Ms Allison Metcalfe:

I thank the committee for inviting us to provide an overview of the home care sector on behalf of HCA and Carers Ireland. I am joined by my colleague, Mr. Conor McCarthy. We represent professional carers working in the industry. We thank the committee for choosing to focus on the regulation of future planning in home care provision. HCA and Carers Ireland was established in 2016. We are a platform for professional carers and health care assistants to provide support, enable dialogue and share the experiences that they face every day in seeking to provide quality service. This has proved to be an essential platform in combatting the isolation that many carers feel when working in this sector. Currently, we have just under 16,000 members.

In 2011, the Law Reform Commission, LRC, recommended regulation of home care, and we are happy to support movement in this regard. We believe a sector providing care needs to be regulated by an external body. Our home care sector is in crisis. Professional carers are leaving the sector every day, with precious few being attracted to replace them. This exodus is reflected in the increasing waiting list for home care packages, which currently stands at more than 5,000 people.

Carers are used inefficiently, as they often work with several providers and cover large geographical areas, resulting in them spending large amounts of their time travelling rather than being with the clients. Considering the demand coming down the tracks, the situation is even more worrying. The recent ESRI report on the future demand for healthcare predicted an increase of more than 50% for home care over the next 12 years. The recruitment and retention problems, which both the for-profit and not-for profit sectors are facing, together with their inability to meet demand, have many serious consequences for people needing care and for our health sector in general. First, the high turnover of carers that providers are experiencing has serious consequences for the quality of care they provide. Continuity of care is one of the principal tenets of quality home care and if the carers for people are changing every few months, the quality of care will be seriously affected no matter how much supervision or governance is in place. Second, if we do not have capacity in home care, this increases the pressure on our hospitals and results in more delayed discharges and a huge drain on the health budget. It also pushes more families towards residential care under the fair deal scheme, which is generally not their first choice. Most people's first preference is to continue living independently at home for as long as possible.

The reasons for the severe shortage of carers in the sector are many, but there are two principal ones. The first is poor employment conditions. On average, professional carers are paid €11 per hour for contact time with clients while many get no travel expenses. This appears to be a pittance given that providers are generally charging €26 per hour for their services. While we understand that there are costs to be covered, these margins are excessive and are putting too much money into the pockets of the providers. They say that the HSE needs to change how it commissions care for them to improve carers' employment conditions. This is just passing the buck. The published accounts of many of these providers show a high return to the owners in comparison with what they are paying their carers. The required change has less to do with HSE commissioning and more to do with profit.

The second reason is that there is little guarantee of work. Most working carers are on if-and-when contracts. This means carers have no guarantee of work and no visibility of earnings to allow them live a normal life where they can plan ahead for holidays and mortgages like the rest of society. These type of contracts enable providers to treat their most important asset, their carers, as a variable cost to be turned on and off at their whim. With increasing waiting lists for home care packages, there is no lack of demand or worry about where the next client will come from. What is the justification for not giving carers guaranteed hour contracts?

To address the capacity crisis and make caring an attractive career, the employment conditions of carers, principally their pay, must radically improve first. This is not so much a need to increase funding but rather to ensure that more existing funding goes to front-line workers and not to the company owners. A happy, well-rewarded carer is the best guarantee of quality home care provision. Providers will not give up their attractive profits easily and, therefore, they must be encouraged to do so. Unfortunately, the recently published HSE home care tender missed an opportunity to insist on a minimum wage for carers who provide HSE-funded care. In the absence of this, why can we not have a joint labour committee for home care that sets and regulates what carers should be paid? Another way of encouraging providers to treat their carers better would be by giving clients the choice of either a commercial provider or directly employing their own carer using the same State funds in a tax compliant manner. Providers talk a great deal about governance and supervision issues when discussing carers working directly with families, but they forget to say that because of their poor record in retaining carers, their supervision is carried out on a different set of carers each time. Continuity of care is perhaps the most important component of delivering quality home care.

Second, many carers are limited by our rigid social welfare system and are prevented from taking on more hours for fear of facing a sharp drop in benefits. Why can we not make the system more flexible and move from one that only considers the number of days worked to a total hours-based system, and which tapers the drop-off in benefits in order that carers are encouraged to take up more work?

Third, carers must be paid for travel time as well as travel expenses. We must enact in Irish law the European court's ruling in the Tyco case whereby mobile workers with no fixed place of work such as carers are paid from the moment they leave their homes. Carers should also be paid for the wear and tear on their cars. These changes would encourage care to be delivered locally.

Fourth, the number of 30-minute visits to those cases where there is a compelling clinical reason must be limited. Currently, 30-minute visits are used to spread the home care budget.

Finally, the training and upskilling of carers must be funded. Currently, providers do not pay for carers' training. Carers are expected to fund their own training. The State must set up a fund to pay for carers who wish to upskill and progress their careers. The fund should not be channelled through providers but directly to carers themselves. Carers need to be able to see a pathway of career progression through upskilling.

In summary, regulation in home care provision is overdue. External monitoring is required to ensure standards are met. Caring should be made a more attractive career, which will allow the sector to participate fully in the overall health sector. The power of providers must be rebalanced in respect of carers. The best way to do this is by the HSE truly valuing front-line workers by ensuring more funds find their way to the carers and offering choice to families regarding the care they receive.

I welcome any questions from members.