Seanad Éireann - Volume 195 - 10 June, 2009

Nursing Homes Support Scheme Bill 2008: Second Stage.

Question proposed: “That the Bill be now read a Second Time.”

  An Cathaoirleach: I welcome the Minister of State to the House.

  Deputy Áine Brady: I am pleased to have the opportunity to introduce to the House Second Stage of the Nursing Homes Support Scheme Bill 2008. The Bill will put in place a new scheme of financial support for those in need of nursing home care. It aims to ensure that care is affordable for each person [944]and to be fair to all. Before detailing the provisions of the Bill, I wish to begin by examining the wider policy vista and the reasons for introducing this Bill.

Government policy on older people long has been to support older people to live in dignity and independence in their own homes and communities and, when this is no longer possible, to support access to quality nursing home care. At present the State supports people in public and private nursing homes very differently. In a public facility, the State meets approximately 90% of the cost of care, while in marked contrast, the State effectively meets only 40% of the estimated average cost of care in a private facility. This discrepancy is wholly at odds with the principle of equity endorsed by the Government. It also is unfair to individuals and their families.

At present, an individual who obtains a public nursing home bed may be charged a maximum of up to 80% of the non-contributory State pension towards the cost of care. By contrast, the same individual availing of a private nursing home bed may be entitled to a subvention but is otherwise obliged to meet the full cost of his or her care. This can amount to as much as €1,200 per week. In addition, applicants for subvention are subject to stringent means testing and may be deemed ineligible for subvention based on the means test. This is in marked contrast to the current public system under which an individual may never be charged more than 80% of the non-contributory State pension, regardless of his or her level of means. The capped public charge is also regressive since better-off people pay a much lower proportion of their income towards the cost of their care. The net result is that many people in private nursing homes face uncertainty and unaffordable care costs. Some must sell or remortgage their family homes to pay for the cost of nursing home care, while others must turn to family and friends for assistance in meeting care costs.

In short, the present situation is unfair and unsustainable. It is deeply unfair that people of the same means face radically different costs for nursing home care, depending on where they live or whether their nursing home is public or private. It is deeply unfair that one person and his or her family with modest means could face very high bills to pay for care, while another might pay relatively little even though he or she had substantial means and assets. It is deeply unfair and unsettling that so many people and their families had no other option but to sell the family home to pay for care. All that will change with this legislation.

The genesis of the legislation may be traced back to 2005 when my colleague, the Minister for Health and Children, in conjunction with the Minister for Social and Family Affairs, established an interdepartmental working group on long-term care. The group examined the range of benefits, services and grants relating to long-term care for older people and examined policy options for a financially sustainable system of long-term care. It reported to the Government in January 2006. The group’s recommendations informed the current social partnership agreement, Towards 2016.

That agreement reaffirms Government policy to support older people to live with dignity and independence in their homes and communities and to support access to quality residential care when needed. It also contained the following principles to guide the development of future policy on long-term care for older people. All relevant public services should be designed and delivered in an integrated manner centred on the needs of the care recipient and based on a national standardised needs assessment. Care needs assessments should be available on a timely, consistent, equitable and regionally balanced basis. The use of community and home-based care should be maximised and should support the important role of the family and informal care. When community and home-based care is not appropriate, quality residential care should be available. In addition, there should be appropriate and equitable levels of co-payment by care recipients based on a national standardised financial assessment. The level of [945]State support for residential care should be indifferent as to whether that care is in a public or private facility and no current resident of a nursing home, public or private, should be put at a disadvantage by whatever new co-payment arrangements for residential care are introduced.

The proposed nursing homes support scheme, a fair deal, is consistent with the aforementioned principles. It will put in place one transparent system of support towards the cost of nursing home care. For the first time, there will be a uniform system of financial support for individuals in public and private nursing home beds. In short, its key objectives are to equalise State support for public and private long-term care recipients, to render private long-term care affordable and anxiety-free and to ensure that no one must sell his or her home during his or her lifetime to pay for care. These objectives have informed the approach taken throughout the Bill.

The Government announced the fair deal in December 2006. At the time, it gave a number of basic commitments regarding the new scheme, which I will outline. Individuals will contribute towards their cost of care based on their income and assets. The HSE will meet the balance of cost in nursing homes approved for the purpose. Individuals will not be obliged to sell or mortgage their house or borrow to pay for their care. Individuals will not experience unaffordable care costs. An individual’s family will not have to find money for his or her care. As with the overall objectives, these commitments remain in place and underpin the provisions in the Bill.

I propose to briefly outline the main provisions of the Bill. Section 3, which sets out the scope of the scheme, defines certain terms used in the Bill. I draw the attention of the House to the definitions of “long-term residential care services” and “approved nursing home”, which essentially circumscribe the scope of the scheme. “Long-term residential care services” are defined as maintenance, health and personal care services provided in designated public and voluntary facilities and approved private nursing homes. Services must be provided for not less than 30 consecutive days, or periods aggregating not less than 30 days, within a period of 12 consecutive months. For the sake of clarity, the definition explicitly excludes certain services, such as respite care services. To qualify as a designated facility, a public or voluntary facility will have to be designated in writing by the HSE as being a facility that is predominantly for the care of older people and will have to provide 24-hour rostered nursing care. To qualify as an approved nursing home, a private facility will have to the do the following: be registered under the appropriate legislation, reach an agreement with the National Treatment Purchase Fund on the maximum prices to be charged for care under the scheme, be tax compliant and provide 24-hour rostered nursing care. Another key term used in the Bill is “financial support”. This encompasses straightforward financial assistance towards nursing home costs — such assistance is referred to as “State support”. It also encompasses the option to defer payment of certain contributions during one’s lifetime — this is referred to as “ancillary State support”.

Section 4 of the Bill defines a “couple” for the purposes of the scheme. A couple is defined as a married couple or as a heterosexual or same sex couple who have been cohabiting as husband and wife for at least three years. In each case, the couple must have been habitually living together at the date of applying for State support or at the date of beginning to receive care services. Section 5 establishes the nursing homes support scheme and stipulates that the scheme is resource-capped. Therefore, the scheme is premised on the principle of eligibility rather than entitlement. Section 6 provides that eligibility for the scheme extends to those who are ordinarily resident in the State. In other words, the scheme is not limited to older people. Section 5 also enshrines the principle of patient choice in the legislation. Applicants who are deemed to require long-term residential care shall be informed of the names of all public and approved private nursing homes. They may select their home subject to its suitability to meet their needs and the availability of a bed at the home.

[946]Sections 7 and 8 provide for the arrangements for care needs assessments. Section 7 provides for a care needs assessment to be conducted to ascertain whether a person needs to be provided with long-term residential care services. It stipulates who may carry out such an assessment and what factors may be taken into account in the assessment. These factors include the person’s ability to carry out the various activities of daily living and the medical and social supports that are available to the person. Section 8 sets out the basis for unsuccessful applicants to seek a review of care needs.

The regulations governing financial assessments are set out in sections 9 and 10 and Schedule 1. Sections 9 and 10 provide for an application for State support and a subsequent financial assessment of means to establish the contribution an individual may have to pay towards the cost of his or her care. Section 10 stipulates that the assessment shall be carried out in accordance with Schedule 1. Parts 1 and 3 of Schedule 1 set out the rules for calculating the contribution payable by a single applicant. In summary, a person will make a contribution of up to 80% of his or her income and up to 5% of the value of his or her assets, after deductions and safeguards have been applied. Parts 2 and 3 of Schedule 1 outline the rules governing the contribution to be paid by a member of a couple. In this case, the assessment is based on the principle that each member of the couple owns 50% of the couple’s combined means. Therefore, a person who is a member of a couple has an annual assessed contribution of 40% of the couple’s combined income, or 80% of half the combined income; and 2.5% of the couple’s combined assets, or 5% of half the combined assets.

The Bill contains a number of safeguards to protect the income and assets of care recipients and their spouses or partners, as well as the residual value of the principal residence. The use of the “minimum retained income threshold” will ensure that a person entering care will retain at least 20% of the maximum rate of the State non-contributory pension, while his or her spouse or partner who remains at home will retain at least the maximum rate of the State non-contributory pension. The “general assets deductible amount”, or asset disregard, will stand at €36,000 for an individual or €72,000 for a couple. The cap on the principal private residence will ensure that contributions based on the residence will be payable for the first three years of care only. This is often referred to as the 15% cap. A new provision that was inserted on Report Stage in the Dáil will extend the three-year cap to farms and businesses in certain circumstances. This will apply to a person who has suffered a sudden illness or disability that caused them to require long-term residential care; if the person or their partner was actively engaged in the daily management of the farm or relevant business, as the case may be, until the time of the sudden illness or disability; and if a family successor certifies that he or she will continue the management of the farm or relevant business, as the case may be.

Sections 11 to 14, inclusive, set out the basis for determining applications and paying State support. They provide that, subject to resources, the State will pay the full difference between the total cost of care services and a person’s contribution. This State support will be paid directly to the relevant nursing home on behalf of the person. In the case of existing residents whose nursing homes are approved under the scheme, State support will be paid from the date of full commencement of the legislation.

Sections 15 to 18, inclusive, and 28 provide for ancillary State support, which is another important feature of the scheme. Ancillary State support is an additional support that is designed to ensure that people do not have to sell assets, such as their homes, to meet their care costs. It enables people to defer contributions payable on Irish land-based assets for the duration of their lifetimes. It may be thought of as a loan advanced by the HSE and recouped at the settlement of the person’s estate. The payment of ancillary State support is subject to a charging order being placed against the assets of the person to secure the amounts advanced. [947] The HSE will register the charging order in the Registry of Deeds or the Land Registry, as appropriate. Section 28 provides for the discharge of such charging orders as soon as the amount advanced as ancillary State support has been repaid. The Bill provides that ancillary State support will be paid directly to the relevant nursing home on behalf of the person and that it may be paid to a person even though that person does not qualify for State support.

