The policy of the Government on health services for older people is as outlined in the report, The Years Ahead, first published in 1988 and reaffirmed in the Review of The Years Ahead, published in 1997. This policy is to maintain older people in dignity and independence at home in accordance with their wishes, as expressed in many research studies; to restore to independence at home those older people who have been ill or dependent; to encourage and support the care of older people in their own community by family, neighbours and voluntary bodies; to provide high quality hospital and residential care for older people when they can no longer be maintained in dignity and independence at home.
The anticipated change in demographics in the period 1996-2011 has, and will continue to have, significant implications for service planners, service providers and all in government, whether at local or national level. The changing health and social needs of older people present a major challenge to society. The longer that older people remain in good health and disability free, the better will be their quality of life and the greater their contribution to society. Ageing is a normal dynamic process, it is not a disease. While ageing is inevitable and irreversible, the chronic disabling conditions that often accompany it can be prevented or delayed, not only by medical interventions but also by social, economic and environmental policies. These policies need to be informed by a wider, more positive view of old age.
Since coming to office in 1997, the Government has allocated significant resources to services for older people, particularly health services, in an attempt to deal with this change and the resulting issues which will emerge. Additional funding for the development of health services for older people has increased significantly from £10 million in 1997 to an additional £36 million in 2000, while in 2001 an additional £57.42 million will be provided. This has resulted in approximately 880 posts approved to services for older people between 1997 and 2000. Between 1998 and 2000, over 400 additional beds have been provided in ten new community nursing units and over 1,000 day places per week have been provided in ten new day care centres.
A total of £2 billion has been made available by the Government for investment in the health services under the National Development Plan 2000-2006. This represents a trebling of investment compared to the previous seven-year period. The purpose of the plan will be to create an infrastructure that will bring significant and tangible advances in delivering a more patient-centred and accessible service. There is a commitment from the Government to shift the balance of capital investment towards the non-hospital sector so that the £2 billion is divided equally between the acute hospital and non-acute sectors.
In the case of services for older people, it is proposed to provide for a greatly improved physical environment to ensure a high quality and client-centred service. Approximately £200 million will be available for the capital development of services for older people over the period of the plan. A broad range of facilities will either be provided, replaced or upgraded as a result, including assessment and rehabilitation facilities, ambulatory care facilities, community hospitals, community nursing units, convalescent and respite beds, day care centres and services for the elderly mentally infirm.
It is acknowledged that there are specialised areas which require particular attention, including the provision of assessment and rehabilitation units and day hospitals, extended care units and, in particular, the development and enhancement of community based services. The latter include the provision of day care centres, the promotion of home help services, home care teams and paramedical supports, which are essential to facilitate an older person remaining in their home and familiar surroundings.
Together with considerable investment in health board facilities and the area of community care, substantial additional resources have also been made available for the nursing home subvention scheme. As Members will be aware, the Health (Nursing Homes) Act, 1990, under which subvention regulations were made, has two principal objectives: first, to ensure high standards of accommodation and care in all nursing homes registered under the Act and, second, to provide for a new system of nursing home subvention in order that dependent persons most in need of nursing home care will have access to such care.
The latest figures available from the health boards and the Eastern Regional Health Authority indicate that there are currently 8,001 people receiving the benefit of the subvention scheme, either through the provision of a basic subvention, enhanced subvention or contract bed. It is also worth noting that in the first full year of operation, the funding allocated for the nursing home subvention scheme was £12 million. This year the funding available for the scheme is £52 million, more that four times the original allocation.
The report of the Ombudsman on the nursing home subvention scheme was published recently. It deals with the role of the Department of Health and Children in making regulations and overseeing the introduction of the scheme and examines the administration of the scheme by the health boards since its inception in 1993. Certain articles in the nursing home subvention regulations were the subject of critical comment, namely, article 8.2, the "pocket money" provision, and articles 9.1 and 9.2, which allowed for the income of adult sons and/or daughters to be assessed when determining the level of subvention to be paid. The immediate priority of the Department of Health and Children is to ensure the two aspects of the regulations that have the most direct impact on nursing home patients and their families are fully addressed without delay. In this regard, I will outline the action taken to date.
Article 8.2 of the Nursing Home Subvention Regulations, 1993, allows health boards disregard a sum equivalent to one fifth of the old age non-contributory pension when assessing means and calculating the amount of subvention to be paid. An additional allocation of £4 million was made available in 1998 to six of the health boards where the regulations were applied incorrectly to meet the costs of arrears payments in respect of the full implementation of the Health (Nursing Homes) Act, 1990, and subsequent regulations. The sum of £4 million was not provided solely for the purposes of article 8.2 arrears. Health boards were also incurring additional expenditure as a result of the easing of the family circumstances regulations in 1996. These regulations, signed in July 1996, increased the personal allowances applied by designated officers of the health board when assessing the circumstances of adult sons and daughters of an applicant for subvention. The funding was intended to address both problems and meet funding shortfalls in the scheme generally. My Department has been informed by the health boards concerned that the funding provided was also used to cover arrears payments under article 8.2, the payment of enhanced subventions and expenditure shortfalls arising from increasing demands under the scheme.
