Mr. Pat Healy:

I thank the committee for the invitation to attend today's meeting to discuss the regulation of and future planning for home care provision. I am joined by my colleague, Mr. Michael Fitzgerald, who is assistant national director in community strategy and planning division with responsibility for services for older people.

I have provided a briefing note with my opening statement that outlines the current position and the actions being taken by the HSE to improve the current service model and to support the work of the Department of Health on the planned legislation and regulation of this service. In this context the focus of my opening statement will be on some of the key issues involved.

The HSE National Service Plan 2018 provides for a little over 17 million home support hours to be delivered to 50,500 people at any one time within a budget of €408 million. This includes the support provided through winter measures for 1,170 people requiring discharge from acute hospital care to a value of €18.2 million. A further initiative saw 324 people being provided with home support services in the context of the recent adverse weather with a value of €5 million in full-year cost.

Home support services for older people funded by the HSE are provided either by directly-employed home help staff or by voluntary and private providers who have formal arrangements with the HSE to deliver the services. The type of support that is provided includes personal care and, where appropriate, essential household duties relating to the people's needs to maintain themselves in their own homes and communities.

With the approval of the Department of Health, from 1 January 2018 the HSE moved to a single funded home support service which combines home help and home care package services into a single service, namely, the home support service for older people. For service users, the public and the health system, the services will be easier to access and easier for the public to understand. Through the streamlining of application processes, there will be a requirement to make only one application and decision for home support services for older people. Service users will also be facilitated to move to changed levels of service as their assessed needs change without the need for an additional application process.

Intensive home care packages are funded separately within a budget of €9 million. The service is being delivered to approximately 235 people at any time. The majority of these people have been diagnosed with dementia and, therefore, have extremely complex needs. They require bespoke combinations of services based on their specific care plans. Without such services, these people are more likely to be admitted to long-stay residential care.

There has been a significant investment of €112 million in home support for older persons over the past three years. However, demand for such services continues to grow as the population of those aged over 65 years increases. As of 31 March 2018, there were 6,458 people assessed and approved for home supports, both new and additional, who were put on a waiting list for services. The vast majority of these people reside at home.

The Department of Health is engaged in a detailed process to determine what type of home support scheme is best suited for Ireland. This process will consider the future design of a scheme as well as the licensing or regulation requirements for these types of services. The HSE welcomes this development and supports the introduction of future legislation in this area. The demand for home support and its importance, as an alternative service to long-stay care, has grown considerably in recent years. Similarly, the type of home support that is now required to meet the needs of the population is a more person-centered personal care model rather than the more traditional home help service of earlier years which was centred around household duties. The development of this new service model, which is grounded in the national standards for safer better healthcare and which is sufficiently flexible to meet the more complex needs of an ageing population, brings with it challenges of ensuring that all providers are in a position to deliver a quality service and one in which the workforce is trained and competent to undertake the required duties. As a result, standards of care supported by appropriate regulation are necessary to ensure that such quality care is provided and maintained and that governance and oversight are at a level to deliver this service safely and to the satisfaction of the recipients. The regulation needs to ensure that providers can quality assure services to demonstrate that they meet the service users' individual needs across a range of headings such as, for example: the training and qualifications of staff undertaking the home support duties; the policies of the providers to deal with person centred care; the safeguarding of recipients of care; and the reliability of provision and suitability of the service.

The absence of a legislative-based scheme in the area of home support has been challenging given that the qualifying criteria for such services can only be based on the needs of the person. There is no legal basis underpinning the scheme or means testing. Also, account is not taken of other circumstances when deciding upon provision. In the development of such legislation it will be important to ensure that there is equitable access and a firm funding basis for a new home support scheme. We must also ensure that the requirements to have a timely and flexible approach to address the recipient's needs is maintained. In legislating for home support, cognisance must be taken of other legislation that has already been enacted, particularly the Nursing Homes Support Scheme Act, so that there are no unintended consequences that could arise and that people are clear as to which scheme applies to their particular needs.

The HSE employs 6,300 home support staff in all areas outside of the great Dublin area and Wicklow, which includes the community healthcare organisations of CHO 6, CHO 9 and parts of CHO 7, and County Clare. In recent years, the HSE, working with staff and their trade union representatives, under the auspices of the Workplace Relations Commission, WRC, has implemented a comprehensive modernisation and improvement programme to better meet the needs of service users and the staff delivering the services. The details of these arrangements are outlined in the briefing note I have provided.

Section 39 grant-aided providers of home support services have traditionally provided supports with household tasks. However, the majority have evolved over the years to deliver personal care as well as essential household duties in line with the changing needs of older people. These providers are independent operators and they employ staff directly. The HSE has worked closely with the voluntary sector to develop and consolidate the sector in order to ensure that appropriate, sustainable and well-governed models of service which meet the needs of service users are implemented.

As service provision has expanded, including via the emergence of private providers, the HSE has developed appropriate specification and standards for the delivery of services with an increased focus on person-centred care and support grounded in the national standards for safer better healthcare. As part of this process, the HSE has engaged in a formal tendering process for home care services that are renewed periodically. As well as ensuring value for money, these arrangements have also assisted in preparing the sector for future regulation of services and for the anticipated implementation of a national statutory scheme for home support in due course.

The HSE recently commenced a tender process for home support services to replace the 2016 tender arrangements. The relevant documents were published on the Government's tender website. As the specific details for the tender process are only available to those who express an interest in participating in the process and given that the process is live, I am not in a position to go into specific details on the matter. However, I have provided an overview of the overall tender process and arrangements in the briefing note submitted.

The tender arrangement for 2018 will provide for the introduction of a consumer-directed approach to the delivery of home support as an additional mechanism of service delivery. This approach will facilitate clients to choose - and to have more of a say in respect of - the days and times of service delivery. Clients will have the opportunity to contact a number of approved providers in order to consider the services on offer. To ensure quality of care, providers must be included on the approved provider tender list set up following the tender process and they must not charge rates in excess of the agreed tender rates. Furthermore, the provider and the client must have regard for specific requirements identified in the HSE assessment of need.

In 2016, the HSE established a forum involving representatives from the - National Community Care Network, NCCN - the for-profit sector - Home and Community Care Ireland, HCCI - and the HSE to discuss home support service issues and to inform the sector of future developments. The forum has been a useful mechanism over the past two years for the sharing of opinions and addressing concerns.

The HSE is also recruiting staff to create audit teams across the nine CHOs. These teams will have the skill set to audit service provision and ensure that the tender service specifications required of successful providers are being implemented. An audit team is being appointed in each CHO, with an initial focus on external providers. Thereafter, the teams will support HSE direct service provision to improve quality standards.

A capacity review was conducted by the Department of Health. It identified that demographic changes during the period up to 2031 will see the population of those over 65 years of age increase by 59% and that of those over 85 years of age increase by over 95%. The scale of these demographic changes, linked to the Sláintecare recommended shift to community-based services, indicates that the scale of service developments required for home support will be in the range of between 70% to 120% by 2031. Meeting these service development targets will require forward planning in order to ensure the availability of the workforce required to deliver the quantum of service and facilitate the training requirements of the workforce to deliver on the service standards, as well as the funding mechanism required to support it in the context of a new scheme. There is a need to ensure that the oversight requirements necessary for such a comprehensive shift of service to the community is achieved safely and with the additional supports in primary care and other services that will be required.