Sections 19, 20 and 26 relate to repayment. Section 19 of the Bill stipulates the events which trigger the repayment of ancillary State support. These are termed “relevant events” and principally include the death of the person or the sale or transfer of the asset concerned. Section 20 provides for a further deferral of the repayment of ancillary State support in the case of the principal private residence. Those who can avail of such a deferral are the spouse or partner of the original applicant and, in specified circumstances, certain relatives referred to as “connected persons”. People in the latter group can avail of a deferral if the asset in question is their only residence; if they have lived there for not less than three years preceding the original application for ancillary State support; and if they do not have an interest in any other property. Those classified as “connected persons” include the following: a child of the original applicant, or their spouse or partner, who is under the age of 21 or whose assets do not exceed the asset disregard; a sibling of the original applicant whose assets do not exceed the asset disregard; relatives in receipt of certain State payments or with income below the State non-contributory pension; and any person who cared for the applicant prior to the latter entering the nursing home. This is defined by reference to relevant caring-related State payments. Where a person avails of section 20, repayment will be deferred for the duration of his or her lifetime, unless he or she ceases to qualify as a connected person or the asset in question ceases to be his or her principal residence. Section 26 provides that the Revenue Commissioners will be the collection agents for the repayment of ancillary State support.

Part 4 of the Bill provides for an innovative new feature within the scheme. It provides that a person may apply to the Circuit Court to be appointed as a care representative of a particular person. The appointment of a care representative is only necessary where a person does not have full capacity and wishes to avail of ancillary State support. However, a person appointed as a care representative may assist with any matter relating to the scheme.

The Bill adopts a function-based approach to determining capacity which is consistent with the recommendations of the Law Reform Commission. Under section 21, a person is considered to lack the capacity to make a relevant decision if he or she is unable to understand the information relevant to the decision, retain that information, use or weigh that information as part of the process of making a decision, or communicate his or her decision by any means. A person must be certified by at least two registered medical practitioners as lacking the capacity to make a relevant decision in order for a care representative to be appointed. The individuals who may apply to be appointed, either singly or jointly, as a care representative are the spouse or partner of the person; a parent, child, brother or sister of the person; a niece, nephew, grandchild, grandparent, aunt or uncle of the person; a person appearing to the court to have a good and sufficient interest in the welfare of the person, other than the proprietor of a nursing home in which the relevant person resides or is likely to reside.

Section 22 is a technical provision. It amends the Courts and Court Officers Act 1995 to allow for the appointment of care representatives by county registrars in uncontested cases. Sections 23 to 25 provide for the notification of certain specified matters, including the death or discharge of a nursing home resident, the death of a resident’s partner or a connected person or a material change in the circumstances of a resident, his or her partner or connected person.

Section 27, concerning the schedule of assets, applies to a deceased person to whom financial support was provided or to whose partner financial support was provided. The personal rep[948]resentative of such a deceased person must provide the HSE with a written notice of his or her intention to distribute the deceased’s assets and a schedule of such assets at least three months before beginning to distribute the assets. The HSE has the authority to request that sufficient assets be retained to repay any amount due to it. This is consistent with social welfare legislation.

Section 29, on joint ownership, is a technical provision that ensures a charging order in respect of ancillary State support shall not cause the severance of a joint tenancy or be rendered void due to the absence of the prior consent of the other joint tenant or tenants. The section seeks to protect both the interest of the HSE and the other joint tenants.

Sections 30 to 32 concern reviews and appeals. A person or the HSE may seek a review of the person’s care needs, financial assessment or the amount of ancillary State support payable. In addition, a person may appeal certain decisions of the HSE, including decisions taken in relation to his or her care needs and application for State support. A person may also appeal the inclusion of income and assets transferred prior to 9 October 2008 in the financial assessment on grounds of hardship.

Section 33 is essentially a technical provision ensuring the existing legal basis for charges, including the exclusion of certain care groups from charges, is maintained. An amendment made to this section on Report Stage in the Dáil ensures the basis for public bed costs and, by extension, charges will be laid before the Houses. This underscores commitments already given in the context of the scheme in regard to transparency.

Section 34 is essentially a technical provision. In line with the Government’s commitment, it ensures existing public residents will not be made worse off as a result of the new scheme. It also provides that a person in an acute hospital bed who has finished his or her acute phase of care and his or her care needs assessment may be charged as if he or she were receiving long-term residential care services. This provision is necessary to ensure there is not a legal incentive to remain in an acute hospital bed following discharge.

Part 9, including sections 35 to 48, contains a number of miscellaneous provisions. These include technical and standard provisions concerning the making of regulations, the maintenance of records etc. They also include transitional provisions providing that the nursing home subvention scheme will cease for new applicants from the full commencement of the legislation but that existing private nursing home residents can remain on subvention rather than transferring to the new scheme, if they so wish.

I draw attention to sections 40 and 41 which empower the National Treatment Purchase Fund to negotiate prices with private nursing home providers for the purpose of the scheme. Section 43 renders explicit the common law principle that a person providing necessary services for a person of diminished capacity for the latter’s benefit may expect to be paid for such services.

I have detailed the key provisions contained in Schedule 1 and will conclude by clarifying the final part of the Bill, Schedule 2. Schedule 2 sets out the procedure for adjusting the amounts repayable in respect of ancillary State support. This adjustment will reflect the level of inflation, as measured by the consumer price index, between each year in which contributions were deferred and the year in which the debt falls due. In other words, the State will take account of the time value of money.

The Bill is fundamental to meeting the commitment given in Towards 2016 that State support should be equal for public and private care recipients. Critically, it offers assurance to the most vulnerable of groups in society — those in need of long-term nursing home care — that such [949]care will be affordable and will remain affordable for as long as they need it. I commend the Bill to the House and look forward to hearing the views of Senators.

  Senator Frances Fitzgerald: I welcome the Minister of State. This legislation is very important because there will be more than 800,000 people over the age of 65 years by 2025. Thus, many elderly people will need care at various levels, be it in the community or a nursing home. We spend 0.6% of GDP on the elderly. The current spend in the United Kingdom is 1.9%. There is no doubt but that this area will require further investment in the years to come. It is very clear that many families are stressed and under considerable pressure because of the lack of supports, be it in the community or residential care.

I want to raise a range of issues associated with the legislation about which Fine Gael has concerns. Will the Minister of State review the points made in the Dáil and on Committee Stage by Deputy Reilly and determine whether it will be possible to address some of them by way of amendment on Committee Stage in the Seanad? It is clear that this legislation will require more amendments before we will be in a position to support it. In principle, if people cannot make a contribution towards the cost of their care, we must accept it as reasonable. However, the devil is in the detail.

3 o’clock

There are many matters I want to raise with the Minister of State. Let me begin by considering the community care packages available. The Bill caters primarily for those who require high dependency care. Traditionally, nursing homes dealt with persons with a range of needs, but increasingly they are dealing with patients who need high dependency care. However, there may be people who, for a variety of reasons, might not be classified as having high dependency care needs but who may need some form of residential care. Will the Minister of State outline the degree to which the assessments will take social factors into account? There are big questions about community care packages. The issue of standards will increasingly come to the fore. We hear about standards in nursing homes but no public nursing home has been inspected. That will come in on 1 July and I welcome that move. We have all just come from the solidarity march for victims of abuse today. There were no inspections in the homes discussed in the Ryan report. Inspection is a critical issue and whether the Health Information and Quality Authority, HIQA, will have the appropriate resources to carry out the necessary inspection is a key question.

Standards will be a question of the future because people will depend on quality community care packages in which there is huge variation. We all want older people to receive support that enables them to stay in the community. The level, quality and quantity of community care packages will be critical to that support. People do not yet get the kind of support they need to stay in the community. Many who have fairly high needs do not get the wide range of care necessary to remain in the community. There are approximately 750 people in acute hospitals who need placement in nursing homes. I am somewhat concerned about that because there are vacancies in nursing homes. Will the Minister of State and her Department say what the barrier is to placing those people appropriately in nursing homes?

The most important question is what resources will be allocated for the implementation of this legislation. What will happen if, for example, €55 million is allocated in a current year and that money runs out? Will we put pressure on people to go into a nursing home early before the money runs out? How will we deal with that difficult issue? What is the Government approach to the key issue of funding?

A total of 62% of nursing home costs goes on staffing yet there are no criteria for the ratio of nurses and care assistants and so on for public or private nursing homes. The Government needs to address that if this legislation is to be successful. Other issues arise about the detail in the Bill on how assessments will be made. What is the future of public nursing homes? This [950]legislation does away with universal provision. What do the Minister of State and the Government envisage as the future of public nursing homes? Section 5(5) refers to (a) relevant facilities and (b) approved nursing homes. Why is it necessary to separate the two? Section 5(4) raises questions about the criteria for rationing and who will do it.

Under this Bill everything is done within the Health Service Executive, including the appeals mechanism and the care assessment. Surely we need to bring independence into the procedures whether in respect of an appeal or having a second assessment of need or the setting of nursing home fees. Is there not room for a more independent procedure in the various arenas that the Bill addresses?

Section 7 of the Bill “enables specified individuals to apply to the HSE for a care needs assessment and allows the HSE to make arrangements for care needs assessments to be carried out”. Obviously the goal of this is to ensure that quality care is provided to the older person. Section 7(5) of the Bill, however, allows the HSE as the service provider to operate also as the body which determines whether the person is in need of a service. Surely some assessment should be conducted by a multidisciplinary group of professionals, independent of the HSE and the Department of Health and Children. There is no guarantee that once needs are identified the resources will be put in place to ensure they are met. Will the Minister of State consider that point?

