond to local need.
It might assist Senators if I outline some of the means by which a consistent approach will be taken to the application of the legislation. My Department are already involved with officers of all health boards in a working group who have been monitoring the implementation of the 1985 regulations. This group are now examining the implications of the proposed legislation for health boards as the regulation authorities and, indeed, they have been consulted in the preparation of the new regulations.
There will also be a code of practice dealing with standards of care to be achieved in nursing homes and the operation of the proposed legislation. That code of practice has been drafted. A group of experts have been called together to examine the code and make recommendations. The adoption of the code, and an agreed approach to the assessment by the health boards of the dependency of an elderly person applying for a subvention, will encourage a consistent approach to the application of this legislation. We should have a standing committee, which will co-ordinate the way in which all health boards discharge their responsibilities to the elderly requiring nursing care. Like many other aspects of activity relating to the elderly, the National Council for the Elderly will be involved.
Health board homes and hospitals for the elderly do not come within the scope of the Bill. A number of Senators raised the issue and believed that they should. Health boards are statutory authorities subject to public accountability. They have their regular monthly meeting at which any question can be asked. There are visiting committees visiting the homes for the elderly, and the Minister for Health, as the Minister responsible, may be questioned both in the Dáil and the Seanad on aspects of care. I am satisfied from my own experience that there is an extremely high standard in residential homes for the elderly run by the health boards. Questions of the qualification of health board staff in nursing homes and the monitoring of standards were raised and I should like to assure Senators that health board inspectors are highly qualified staff, being mainly nurses, environmental health officers, area medical officers and, perhaps, technical services officers. There need be no worry about the records that are maintained and nursing homes are obliged at present to keep records about the patients, the staff, the fire precautions and equipment. On medical records, the only people who will have access to medical records, because confidentiality is very important, are the paitients' general practitioners and a medical officer of the health board who has a bona fide right to such records.
Senator Cosgrave and others were concerned that health boards would not be in a position to effectively monitor nursing homes under the Bill. Health boards are already inspecting on a regular basis — every six months — the vast majority of homes, namely the private nursing homes, which are covered under the existing legislation. Indeed, it is thanks to this power to inspect that the owners of a small number of homes were brought to court and convicted of being in breach of the 1985 regulations. This Bill will add the voluntary homes to those to be inspected but the number of those homes is small and their inclusion should not create difficulties for the boards in continuing regular inspections.
Reference was made to the draft regulations. They were circulated this afternoon. We were anxious that Senators would have them in advance of Committee Stage.
A number of Senators raised the issue of subventions. It was suggested that section 7, dealing with subventions, was a retrograde step, but that is not so. In fact, it is a step forward. The section removes the distinction between approved and unapproved homes that denies the vast majority of homes any subventions at all at present. Senator Jackman referred to the fact that a number of nursing homes received no subvention, and that is correct because the Minister approved nursing homes that could be subvented. As was pointed out during the debate, no new nursing home has been approved since 1980. This legislation will facilitate the introduction of a subvention rate which more closely reflects the costs of caring for dependent people than the current subvention rate. At present a person may receive a section 54 payment without assessment as to whether they are so dependent as to require nursing home care. The existing legislation does not require any means testing of persons claiming a subvention. These are the reasons why the National Council for the Aged and the Report of the Working Party on Services for the Elderly called for a new approach to subventions in nursing homes. The provisions of the Bill reflect the recommendations of those bodies.
Under the Bill it will not be a matter for the Minister for Health of the day to subvent beds in nursing homes. It will be a matter for the health boards to assess each patient and, having regard to the patient's dependency and income, to decide what the subvention should be. The interest of those currently in receipt of a subvention in a nursing home will be protected. Anyone in receipt of subvention under section 54 of the Health Act, 1970, on the day this Bill is implemented will not be affected by the new arrangements proposed by the Bill. However, if such a person they would benefit under the new system of subvention, there will be nothing to prevent him or her applying for subvention under the terms of this Bill in lieu of a section 54 subvention. Such a person will be assessed in the same manner as all other applicants.
Senator MacDonald, and others, criticised the Bill, saying it represented a cheaper option, but nothing could be further from the case. As I said in my opening statement, there will be no diminution in the amount of resources now devoted to caring for people in nursing homes. This Bill will give health boards more flexibility in targeting the use of available resources in a more effective and efficient way. I do, however, recognise that the demand for nursing home places is projected to increase sharply and that the redeployment of resources to support elderly dependent people is inevitable.
Senators will be aware that in recognition of the need to develop our services further for the elderly, the Government provided an extra £5 million in the budget this year and I have retained £500,000 of that to be used to implement the provisions of this Bill later this year. I certainly refute any allegation that we are looking for a cheaper option in the implementation of this Bill. I have no doubt that more and more resources will be used in the care of our elderly in the years to come.
Senator McKenna, and others, drew attention to something which is very important in our community, the right of the elderly to live in their own homes. It is important to recognise that there only 5 per cent of our elderly are in long-stay residential care, both health board care and voluntary nursing homes at present, that 17 per cent of our elderly are looked after by their own families and the remainder are living independent lives. It is very important that we recognise that everybody has the right to live in their own home for as long as possible. Certainly, there is an obligation on the State to ensure that they can do that by having supports in place for them. It is also important to recognise the contribution families make because the great carers in Ireland are the families and, indeed, we have a great tradition of family caring in Ireland. Again, that is something which should be supported. The Government recognised it when my colleague, the Minister for Social Welfare, introduced the carer's allowance this year which is a major advance and will replace the criticised prescribed relative's allowance that we heard about this afternoon. Senator Finneran drew attention to the prescribed relative's allowance.
The elderly who are not fit to be looked after for one reason or another by their own family and cannot live on their own have every right to live in the community for as long as possible through sheltered housing. Senator Cosgrave referred to the need for the Minister for the Environment to take an interest. Of course, the Minister and the Department of the Environment are very conscious of their responsibility. There is the voluntary housing scheme, the essential repairs scheme and the disabled persons reconstruction grant. There are good provisions in Department of the Environment legislation to ensure that they support the elderly. That is as it should be. It is only as a last resort that people should find their way into long stay residential care. It is to ensure that we have the highest standards in that long stay residential care that we are introducing this legislation.
I thank Senators for their very constructive contributions. We look forward to going through the Bill on Committee Stage.
Question put and agreed to.
Committee Stage ordered for Tuesday, 10 July 1990.
An Leas-Chathaoirleach
When is it proposed to sit again?
At 12 noon on Tuesday, 10 July 1990.