I understand a proportion of the allocation was used by three of the health boards to fund other services for older people, including the provision of aids and appliances, improved home help services and the opening of a unit for the elderly mentally infirm. While this money was not expended on the subvention scheme, I am assured it was used by the relevant health boards for the benefit of older people. Nonetheless, when my Department became aware of continuing delays in paying arrears, it took the matter up with the relevant boards and is continuing to pursue it. The health boards have advised that, to date, approximately £1.5 million has been paid out in respect of article 8.2 arrears. It is not possible at this stage to provide a figure for the total cost of article 8.2 arrears payments as a number of boards have not as yet completed the process of calculating the amounts due. However, my Department is continuing to pursue this matter with the health boards concerned to ensure every effort will be made to pay all outstanding arrears as soon as possible.
As Members will be aware, articles 9.1 and 9.2 of the Nursing Homes (Subvention) Regulations, 1993, allowed health boards to assess the ability of the adult sons and/or daughters of older people who apply for nursing home subventions to contribute towards the cost of their parents' nursing home care. A review of the operation of the subvention scheme was carried out in 1995, following which an amendment was made to the Schedule which provided that, in calculating the income of sons and daughters, health boards were to disregard income tax, rent, mortgage repayments and certain other outgoings. This Schedule increased the personal allowances applied by designated officers of the health board when assessing the circumstances of adult sons and daughters of an applicant for subvention. The subvention regulations were further amended from 1 January 1999 and the provision to assess the capacity of adult sons and/or daughters to contribute towards the cost of nursing home care of their parent was deleted.
The amendment to which I refer was made because the provisions in question were not consistent with the assessment procedures adopted in the granting of medical cards by health boards or the social assistant payment schemes administered by the Department of Social, Community and Family Affairs, wherein there is no consideration of the financial circumstances of adult sons and/or daughters of applicants. Nonetheless, I am concerned that the issue of making payments to those adversely affected by this regulation remains. However, it is important to state that legal advice received from the Office of the Attorney General indicates there is no legal liability on the State to make retrospective payments in relation to family circumstances. Nonetheless, in the interests of fairness and natural justice, it has been decided that moneys should be paid to those adversely affected by this provision and my colleagues in government agree with this view. It is anticipated that these payments will cost in the region of £6 million.
A group representing the Department and the health boards and the Eastern Regional Health Authority has been established to ensure this process is carried out on a uniform basis as speedily as possible. However, as Members will appreciate, and bearing in mind that since the scheme's introduction, approximately 35,000 applications for subvention have been received, this will be a complex exercise involving, inter alia, difficult issues of traceability, and may take some time to complete. It is, nonetheless, expected that payments will begin this month and I offer assurances that every effort will be made to make payments as quickly as possible.
An issue that has been raised in this debate is that of inspection procedures for extended care facilities. The Health (Nursing Homes) Act, 1990, requires nursing homes to be registered with their local health board. Regulations made under the Act require that there must be proper standards in private nursing homes in respect of adequate and suitable accommodation, staffing, kitchen and sanitary facilities, access to medical care, facilities for recreation and other arrangements to ensure the health and well-being of residents. Many Members, including Senator O'Dowd, highlighted the need to investigate the position vis-à-vis the standards which apply in respect of food preparation and provision. Nursing homes are required to renew their registration every three years and a health board may impose conditions in relation to registration. These regulations provide for periodic inspections by health boards, which are empowered to prosecute registered proprietors and persons in charge in the event of breaches of those regulations.
The Nursing Homes (Care and Welfare) Regulations provide that the registered proprietor and any member of staff shall permit designated officers to enter and inspect the nursing home, to examine records kept by it, conduct interviews with persons, including staff, and examine any dependent person there, where the officer has reasonable cause to believe that a person in a nursing home is not, or has not been, receiving proper care. During such inspections, any shortcomings should be brought to the attention of the proprietor and the person in charge.
Homes are duly monitored to ensure compliance with the regulations. There is no limit on the number of times an inspection may be conducted and the boards may visit at more frequent intervals where this is felt necessary. In order to obtain a rounded and comprehensive view of a nursing home and the standard of care, it will be inspected by professionals of various disciplines, such as a public health nurse, medical officer and environmental health officer. An inspection involves a systematic review of facilities, services and care to ensure continuing compliance with the statutory requirements and the conditions for registration.
There is concern that while there is provision, as outlined above, under the nursing home legislation for monitoring standards in private nursing homes, no similar arrangements are in place for health board facilities, an issue both I and my colleague, the Minister for Health and Children, will rectify. As Members will be aware, the social services inspectorate has the authority to monitor standards in children's residential centres and is operating effectively. It is intended to expand its role to cover extended care facilities for older people. It will also extend its remit to residential services for children with disabilities arising from the provisions of the Children Bill, 1999, which is shortly to be enacted. Given the heavy demands on the inspectorate in monitoring standards in the child care area, additional resources are required to enable it to take on this additional function. Proposals in regard to services for older people will be introduced as soon as possible.