Will the Minister of State define what is included and excluded? What does “specified services” mean? What does one get in return for 15% of one’s income and a proportion of one’s assets? Does one get a basic service or access to the other services that an elderly person might need, such as occupational therapy and various ancillary services? It is very important to spell that out. The Minister indicated on Committee Stage that she would introduce regulations to outline to some degree what would be included. Will the Minister of State say in her response to this Second Stage debate how it is intended to address that issue? Otherwise people will have fewer services than they have now. Provision in this area is inadequate.

Many involved in farming and in small businesses are extremely concerned with the implications of this Bill for their livelihood. They are particularly concerned that there is no cap on the deferred charge and other fixed assets such as land, farm buildings, commercial and investment property and small businesses that may not be highly profitable. This situation is not fair because a person with a very valuable residence would relatively speaking be undercharged but the Bill does not take account of the sustainability of farms and small businesses in rural areas and gives preferential status to principal private residences. The Bill does not address this and the Minister of State needs to outline how she intends to deal with it. She needs to deal with the absence of a ceiling on farms as a priority.

I welcome the changes made in the repayment of ancillary State support but I would appreciate clarification from the Minister of State on amendments made to the definition in section 20(4)(a)(ii) whereby a child who remains in the home and is over the age of 21 will be eligible for a further deferral if the aggregate of his or her cash assets is not greater than the general assets deductible amount. Will the Minister of State give information on the general assets deductible amount, how it is calculated and what it amounts to? If a sibling over the age of 21 has inherited the assets, cash or land will the Minister of State clarify how this will impact on the ability to apply for deferred payment? These are important issues. This is in many ways a technical Bill but it will have a serious impact on individuals, their futures and their ability to continue in business or stay on their farms.

The role of the National Treatment Purchase Fund, NTPF, also needs to be addressed. Will people be able to choose a nursing home that is close to their home or will the NTPF choose [951]a nursing home at a certain cost that is 100 or 200 miles from their homes? We must build in criteria for the community that enable elderly persons to have access to a nursing home that is close to his or her home and family.

The HSE used to deal with this but it now appears the hospitals make the payments under the delayed discharge initiative. To minimise the cost to the hospitals, older people are being offered places in nursing homes which are at a distance from their family homes and communities. That needs to be addressed. Many people are being placed in nursing homes far away from their homes, as is happening in Dublin where there is a shortage of such accommodation. One understands why this is happening but in terms of the development of this scheme, this issue needs to be given further thought.

The National Treatment Purchase Fund will be given responsibility for contracting beds in nursing homes and agreeing fees. Nursing homes, both public and private, will be required to negotiate fees with the NTPF if they wish to be approved providers under the scheme. There are some contradictions in this respect. The NTPF is being given the challenge of keeping the cost of care down while the HSE wants to ensure high standards are met. Quality should not be determined by the prices that are set by the NTPF. We must ensure quality is maintained in residential nursing homes and that there is not a drive down by nursing homes to the lowest standards to ensure they become approved nursing homes. How will that be ensured?

The means assessment aspect is dealt with in section 10. Under the terms of the Bill, the HSE is entitled to seek an assessment of means, which will be conducted by a suitable person of its choice. From the legislation it is not clear what is meant by a suitable person or who will conduct the assessment of means. Will the means test be carried out by the HSE, State officials or an independent third party? We believe the financial review should be conducted by an independent third party in order that a fair and reliable estimate can be established in which both the applicant and the HSE can have faith. A person’s right to avail of care through this scheme should not be jeopardised by obstacles in seeking a financial review and such people are entitled to seek a financial review if and when they need to. The Minister of State might consider this issue on Committee Stage.

We have seen in recent months how the values of assets can change very quickly. In terms of an allowable deduction, will the Minister of State take into account in the development of this scheme the changing value of assets when somebody has been assessed? Is there a review mechanism in this respect?

I also raise the question of extending the nursing homes support scheme to private care in the community. That is a matter the Minister of State may want to examine.

This is an area that deserves the highest attention and the highest investment because it determines the quality of people’s lives in their later years. It is critical that we get this legislation right. I commend the Government’s attempts to move in this direction but there are many serious questions in this area. I urge the Minister of State to take note of the points that have been made on Committee Stage in the Dáil and the points I have made. I will communicate with her privately on a range of other concerns we have which I have not had the opportunity to put on the record because of time constraints.

  Senator Larry Butler: I wish to share time with Senator Ó Murchú.

  An Cathaoirleach: That is agreed.

  Senator Larry Butler: I welcome the Bill. It is important given that people are living much longer. We need to provide for people in their old age. When it comes to the time that a person will require care 24 hours a day, seven days a week, this Bill will come into play.

[952]An important point is that older people who are healthy and living in the community do not need care 24 hours day, seven days a week such as that provided in a nursing home. Older people should be encouraged and supported to live in their communities for as long as possible. The health benefits of day care centres, which provide various activities for older people to enjoy life, their community and surroundings, are evident. This Bill provides the security, dignity and stability that older people require.

The standards required to be maintained in nursing homes is a vital aspect of the Bill but standards are only as good as the people who manage these provisions and those who carry out inspections provided for in the legislation for the benefit of the elderly. It is also fair to note that people like to make a contribution towards the cost of their care. It has always been the way that older people residing in nursing homes made a contribution, through their pension, savings or some other means, towards their care. That brings dignity to the care that is being given and it gives the person receiving the care a sense of independence. It is important we maintain that type of service for older people.

The purpose of the Bill is to equalise the State support for public and private long-term care recipients, render private long-term care affordable and remove the anxiety of obtaining such care for people. Many old people probably did not think about what would happen when they required nursing care 24 hours a day, seven days a week. It is fine in cases where the family and home care help is in situ but often that can be too great a burden for the family and the next step is for the person to be well looked after in a nursing home but a home is the last place I would recommend any older person to be sent. Community care is vital. We must ensure such care does not become part of community care. The care provided for in this Bill is a secondary level of care and a last resort for people who cannot manage on their own.

I would like to deal with the part of the Bill that deals with property. The approach taken has sought to be as fair as possible when it comes to dealing with a property and a contribution. It is fair that 85% of the property value will continue to be available to the siblings or the family who is left behind. The cut-off thresholds of €72,000 for a couple or €36,000 for a single person are correct, but the Minister might examine those levels in terms of inflation because they may need to be adjusted. The same may apply to the property aspect in that an adjustment might also be required. The Minister of State might examine the Bill in terms of those two issues which, on the one hand, would protect the home owner and, on the other, would protect the State. Those in this House have an obligation to ensure that when legislation is passed it is fair and is seen to be fair. That is the reason it is important for us to get this legislation right.

The main provision of the Bill is the assessment of individuals to ascertain whether they need to be provided with long-term or residential care. That is an important point, namely, the evaluation of a person who is to receive long-term care and whether that is done in a correct way. I am not sure how that will work. However, it is important that this Bill is not used to put people into such facilities before their time. This is something about which we should be careful. It is down to management and assessment. Those who are dealing with older people — doctors and so forth — must ensure they are protected in this regard. We all know that the last place a person in his or her final years would wish to go is a nursing home. He or she would rather stay in the community for as long as possible.

I thank the Minister of State for her hard work on the legislation and welcome her to her new portfolio. I am delighted to see her here today.

  Senator Labhrás Ó Murchú: Is mian liom fáilte a chur roimh an Aire Stáit agus buíochas a ghabháil léi as ucht an cur i láthair a thug sí dúinn ar an mBille. Bhí sé an-cabhrach ar fad. I [953]welcome the Minister of State and thank her for her presentation of the Bill, which I found helpful. I also thank Senator Butler for sharing time with me.

I welcome the Bill, which is visionary and exceptional legislation. It has all the hallmarks of compassion, which is exactly as it should be with a caring Government. Anybody who has a loved one in a nursing home would have no difficulty in identifying with many of the issues the Minister has raised today. Anybody who has visited a nursing home and taken the opportunity to observe the difficulties for people, many of whom have found themselves there very suddenly, perhaps as a result of a stroke, Parkinson’s disease or some other ailment, will realise how it changes the lives of not only those in the nursing home but also their families.

One phrase the Minister of State used which struck home to me was the effort that should be made to avoid anxiety for people at a time such as this. When one is in full health it is amazing how one can respond to difficulties and challenges, no matter how they may come at one, but if one is helpless and vulnerable one’s attitude to life changes so that every problem results in excessive anxiety, which adds to the suffering already being experienced. It is evident in this Bill that ears were kept to the ground over a long period by many people, professional and otherwise, to discover what was required to improve the situation of people who find themselves in long-term nursing home care.

One thing about which a person is always particularly conscious, whether sick or otherwise, is his or her house. It is difficult to explain the trauma that results from having to give up one’s house while one is still living. A few years ago there were not many people who could have foreseen a solution to this problem. That is why I say the legislation is exceptional and visionary. I compliment those who are responsible for introducing it, for a number of reasons. If one owns a house it is obviously as a result of one’s own efforts through work, thrift and so on to ensure one had a roof over one’s head. I see no reason, if a person needs to avail of that asset, that they should not have the opportunity of doing so. This is important and it must be the bedrock of our approach to a socialist Ireland. It is very well put in Bill.

When one reads further into the Bill, one considers the difficulties that can sometimes arise from the necessary bureaucracy which exists due to exceptional legislation. Those create anxiety in their own right. I refer, for example, to the identification of people who can act on behalf of those who are not capable of acting on their own authority. These are listed in the Bill. The legislation is comprehensive and, in alleviating one source of anxiety, avoids creating further anxiety. With regard to the level of contribution, that is, 80% of net income, it is true that if people have full services in long-term residential care they do not require the same amount of disposable income as they might if they were out in the real world. However, it is important that some percentage remains. The issue of dignity is vital in this legislation and the fact that a person retains 20% of his or her net income is important.

The allocation of 5% of the value of a person’s house seems very reasonable. Nobody will feel hurt by this. It is important to defend the State also. That has been done well by providing specifically for the manner in which registration will take place, where it will take place and who will be responsible for its implementation. It is provided that the institution will be notified when the time comes that there is a three-month period to allow those who have a claim, from the State’s point of view, to respond. I am not speaking from the point of view of those who might benefit from a legacy or similar, but it is important that these matters are provided for in the Bill and that they do not undermine the requirements of looking after the individual concerned.

Another thing we should bear in mind is that not only are we looking after the rights and dignity of the individual, but we are also helping the family, who are subject to considerable anxiety at such times. They want to do what is right for a loved one but they feel guilty when [954]they cannot do enough for him or her. Enshrined in this legislation is the possibility that they can feel protected and insulated. There is no reason for them to feel guilty because they know the property of the person is being used to provide them with what is required, whether it is in their twilight years or as a young person.

There are many things I could say about the specifics of the Bill, but I do not have any great difficulty with these, although there are a few issues to be teased out. The Bill is comprehensively thought out and protects everybody concerned. I compliment the Minister, the Parliamentary Counsel and the Government on the Bill. It is exceptional, visionary and compassionate. Such qualities are needed more than anything else in this area.

  Senator Joe O’Toole: Cuirim fáilte roimh an Aire Stáit ar an gcéad uair dom a bheith ag déileáil léi sa Teach seo — go n-éirí léi sa job nua.

I welcome the Bill wholeheartedly. During the years many of us as public representatives have come across examples of the strains and pressures exerted on families when their elderly loved ones are no longer able to look after themselves. It was easier in the old days when the extended family lived in the same area. A person with mild dementia could live within the family home securely and one would know if he or she was acting a little strangely. The world has changed since and there are now places where people live on their own in farmhouses with no family nearby.

I compliment the Minister of State on the use of the words “dignity and respect” throughout her speech. That is welcome. At a time when people talk about politicians being uncaring, we can leave party politics aside to say this is an objective we all share.

When the Minister for Health and Children, Deputy Harney, announced this idea some years ago, the original response included significant opposition that I always considered emanated from people who never had to cope in these circumstances. We are talking about an elderly parent who may be suffering from Alzheimer’s disease for whom it is unsafe to live on his or her own. No one wants to talk about the option of that person going into institutional care as it causes families huge trauma. Children feel they are betraying their parent, even if they know it is the most logical and correct thing to do to place him or her in a safe environment in a nursing home. However, I have yet to meet someone who had a parent in a nursing home and did not have a trace of guilt. All of us — I include myself in this — have been there.

The cost of nursing home care is around €3,500 to €4,000 a month, a huge amount. I know of cases where a single child is trying to meet the cost of having a parent in a nursing home and do not know how they can do it. Until recently, if money was paid for care, it could be claimed back at the marginal rate of income tax. In recent years that was reduced to the standard rate, a huge hindrance. If there are six, seven or eight people in a family, it becomes easier, but it is still not cheap. People often have no option but to liquidate an asset, often the family home or family farm. The first trauma is placing someone in a nursing home, the second is finding the money to do so and the third is selling the family home. It would be difficult to design a better way to hurt a family.

I welcome the Bill wholeheartedly, it is legislation all parties should support. I have some questions to ask about it, but the general principle is to be greeted.

The Minister of State referred to the first three years in care. When the legislation is commenced, there will be those who will have been in care for some time. I presume the first three years referred to are the first three years of paying 5% and that if someone is already in care and happens to be in his or her fourth year in a nursing home, the three year period will commence when the Bill becomes law. We should make this clear.

[955]The maximum to be taken from the estate or assets of the person in care is 15% of the principal private residence as described in the Bill. When it comes into operation, there will be sighs of relief from families all over the country. People are living longer in better health, but that leads to other difficulties with people of advanced age suffering from associated problems.

I welcome the emphasis on the registration of nursing homes. We have long discussed this idea and the importance of health and safety inspections, medical standards and care issues. I never supported the idea of having a nursing home inspectorate; I thought the local doctor should be responsible for dealing with his area of care, while the local fire brigade should look after fire safety and so on. No one can be an expert in all the areas to be covered by inspections, from dispensing medicines to health and safety. If each of the local agencies picked up these issues one at a time, it would be better.

Perhaps Fianna Fáil is becoming socialist, but it is was great to hear the Minister of State talk about a system which would be indifferent as to whether care was public or private. I have waited for a long time to hear such phrases coming from the Government. I hope the alternative Government is listening carefully and will buy into this when it gets the chance.

  Senator Liam Twomey: The Senator should read the small print.

  Senator Rónán Mullen: Cuirim fáilte roimh an Aire Stáit. Is as mo pharóiste féin di agus is é seo an chéad uair dom a bheith ag déileáil léi chomh maith.

While I welcome the Bill in parts, I do not believe everything is rosy either. There are fundamental questions that remain to be answered. I knew of a lady who had been worrying for some time because she did not know if she had the resources to pay for her nursing care. Thankfully, someone in the family realised this and relations who had done well in life gave a guarantee to let her enjoy peace of mind that had been missing for some time. It brought home to me that we should not be slow to emphasise that while many of our older citizens are active and fit to deal with the tasks life presents, there are others who experience great vulnerability and fear and we should have them in our minds when we consider this legislation.

I draw attention to an extraordinary scandal from the time of the first nursing homes fees scandal. The Supreme Court in its judgment in February 2005 established eligibility to publicly funded long-term care, whether in publicly funded institutions or HSE funded places in private nursing homes. That was put in place for those who needed it at a cost of 80% of the non-contributory pension. Since that time there has been a conspiracy of silence that the only possible way of exercising this eligibility has been through admission to hospital with a critical illness. The provision of such publicly funded beds is often described as delayed discharge initiative beds in what seems to be an effort to avoid clarifying the eligibility of patients to publicly funded long-term care. In some cases, efforts are made to clarify, to all those who wish to use the subvention route which usually covers a minority of the full cost, that the form will only be signed on the basis the patient and-or family have been made aware of their eligibility for a fully funded bed as per the Supreme Court decision.

Senior HSE officials have criticised the practice of geriatricians clarifying this eligibility to patients and families as a factor in the delayed discharges. When it was pointed out to the HSE officials that this eligibility was the law of the land and that there would be no problem at all if they wished to provide written guidance on any alternative interpretation of the situation, the answer received was that the geriatricians should know the score. It seems there are chilling echoes there of certain aspects of the Ryan report.

Some of the worst suffering occurring in the context of nursing homes has been in the case of families who have not been given access to the information about their entitlements and who have crippled themselves with second mortgages etc. to support an older patient in a [956]nursing home. To add insult to injury, they find their tax relief has been reduced. A further degree of suffering is caused to those who await their eligibility in a general hospital and who may come under the moral pressure of being labelled as bed blockers.

The HSE seems to be petrified by the moral hazard of people’s eligibility being made clear to them. The geriatrician or old age psychiatry assessment which, to date, is not standard throughout the HSE converts many requests for long-term to enhanced care in the community. A natural break on the use of nursing home beds is the unwillingness of older people to enter long-term care. If properly assessed and supported, people will choose life at home if that is possible.

The real failure of the Department of Health and Children and the HSE has been the failure to provide for nursing home care in major urban areas, in particular in Dublin. The Prospectus report highlights that although the national average is approximately five per 1,000 older people, it is down to 1.9 or 2.5 per 1,000 older people in parts of Dublin — one third to one half of what is required.

The so-called fair deal draws on a politics of the aggrieved, the increasing numbers who largely through ignorance of their eligibility are crushed by fully funding or part funding with subvention nursing home care and to whom the terms of the new arrangement are presented as an improvement. One must remember the rights people already have. Their rights stem from the Supreme Court ruling. It would appear there are tens of thousands of older people and families suffering seriously as a result of the failure to clarify their eligibility.

The Irish Gerontological Society outlined concerns about this as far back as December 2006 when in The Irish Times, Dr. Cillian Twomey and Professor Desmond O’Neill wrote that no older person objects to a proportion of their pension being used for the board and lodging aspect of this usually reluctant change to a new home where the person’s health and social care needs, which are not easy to disentangle, should be met. It now seems older people who can avail of a publicly funded bed will be asked to provide funding for this care over and above their lifetime of taxation and pension contribution. The contrast with cardiac and cancer treatment could not be more stark. In the case of certain cardiac and cancer treatments, tens and even hundreds of thousands of euro are spent without anybody imagining that the patient should hand 15% of their principal private residence to the State after their death.

The debate on funding is also marked by an inappropriate alarmism — a false demographic catastrophism. In fact, older people are fitter and healthier now. Disability is dropping among older Americans at a rate of 1.5% per year. In tandem, nursing home use is not increasing with the increasing numbers of older people, although there are some regional differences. Going back to 2004 figures, the number of publicly funded nursing home beds in the Republic has remained constant at approximately 15,000. Are we dealing with another example of what Theodor Adorno called the cold indifference of the middle classes?

Both the Leas Cross report and the Irish National Audit of Stroke Care indicated grave confusion regarding who provides therapeutic support for people in nursing homes, such as speech and language therapy, occupational therapy etc.

I wish to make an observation in regard to the appointment of a care representative as per Part 4, section 21(11). This is a sad state of affairs appointing a care representative who has only one job, that is, that of deciding whether the incapacitated older person should hand over a proportion of his or her assets to the State but who has no other care or welfare role. The suggestion that it should be a registered medical practitioner or other such health practitioner as appears to the court to be a fit and proper person to make the application should be altered to ensure this care representative is separate from the team treating the person in hospital. [957] There is huge pressure on teams in hospitals to discharge people rapidly and, therefore, there is a conflict of interest which may not allow for a reasoned advocacy role for a very significant decision which must be made.