In 1999, I established a working group which is currently preparing guidance and training materials in relation to elder abuse, including abuse in institutional settings, following publication of the report, Abuse, Neglect and Mistreatment of Older People: an Exploratory Study by the National Council on Ageing and Older People. The group's terms of reference are to advise on the development of principles, policies and guidelines in relation to elder abuse, and to make recommendations on matters including, inter alia, on definitions, terminology, identification, screening procedures, and assessment protocols and procedures. The group consists of representatives from my Department, health boards, the Garda, the National Council on Ageing and Older People, and other organisations representing the interests of older people as well as a consultant physician in geriatric medicine, a consultant in the psychiatry of old age, a consultant psychiatrist and a general practitioner. It has drafted a comprehensive two year work programme which involves, inter alia, development of a training brief, organisation of pilot projects, implementation of awareness and training programmes, preparation of evaluation reports, and will present a final report to me. I have provided resources to ensure that the work is completed within the envisaged timeframe. The report will be completed following the testing of draft policies, procedures and guidelines in pilot projects. Training programmes will be provided to staff members and ongoing evaluation will take place. The main purpose of the evaluation is to assess whether the draft policies, procedures and guidelines in the identification, assessment and management of elder abuse are appropriately designed and effective in the two health boards areas. The report is expected to be completed by the end of 2001, when the evaluated results of the pilot projects are available.
An expenditure review of the nursing home subvention scheme undertaken by my Department, in association with the Department of Finance, was recently completed. Proposals will be brought to Government on whatever additional measures may be necessary arising from the Ombudsman's report and the expenditure review, together with experience gained from the operation of the scheme since its inception in 1993.
There has been a failure over the years to recognise the contribution of carers to the maintenance of the health and well-being of dependent family members and friends. Support to carers is widely recognised as inadequate. As Minister of State, Deputy and general practitioner, I am well aware of carers' invaluable role in supporting and maintaining dependent relatives or friends. Caring can be at great expense to the carer and many feel isolated, alone and taken for granted by society. The role of and the cost to the carer is only being acknowledged in recent years. I am glad to say that efforts are now being made to address this issue. From talking to carers and meeting with organisations representing them, I know that recognition of their role is important to them. The failure over the years to provide this recognition, with inadequate support services, has been a major deficit in our provisions. That situation is changing. Initiatives have been taken, particularly in the past two years, to address their needs.
In the last three years, my Department provided an additional £4 million to the health boards for the support of carers. This is used by them to fund carer support groups, provide training to carers and support carers through, for example, the employment of liaison officers and the provision of respite breaks. The funding is used to support home care services. Funding has also been provided for the provision of items such as walking sticks and frames, wheelchairs, commodes, bed rests, special beds with hoists, stair rails and other vital appliances for an older person to remain at home and maintain their independence.
My colleague, Deputy Dermot Ahern, Minister for Social, Community and Family Affairs, oversees many improvements in the carer's allowance scheme. An overall review of the carer's allowance was completed by an interdepartmental committee, chaired by the Department of Social, Community and Family Affairs and published in October 1998. Following a detailed examination of the review, measures were introduced in the 1999 and 2000 budgets to improve and develop the position of carers, including the extension of free schemes. As is evident from this, the Government is committed to improving the needs of carers. It will be clear to the House that this Government places a high value on the contribution which older people made and continue to make to our society. It is the Government's aim to ensure that as many as possible of our senior citizens live an independent life for as long as possible, and that the necessary supports are in place to achieve this. We are also committed to providing the necessary level of care, at home or in residential accommodation, for older people who need such services. The additional funding provided by the Government, since it came to office in 1997, is proof of our commitment to older people, a commitment that will not waver in the years ahead.
For this reason, the Government cannot accept the Fine Gael motion and commends instead the amended motion. I thank the Opposition Members, especially Senator O'Dowd, who took the time to investigate the plight of the elderly. It is said that our care should be the best in the world. We examine care around the world and think that our standard of care is generally good. There are exceptions in some nursing homes but we welcome the bringing to our attention of any defaulters which Senators may have discovered.
Much remains to be done and we will still depend on family and community. All the investigations that have been done show that home is the best location for the elderly. It is up to us to provide better community care. We have problems getting physiotherapists and speech and occupational therapists but we have increased the numbers in training and will continue in that vein. Overall we have increased the moneys going to the care of the elderly. Money alone will not solve all the problems and we still depend on the family, community and voluntary organisations to play a part. I did not mention transport which is another particular problem for the elderly. There are numerous problems but overall, despite what we might see on the Internet about the great care service in America, I would rather be an older person in this country.