Senator Ó Murchú rightly used the word “dignity”. As we consider this legislation, we need to test it against the question of dignity. I have pointed out some issues which are of major concern. I recall during our debate on the Broadcasting Bill that I proposed we have a heritage channel as part of our suite of television channels to be provided in the new digital set up. I know from my experience of nursing homes and encountering people that thousands of people do not have access to television or radio services which are addressed to their specific needs. Not every older person needs that but there was an opportunity to make a change in favour of older persons who might be in a vulnerable situation. It is too easy to forget sections of the community who are not vocal or particularly influential politically. I hope the sincere concern about the dignity of persons who use nursing home care and their families will guide our consideration of this Bill.

  Senator Dan Boyle: This Bill is undoubtedly a major improvement on what obtained heretofore. It has had a very difficult gestation. The preceding Bill was rightly found to have legal flaws and the subsequent court decision informed what is a better Bill. That said, it is not widely accepted and Age Action, the umbrella organisation for groups representing older people, has said it remains opposed to the concept in the Bill and is seeking support for a number of amendments to improve it. Consideration should be given to some of these amendments but I support what is proposed in the Bill and recognise it as a vast improvement.

The Bill cannot be taken out of context in terms of how we, as a society, deal with the care needs of our older people. As in the case of most aspects of public policy, the fact we are dealing with it with this sense of priority, while not giving equal priority to other elements of what could be called the care hierarchy, means we are still sadly deficient in meeting many of the care needs of older members of our society.

I categorise the care hierarchy by ensuring as much support can be given to older people in their homes by means of independent living. There is no doubt sufficient resources are not being given. Support should be given to families, communities and care organisations to allow such care needs to be met. Only then should hospitals, health agencies and nursing homes become involved in the long-term care of older people.

The fact we are still failing to adopt a holistic approach is to no one’s credit not only on the Government side but on the part of the political system in general. This is an ageing society and we need to adopt a more comprehensive approach to the care needs of older people.

The programme for Government cites a very good example of meeting care needs. The Westgate foundation in Ballincollig in Cork tries to ally day care needs, including services such as physiotherapy and chiropody, with a social outlet. It takes a village approach to meeting the residential needs of a number of elderly people. If we continue to take a segregated approach by dividing up and categorising the care needs of the older section of our population, we will fall short on a constant basis.

There are arguments as to whether the current provision of certain services is cost effective. In the recent European election campaign, I was made aware of the situation at St. Patrick’s Hospital in Waterford where the Health Service Executive is closing a ward currently designated for the care of elderly patients. The long-term care needs of these patients will be accommodated either by moving them to a different ward in the same hospital or to a nursing home. Either approach will negative any potential savings the Health Service Executive expects to make. Those patients remaining in the hospital will face cramped accommodation while the [958]original ward remains empty. Moving these patients into private nursing home care will incur a cost either equal to or in excess of the cost of caring for them in the closed hospital ward. When these types of inconsistencies arise, questions must be asked as to why this Bill is being adopted in this form and why we are not looking at the broader picture. Given the demographic realities, such decisions will inevitably come back to haunt us. Although our population is young when compared with those of other European countries, it is undeniably aging. In the context of the extent to which our elderly population is predicted to grow as a proportion of the general population, we are not providing sufficient resources to meet future needs.

As I understand it, Government policy is cognisant that there will be larger numbers of older people who will require long-term care needs in the future, that the numbers requiring private nursing home care will more or less remain at current levels until 2020 and that additional supports will be provided by way of increased supports to elderly people in the home, carers and community organisations and dedicated health agencies. However, the lacuna that exists in terms of the failure to date to introduce a national carers strategy is unacceptable. The process that accompanied the national carers strategy did not produce a clear articulation of how future policy would effectively meet the needs of carers as they themselves have articulated them. The need for such clear articulation is as strong as ever. There is an onus on the Government to produce that strategy in the shortest possible timeframe. My party will continue to argue for this.

In terms of the narrowest confines of what this Bill seeks to achieve, namely, meeting the care needs of a certain sector of our older population, it does so in the fairest way possible. The formulae take account of people’s differing financial resources and of the fact that the cost, while never fully met under any particular system, should be contributed to appropriately by the State on the basis of means and the circumstances of the individual. I am pleased to support the Bill. However, I hope it can be tweaked to improve it in terms of its acceptability to those advocating on behalf of older people. I also look forward to a more coherent, cohesive and holistic strategy for the care of older people, of which this Bill can only be considered a small part.

  Senator Phil Prendergast: I welcome the Minister of State, Deputy Áine Brady, to the House. As the Labour Party spokesperson on issues affecting older people, I particularly welcome the measures in the legislation for the provision of simple electronic forms of charging, order and discharge application. However, I do so guardedly given the Health Service Executive’s track record in regard to technology. Given the current state of transitional uncertainty as the executive restructures and reconfigures, I have serious concerns about any aspect of change. The great ongoing transition in the delivery of services makes me fearful for the vulnerable in our society, including older people.

The Minister of State claims these provisions will ensure a speedy, standardised and extremely cost effective approach to the processing of charging orders. She said in the Dáil last month that these new provisions would ensure families are not unduly delayed in selling or transferring property. I hope this does not mean the process can commence without the family’s consent. Some clarity in this regard would be welcome because the issue of property value is sure to be problematic. Wills are often written on the basis of distributing assets according to their financial value. With house prices in such a precarious and unpredictable state, the contribution to the Health Service Executive based on the value of the home may become a cause of dispute for beneficiaries of the will. That must be clarified.

I particularly welcome the decision to accede to the request of my colleague, Deputy Jan O’Sullivan, that the applicant’s family be informed of the details of all available facilities and [959]be allowed to choose a particular nursing home. Geography is a relevant factor and it is important that, where possible, people receive the care they require locally. I am aware of instances in south Tipperary where people have had no option but to take a nursing home bed in south Kilkenny. There is nothing wrong with Kilkenny — it is where I am from — but this creates problems for people in view of the lack of public transport. This is a matter of basic rights and dignity as well as a practical concern. Not everybody’s needs are the same and facilities must be tailored to individual requirements.

The Government has gone some way to addressing the concerns of the Labour Party in respect of the fair deal scheme, but there remain matters of significant and legitimate concern. For instance, the Government has a long track record of implementing schemes which are so poorly funded that few can avail of them. That must not be allowed to happen in this case. The Minister of State was asked about this last month and her answer was not acceptable, offering no assurance about the ongoing funding of the scheme. There is a danger that as demand increases, access will decrease. When the Bill was published, the Minister, Deputy Harney, said:

I am very pleased to publish this draft legislation. For the first time it will make the arrangements for financial support for people who need long-term care comprehensive, clear and coherent. It is totally fair. It is clear, sustainable and affordable.

I understand funds have been set aside for the scheme this year, but this signifies little given that it is not due to come into operation until the last quarter. The scheme will be little more than another fig leaf for the Government if we cannot obtain an absolute commitment on funding into the future. There is a concern that funding may become unavailable or may be sidelined into some other programme that is considered more urgent. Particular sections of the population will always consider their needs greater than those of anybody else.

4 o’clock

There are various examples of where funding has been cut for particular services. I have just come from the launch of a report by the Sub-Committee on the High Level of Suicide in Irish Society which reviewed the Government’s mental health strategy, A Vision for Change, and other issues. Funding for mental health services has been reduced by 12.5% this year at a time when the suicide rate has never been higher, causing horrendous grief to many people. We have all been touched by the issue. As a midwife for many years, I am gravely concerned that €10 million could not be found for the cervical cancer vaccine programme. It is likely that the cost of the scheme may have reduced since the announcement not to proceed with it. This issue must be reviewed. I am aware this does not come under the remit of the Minister of State. However, as a woman, she will appreciate what I have been hearing on the doorsteps. I retain a deep sense of disquiet that so many young women are being caused worry and distress in the absence of a vital preventative service. I have strayed from the point somewhat but this is an issue about which I feel very strongly. It will have to be brought back on to the agenda. It is gravely flawed to have reneged on a commitment which brought hope to so many people. That was not the correct course.

I reiterate the importance of commitments in regard to funding into the future. There cannot be a situation where a person who qualifies for the scheme cannot avail of it as a result of inadequate funding. This could place an intolerable strain on older people and their families. The intention behind the Bill is to provide assurance and certainty to families and to the many people who, on the basis of the scheme, will plan years in advance. It is entirely unacceptable, therefore, that this matter has not been firmly nailed down.

The Minister of State’s reply in the Dáil was far too cagey and evasive, particularly in respect of a matter of this importance. What she said suggests that the Labour Party’s concerns in this [960]regard are well founded. In that context, my party has already proposed a simple solution. Will the Minister of State clarify the position with regard to her comments, “On the care needs, we do not accept that the benchmark for dependency will be moved upwards, particularly because it will be subject to a multidisciplinary panel of professionals and their codes of ethics”? What will be the benchmark for dependency? The Minister of State also indicated in the Dáil that:

This will equalise access for both public and private patients because, as must be acknowledged, the majority of provision in nursing homes is in the private sector. By law, the care needs assessment, which is holistic in nature, must take family, social and community circumstances into account.

I am concerned in this regard and perhaps the Minister of State will clarify the position.

During her contribution to this debate, the Minister of State indicated:

That agreement reaffirms Government policy to support older people to live with dignity and independence in their homes and communities and to support access to quality residential care when needed. [I am in complete agreement in this regard] It also contained the following principles to guide the development of future policy on long-term care for older people. All relevant public services should be designed [Again, I agree with this] and delivered in an integrated manner ... Care needs assessments should be available on a timely, consistent, equitable and regionally balanced basis.

I am interested in the fact that it will be regionally balanced. On what basis has the Minister of State decided what constitutes something being regionally balanced? I take particular cognisance of the fact that acute services will be cited in one particular area in Cork. The Teamwork report, which was published yesterday, has given cause for a great deal of concern in this regard.

I was actively involved in nursing up to two years ago and there was always the concept of a “golden hour” whereby people with acute myocardial infarctions or serious disorders or diseases had to receive treatment within the first hour of being admitted to hospital. Surveys were carried out at the hospital in which I worked in respect of how quickly people received treatment and the long-term outcomes that resulted. I accept that the position varies from individual to individual but the research heavily supports the fact that people who received immediate treatment did far better than those who did not. Some of the latter actually passed away. What does the Minister of State mean by a regionally balanced basis?

The Minister of State also indicated that: “The use of community and home-based care should be maximised and should support the important role of the family and informal care.” There is not enough time for me to discuss the entire matter of carers in the home and those who provide a home care service. These people are responsible for providing millions of hours of care each year. They are under-resourced and underfunded but they provide the most excellent service to people in their own homes. Providing such care represents the optimum and it is what we all want. I have met those in the Carers Association who provide a service to their own families and loved ones and who also provide such a service to others on a community basis. I am aware the country is in a bad position financially. However, let us consider the case of a person who is content and well enough to live at home and whose confidence is strengthened by the fact that he or she will be visited by a carer for two or three hours per day. Where his or her care is cut to two, three or four hours per week, his or her confidence will be sapped.

Last week I was lucky enough to visit the Marian Court in Clonmel, a sheltered housing facility for the elderly. I met some wonderful people there who have a great sense of fun and youth. Marian Court is a fabulous facility and the services on offer there cost €100 per week. [961] People can obtain a four-course hot meal during the day and have access to beautiful gardens. The facility is situated adjacent to the local church, which means that the needs of everyone living there are likely to be met. This is a fantastic care-taking facility where assistance is available to local elderly people. I cannot praise Marian Court highly enough.

The dignity of older people must be maintained and they should not be obliged to worry. Unfortunately, however, they are concerned in light of the sensational reports that appear in the media every day regarding the recession. I met some people at Marian Court who are in their 70s and 80s and who read the newspaper on the Internet each day. I admire them because it was recently enough that I began to do so. These people are worried as a result of what they are reading. Financial concerns can give rise to high blood pressure and create a lack of confidence, which in turn can cause many problems.

My area of expertise in nursing was midwifery and I found that a woman who was confident when commencing the process of childbirth had a much shorter and easier labour than someone who was frightened and who did not have someone to attend to her needs. I am of the view that I have a depth of personal experience which allows me to speak on this subject.

I thank the Minister of State for coming to the House. I hope she will be able to address some of the concerns I have expressed.

  Senator Mary M. White: I welcome the Minister of State, Deputy Áine Brady, and wish her the best of luck with her portfolio. I compliment Senator Phil Prendergast on her contribution. It was a pleasure to listen to what she had to say.

The Bill is aimed at transforming the current system of residential nursing home care in Ireland to one that is accessible, affordable and anxiety-free. In line with recommendation 18 of my policy document, A New Approach to Ageing and Ageism, the Bill will provide much needed clarity regarding the State arrangements for financial support for all people who require long-term care in both public and private nursing homes.

The enactment of the Nursing Homes Support Scheme Bill, or the fair deal legislation as it is also called, will give rise to significant changes. It is worth noting that a fundamental principle of the scheme is that no person currently in care will be disadvantaged in any way by these changes.

People face very different costs depending on whether they are in public or private nursing homes. Some private homes cost approximately €50,000 per year. Certain individuals do not receive support from the State. Many of those who do receive financial support from the State still cannot afford to pay the remainder of their costs. Consequently, people are sometimes obliged to sell or mortgage their homes to pay for their care and must often rely on contributions from their families or friends.

The nursing homes support scheme will benefit everyone because individuals will, based on their means, make contributions to their care costs and the State will then pay the balance. This will apply in respect of both public and private nursing homes. As a result, people, their spouses or dependent children will never be obliged to sell or mortgage their homes to pay for nursing home care. Family members will not have to provide cash from their own incomes to pay for care and the State will continue to pay the majority of overall care costs. The benefits of the scheme are that the State will fund the largest part of people’s care costs, the basis for contributions will be equitable and will be based on the income and assets of the person who requires care, individual contributions will be affordable, people will not be obliged to sell or mortgage their homes to meet their contributions, and the deferred contribution from the principal private residence will be capped at a maximum of 15%.

[962]This scheme is not just for those over the age of 65. The current subvention scheme does not make a distinction on age grounds, nor will the new arrangements. The service and the population for which the scheme will be provided is defined in legislation. The scheme covers long-term residential care only, not respite or day care, although these services may be provided in a particular nursing home.

The definition of a couple is a critical point and a landmark in the Oireachtas. Section 4(1) states:

In this Act, “couple” means—

(a) two persons married to each other,

(b) a man and woman who are not married to each other but are cohabiting as husband and wife, or

(c) two persons of the same sex who are cohabiting in domestic circumstances comparable to that of a man and woman who are not married to each other but are cohabiting as husband and wife,

who are habitually living together at the date of the making of an application for State support by either or both of them or at the date of the commencement of the provision of care services to either or both of them.

This is far-sighted and it is about time that couples devoted to each other but not married are entitled to the same legislative provisions as married couples.

  Senator Liam Twomey: Senator O’Toole praised the Government for introducing this legislation but he should be wary of Fianna Fáil bringing in legislation such as this, which may have been drawn up two years ago and based on a time when property was worth more, people had more assets such as shares and the criteria used here would have excluded most elderly people from being eligible for assessment. The sum of €36,000 and one’s home keeps one within this system. If one has more than that, one is excluded. Elderly people with significant amounts of shares and businesses would have been excluded from the financial point of view. Now that the Government has wrecked the economy, those shares and properties are no longer worth the same and a far greater number of people will become eligible for this scheme.

We must be concerned at the assessment of health needs carried out by the Government. The NEPS decides if one is eligible for education services and we see major delays of up to nine months, with obstacles placed before parents who seek these services. This will happen in this case as well. We saw this happen in the good times. Disability grants and care packages for elderly people were restricted to an unbelievable degree over the past few years. This is a Progressive Democrats way of thinking that still infects Fianna Fáil. Patients will not get access to these services, no matter how good this reads in principle, based on the history of this Government, which has restricted services to an unbelievable degree. If they were not available in the good times, the Government certainly will not make them available in the bad times. I would like the Minister of State to tell us when the legislation will come into force once it is passed. What will happen to the two public nursing homes that provide services to people in Wexford, St. John’s in Enniscorthy and the New Haughton hospital in New Ross? They provide excellent services but it may cost up to €1,700 per week to care for a patient there. Private nursing homes that do not need to provide the same level of services charge between €800 and €1,100. Will the National Treatment Purchase Fund, which is the Minister’s responsibility, reduce the quality of care provided at St. John’s in Enniscorthy and the New Haughton hospital [963]to reduce the cost per bed? These are the questions that must be answered. Will these facilities be closed? The Minister of State must make clear whether that will be the end result of the legislation. If public beds could not be provided in the good times and this problem developed while the Celtic tiger was roaring for the past ten years, how can we trust the Government to get this right in more difficult times?

What will the Minister of State do with the public nursing facilities where I send my patients in County Wexford? Will they be forced to cut the number of nursing and care attendant staff or will the remuneration of private nursing homes be improved so that the facilities provided will improve? These are the real questions Senator O’Toole, who supports this legislation, should be asking.

I am worried about the assessment because I can see it being used to make those with dementia, Alzheimer’s disease and strokes the only ones eligible for services. I see people with leg ulcers, heart failure and significant breathing problems being given all sorts of cobbled together home care packages to keep them in their homes. This is not because the Government wants to keep elderly people at home but because it is cheaper.

The Minister of State referred to the majority of elderly people wanting to remain in their homes rather than going into nursing homes. If the majority of people prefer this, why is this legislation not rights-based? Why does it hark back to what the Progressive Democrats used to do with human rights? They used to put a cost on it, as the Minister of State is doing. If she says it is resource dependent, she must know how much she can put into this service for the next three years the minute the legislation is signed. If the Department has carried out a financial needs assessment on how much will be spent in the coming years, how much is the multi-annual budget? How many patients can be cared for using that budget? If the National Treatment Purchase Fund has completed its assessment to this degree, it should be able to tell how many patients it will look after and the Minister of State should be able to tell us. From that, the organisations representing elderly people and the Opposition may be able to work out the commitment of the Minister of State to elderly people. There is a major restriction on services for elderly people in the community at present. Home help and care packages are restricted and there are not enough public health nurses. At the same time, it is almost impossible to get people into public nursing homes.

The Minister of State has the figures and understands the problems. I would like her to indicate how many beds she envisages in the coming years. Anything else is only a sham, the same as when the Minister for Health and Children, Deputy Harney, announced the home care packages that would sort out problems for elderly people in the community. A recent report stated that it is almost impossible to work out whether one is entitled to a home care package. Even if one is entitled to it, it is impossible to get the full range of services promised. If the home care packages cannot be provided, how can this be right?

This is legislation and it must be better defined. This is not like one of Senator Mary White’s policies announced today. Legislation must be accurate, not full of high, noble ideas and fancy words. It must be cut and dried, explaining what the people of Ireland are entitled to. Every one of us respects the dignity of older people and would love to see older people remain in their homes. If that is not available to them, I want to know how far the Government will go in looking after those people. The record of the Government up to this point has been measly. This type of legislation, which deals with the protection of people in the last years of their lives at a time when they are most vulnerable, should be rights-based.

If we look across the European Union or even the UK and Northern Ireland, they are able to provide far greater services on a rights basis than this Government is able to in this country. The Government was not even able to provide these services in the good times and I have my [964]doubts whether it has the commitment or will to provide such services in these difficult times. The comparison can be made with other European countries and one can see the deficits. That is the reason this legislation should have been rights-based. It would have given confidence to families and elderly people that the Government means what it says in putting this type of legislation through the House. I do not see that currently.

I will look for the Minister of State to return to this House at a later stage to answer a few simple questions. When will the legislation come into force, has the needs assessment been done and may we have access to those figures with regard to the financial impact? What could happen to St. John’s Hospital in Enniscorthy, New Haughton in New Ross, the Ely Hospital in Wexford town or the district hospital in Gorey when this legislation is introduced? They provide a significant range of services and would not be able to compete on the cost basis that the National Treatment Purchase Fund will use.

  Senator Maria Corrigan: I welcome the Minister of State and I welcome the opportunity to discuss this Bill. I also welcome that where people will require long-term nursing care, the three main aims of this Bill will ensure such care will be accessible, affordable and anxiety free.

As colleagues have noted, the current position is one which causes considerable anxiety for people, their spouses and their families. The costs of nursing fees are escalating and they appear to be the only costs not being reduced. Depending on where one lives, prices and costs can vary but there are very few nursing homes that are not charging the guts of €1,000 per week per person, which is quite a substantial cost for people to bear.

This also comes at a time which is upsetting and distressing for a family or spouse, if a member of a family can no longer live in the family home and where it is necessary to identify a place in which the family must have the peace of mind that those in care will be safe, secure and in receipt of the care needed. The family would also know that there will be long periods when those being cared for will be out of the family’s sight. It is a significant leap of trust and faith to take and to combine that with financial worry as to how that care will be paid for should be unnecessary as it exacerbates an already very difficult position.

I have met constituents, as I am sure other colleagues have, who fear that as they try to meet costs, they will see life savings depleted at an alarming rate. They are aware that they may live longer and require such savings which may become fully depleted. If one is paying approximately €1,000 per week, a year of nursing home care would come to approximately €50,000. If a person has limited savings, his or her concern will be what happens to a loved one in a nursing home when the money runs out. There is anecdotal evidence of people being asked to leave nursing homes because their families are no longer in a position to pay those fees, which would be particularly distressing. This Bill will provide comfort and relief for family members and spouses feeling the pressure of those mounting nursing home costs.

I apologise if the Minister of State has answered the following question. With regard to how the contribution is to be calculated, where it is reckoned at the time of care and the family opts to defer payment until after the death of the person or spouse, how would a change in asset value be reflected in the reckonable amount? Will the amount be specified in value rather than as a percentage at the time of care? If assets subsequently decrease in value and money is not available, what will be the position? If the individual or couple have other financial commitments — they may have undertaken an action on behalf of a son or daughter, owe money or be discharging other financial commitments — will the amount of disposable income available to them be calculated on a net or gross basis for the purposes of determining the 80% amount?

[965]While the Minister of State is present, I take the opportunity to address a number of aspects specifically relating to the Bill, although I do not wish to repeat what colleagues have raised. I apologise if the issues have been mentioned. I will address specifically the issue of capacity within the Bill. I am aware that there is a concern from advocates, including Age Action Ireland, in this regard. What regard will there be for the individual’s personal opinion? I welcome the functional approach to capacity but I am very conscious that such an approach recognises that capacity can vary over time and be issue specific.

I note that on how we will determine capacity, there is a specific reference to two medical practitioners. What is the definition of a medical practitioner and will it include psychologists, for example, where the profession has established competence in the determination of capacity? It is the only profession that has established competence in the diagnosis and assessment of cognitive functioning and, arising from that, there are a number of questions.

Is there a mechanism to reflect a variation in capacity over time? For example, in the case of the onset of dementia, there can be occasions where a person would have very lucid periods and the definition we have provided within the Bill could be met. There would be other occasions when it would not be possible to meet that definition. A functional approach to capacity is such that we recognise it can vary over time and be time and issue specific.

I welcome the commitment within the Bill given to individual choice and recognise in regard to functional capacity that we could very well have a position where an individual will not have capacity in the decision around the financial arrangements. The person could very well have capacity with regard to which nursing home would be used. Will there be a provision for that?

Where capacity is determined not to be present for an individual, what measures will be put in place to monitor formally resident satisfaction with the nursing home that is to become a person’s permanent home? Where capacity is determined not to be present, a very strong case is to be made for the adult to be designated a vulnerable adult, and particular regard should be given to such a person’s circumstances in the context of an audit by the inspectorate. I welcome the commitment to inspections and ensuring all nursing homes will be registered and audited. In cases where individuals are determined not to have capacity, particular regard must be paid to them in these audits and that their families or carers be included.

Will there be a specific process for the care needs assessment? Some concerns have been expressed as to who will conduct them. Will there be an appeals process? What is the timeframe for implementing the legislation’s proposals? Is it planned to apply this legislation to the numbers occupying acute hospital beds? That does not provide them with a good quality of life, wondering if they will keep the acute bed or be moved somewhere different. It is also not a good use of public moneys.

  Senator David Norris: I welcome the Minister of State, Deputy Áine Brady, and this necessary Bill. While I have some reservations and questions about it, generally it is improving legislation. These are difficult economic times in which to cope with vulnerable and elderly people.

Yesterday, I received a communication from a very fine young graduate on the situation faced by him in the care of his elderly mother, one faced by many others. Although she is residing in a care home in the countryside, it comes to €3,000 a month. When her savings run out, this young graduate and his sister will find it impossible. That is why he welcomes the Bill’s aim to provide some alleviation in paying for the care of his elderly mother, to whom he and his sister are devoted. He informed me he would be grateful of my support for the Bill and, although it is not a perfect solution, he feels its goes a long way to removing the current financial stress facing many families across the country.

[966]I am concerned about the whole area of care for the elderly, having had some experience of it myself. I recall an aunt, whom I adored, when she reached her 90s but, even with her indomitable spirit felt she had to go to some home. We examined some places which were pretty grim but eventually found a marvellous home, the Alexandra Guild House. The personal touch there, respect for the individuality of the person- my aunt could even have some of her own paintings and furniture in her room — home cooking and so forth made it wonderful. Unfortunately, it ran into trouble. With the assistance of Anne Byrne, programme manager to the then Minister for Health, Deputy Howlin, we managed to rescue the place. I am very proud this was done through the political system.

I am less proud of the treatment of people in several other nursing homes. I, along with my colleague and friend Senator John Paul Phelan, have raised the matter of Bethany House in Carlow. Both of us were seriously misled on the closure of this home. People were forcibly lifted out of the home against their will and the instructions of their relatives. It was shameful. People were bundled into ambulances against their will. In some cases that amounts to a death sentence. They were taken to a hospital where they will be confined to bed most of the day or forced to stay on lounges for long periods, taking away their independence which will kill them. I knew of someone who got bedsores because of this kind of treatment which eventually killed her. With proper nursing that should not happen. I appeal again to the Minister of State to re-open the file on Bethany House. For a time it was a unique case but I have discovered it has happened in other homes in Cavan and elsewhere. This is brutalisation and abuse of the elderly. We could have another scandal on our hands.

The nuclear family model has to a large extent broken down and for various reasons one can no longer expect an extended family automatically to be in a position to look after elderly relatives. It is necessary, therefore, the State takes some responsibility in their care. In her clear and positive speech, I appreciated the Minister of State saying, “It is deeply unfair that one person and their family with modest means could face very high bills to pay for care, while another might pay relatively little even though they had substantial means and assets”. I am glad a mechanism will be established in the Bill to achieve some degree of equalisation.

I also approve of the move towards community and home-based care solutions where it is appropriate — that is the key. Such care is the best. To my mind, hell would be to be stuck on one of these stretchers surrounded by other old half-corpses, drooling and moaning, with the blasted television on at full volume. Imagine the torture that must be for those who are locked into this state even though they are intelligent. I appreciate the Minister’s speech in its interest in the humane treatment of elderly people.

I also discovered a little nugget in her speech on which I want to celebrate and congratulate her. One of her ministerial colleagues, a female, did a disservice some years ago to democracy in this House in a Social Welfare Bill. Under equality legislation a case had been brought where a same-sex couple were denied transport facilities and they won. Instead of addressing it, the Minister in question opted to redefine the term “spouse” to do gay people out of their rights. It was most horrendous.

It was a source of real pleasure to me today, however, when I noted in the Minister of State’s script:

Section 4 defines couples for the purposes of the scheme. A couple is defined as (i) a married couple or as (ii) a heterosexual or same sex couple who are cohabiting as husband and wife for at least three years.

[967]Well done to the Minister. I am not sure whether anyone else spotted this or said how historic it is. I am almost persuaded to believe the Government is serious about introducing a civil partnership Bill. This is the first little step. In the old days in Dublin 4, little brats like myself played a game called Relieveo which had various classes of penalties such as scissors steps, giant steps and baby steps. While this provision is just a baby step, it is in the right direction, of which I am heartily glad. I thank the Minister of State from the bottom of my heart for recognising a real human situation.

The care needs assessment is a good provision as long as it is serious and not used as a means to avoid confronting the difficulties in care for the elderly. There will always be financial implications in this area. The danger is these mechanisms may be used by the State to avoid having to cough up. However, I understand the great strains under which the State is operating at present.

I wish to ask questions about a number of other areas that are of interest. I refer to sections 9 and 10 and Schedule 1. The Minister of State stated:

Parts 1 and 3 of Schedule 1 set out the rules for calculating the contribution payable by a single applicant. In summary, a person will make a contribution of up to 80% of his or her income and up to 5% of the value of his or her assets, after deductions and safeguards have been applied.

In an uninformed view from the outside, this seems to be reasonable. How was this formula arrived at and what method was used to calculate it? It appears appropriate because if one is in a place permanently, what capacity has one to spend money anyway? It is not as though one will go off on a cruise. Moreover, one will have 20% left, which is a hell of a lot better than when such people were being given sixpence as pocket money. The phrase “pocket money” actually was used and I shuddered when I heard we were treating elderly people as though they were children.

My final question pertains to Parts 2 and 3 of the Schedule, which contain the rules on the contribution payable by a member of a couple. While I will not go into the whole matter, in this case the assessment is based on the principle of each member of the couple owning 50% of the couple’s combined means and so on. I refer to the healthier member of the couple, that is, the person who remains in the community. Could this assessment render vulnerable his or her ownership of the home or his or her capacity to continue to reside there? That would worry me. In other words, if such people, who are expected to pay up to 50%, are assessed on the home and have a small income, they may find it difficult to make a contribution. Consequently, I am concerned they might be vulnerable in the enjoyment of their principal residence simply because their spouses were in nursing homes. I hope this is not the case and I may have misinterpreted it. I thank the Minister of State for this good day’s work on which I applaud her. I again ask her to consider the question of Bethany Home and the other associated homes. This is not a partisan issue because there also was strong support on the Government side.

  Senator Nicky McFadden: I welcome the Minister of State. This has been an interesting debate and I believe that all Members are singing from the same hymn sheet, that is, they unanimously seek the best for elderly people. While this Bill goes a long way it does not go far enough and, as Senator Twomey stated, the devil is in the detail. I have concerns with the present position with regard to eligibility and with, as some of my colleagues have noted, the availability of beds. The question of who decides on priorities as to who should get a bed in a particular area is a major issue. The local care hospital in Athlone has a waiting list that is as long as one’s arm and it is the same for the local public nursing home. How people gain entry [968]to them beggars belief. If possible, I seek clarity from the Minister of State as to how this will be defined in the new system.

I welcome this Bill’s policy content in respect of home care support. From my experience, the optimum is to enable people to live in their own homes. However, there have been serious cuts, to which Senator Prendergast referred, regarding home help hours. While Senator Corrigan made the point that money has been put into this area, it is a case of being penny wise and pound foolish to fail to continue to invest in keeping people at home and enabling them to live with dignity there, rather than having them enter nursing homes or ending up in hospital, because that is what will happen eventually. Unless people are cared for properly and sufficiently, they will end up becoming ill and being obliged to enter hospital. In the long run, this costs a lot more money. Having worked in this field, I am familiar with how important it is to have proper therapists and enough public health nurses to deal with people, to spend time with them in their own homes and to provide the tailored individual needs for those concerned. As for the local authority systems, there must be more joined-up thinking to provide comfortable and accessible bathroom and bedroom facilities for people to allow them to remain in their own homes. In the long run, doing so also will keep people happy and at home.

Other Members commented on our society’s changing demographics. One statistic I noticed pertained to a 138% increase over a 30 year period in the number of people over 35. Consequently, we must make provision for the elderly now. One should remember these are the people who contributed to the taxation system, who worked all their lives and who deserve to be cared for properly and with dignity. It is a no-brainer to state that proper home care is the proper alternative to residential care.

While I do not wish to repeat everything, another issue on which colleagues have touched pertains to nursing home standards, about which this Bill is to be commended. I welcome the fact that public facilities will be checked upon and overseen. I visited a number of nursing homes during the recent election campaign, some of which were clean and clinical but not very homely. Other nursing homes were fantastically homely and provided services such as entertainment and quality of life facilities. It is not all about therapeutics, it is about people living with dignity and respect, and such considerations should form part of the entire package.

I have very serious difficulties regarding the definition of a couple — other Members addressed this issue. I too welcome the Minister of State’s intervention on same-sex cohabiting couples. However, Age Action Ireland referred to another category of people, namely, siblings. Senator Cassidy will identify with the point that there are many elderly brothers and sisters throughout the country who have not been identified in this Bill. Age Action Ireland’s suggestion is that two persons living in a shared economic and social relationship should be categorised.

The other amendment I suggest is that the multidisciplinary team of health care professionals should be closely linked to the individual. The Minister of State previously expressed her belief that it should be a multidisciplinary team and this must be guaranteed by the legislation because it is crucial. Another suggestion is that social workers should form part of such a multidisciplinary team. I agree with Age Action Ireland in this regard because social circumstances also have a bearing on the manner in which people end up in nursing homes.

Senator Corrigan touched on the issue of house valuations. What will happen if there is a change in the valuation of a house? How will the 15% be calculated in such circumstances? I suppose the bottom line is that the amount of money charged should never exceed 15%. I would like the Minister of State to comment on that. I commend the Minister, Deputy Harney, and the Minister of State on introducing the initiatives contained in this Bill. I remind the [969]House that a great deal of detail remains to be teased out. However, it is a step in the right direction.

  Senator Paul Bradford: I am glad to have an opportunity to say a few words on this legislation. I have raised this matter on the Order of Business on many occasions over the past two years. Senators have eagerly awaited this opportunity to have their say. I understand the Bill was given a reasonably thorough airing in the other House and I hope the Seanad will prove its worth once again when it offers its views and opinions on this important social legislation. I am happy to avail of this opportunity to say a few words on the record. Over 25 years have passed since Ireland was greatly divided when the people were asked to vote on a famous constitutional amendment. I refer to the pro-life amendment, which was designed to give constitutional protection to the unborn. I suggest to the Minister of State, Deputy Áine Brady, that it is about time we reflected on the possibility of introducing a constitutional amendment to enshrine the housing and health rights of the elderly in our community, including in our nursing homes.

  Senator Nicky McFadden: Hear, hear.

  Senator Paul Bradford: In that regard, the Bill before the House can be deemed to be a step in the right direction. I am worried about much of the content of the legislation. I refer to some of the definitions in the Bill, for example. Above all, I am worried about what the philosophy underpinning this legislation means for the future provision of services for elderly people. It used to be said that “children should be seen and not heard”, but that phrase has been removed from the lexicon, thankfully. Sadly, society now seems to have decided that the elderly should be neither seen nor heard. There is a view that the State should be satisfied as long as proper nursing home care is being provided and can be afforded. In other words, many people believe our only political and social aspiration for the elderly should be to ensure nursing home beds are available for them. That is not just inadequate but inappropriate and very sad. I see this legislation not as a major part of the jigsaw of measures that need to be put in place to assist our maturing citizens, but as a tiny part of the jigsaw.

We must recognise that the demographic profile of Irish society is of a greater number of elderly people. Many people will be concerned about long-term residential care. We have to put in place the supports and mechanisms they require. I appeal to the Minister of State to ensure that residential nursing home care is not at the core of her thinking and philosophy. It should be the final part of the equation, when all other options have been ruled out. Over the past two years, this House has had a number of discussions on this issue on the Order of Business. As I see it, the strong view of all sides of the House is that we should ensure that suitable policies and procedures are in place to allow the maximum number of people to remain in their homes, with their families and in their communities. It would be interesting to survey those who are currently in nursing homes and long-stay institutions to see what they think of their present whereabouts. We should ascertain what alternatives they would like to have offered to them. I suggest that the majority of respondents would prefer to be cared for in their own communities.

I am a realist. As Senator Norris said, society has changed. The current economic and social conditions dictate that suitable long-stay facilities have to be made available for people whose families cannot provide for them. It is for that reason that there is a place on the Statute Book for legislation of this nature. We cannot ignore the fact that the majority of people would prefer to be looked after in their own homes, families and communities. It costs much more to provide public beds than it does to meet the meagre cost of the carer’s allowance payment. Thousands of HSE staff work in public nursing homes and district hospitals. The number of [970]people who work in the health sector in our communities — I refer to our hard-working district health nurses, for example — is much smaller. We need to re-examine that equation as a matter of urgency.

The former Minister for Social and Family Affairs, the late Séamus Brennan, had an outstanding vision for the future of this sector. He made tremendous strides when he reformed the carer’s allowance system. He introduced the carer’s benefit scheme. Some time ago, he gave me a strong commitment in this House that he was willing to reflect on the possibility of removing the means test for carer’s allowance. I was hugely surprised and bitterly disappointed when the current Minister for Social and Family Affairs absolutely dismissed any prospect of a genuine relaxation of the rules in relation to carer’s allowance and carer’s benefit. I hope the Minister of State will discuss the need to re-examine those rules with the Minister, Deputy Hanafin, and her Cabinet colleagues. At a time when hundreds of thousands of people are, unfortunately, out of work, many people are willing to support and care for their relatives or neighbours, thereby allowing such people to remain in the community. If we were to help them to do so, that would be the answer to many people’s prayers. We need a holistic debate on the much greater question of long-stay care.

At a time when many people are in nursing homes and many more are about to go into nursing homes, it is important that this Bill is before the House and that we are debating the need to put in place a financial system or package to provide for such people. While I did not hear the Minister of State’s speech, I read it with great interest. I am glad that some of the anomalies in this legislation appear to have been tidied up during the Dáil debate. That is certainly welcome. As many people with a cottage or an acre of land were worried that the 5% annual charge might be imposed on them ad infinitum, it is right that a three-year cap has been put on the charge. I am sure that positive measure resulted from the debate in the other House. I hope this debate will lead to similar positive developments.

I acknowledge that this legislation is necessary because public or private nursing home beds are needed by many people. The nursing home system needs to be underpinned with a secure system of financial support. It is very important, in the interests of elderly people and their families, that the highest standards apply in our nursing homes.

I listened with interest to what Senator Norris said about the low standards in one or two nursing homes — I will not call them institutions. I accept that standards in the public system of nursing home care can sometimes be far from sufficient. One of society’s strong aspirations must be to raise the bar in this respect. The decisions we take now on the future of elderly people will affect our lives as we get older. We need to make it clear that we are prepared to support our elderly people fully. We will do that as a gesture of thanks for what they have done for Irish society and as a marker for where we want society to go. I hope we can scrutinise the relevant sections of this Bill during the Committee Stage debate. I hope the Minister of State will look beyond the question of nursing home care and recognise and respect the fact that a much broader jigsaw of measures needs to be put in place to support our elderly people.

Debate adjourned.