Mr. John Dunne:

Family Carers Ireland, FCI, is a national charity that works to improve supports, services and recognition for anyone living with the challenges of caring for a family member or friend who is ill, frail, disabled or has mental health difficulties. We say this because traditionally there has been a sense that family carers look after old people. but we have a much bigger agenda than that. We engage with more than 20,000 families each year. We also deliver 350,000 hours of home care every year, which gives us an insight into the operational aspects of caring. I would like to formally say that we are a member of the Home Care Coalition and support its goals. We also support many of the points put forward by HCCI.

Our position engenders a slight degree of confusion. When Mr. Musgrave spoke about labour and manpower shortages he was speaking about carers. Under Government policy, carers are unpaid. Care workers and care assistants are people who work in the home. There is a lot of confusion when people talk about caring, and it is very important that this committee is clear about it. Our agenda concerns the co-production of care, because we would maintain that the State has no remote prospect of being able to afford home care without co-production with unpaid family carers. Taking the CSO's estimate and charging it up very conservatively, families provide €10 billion worth of unpaid care in the home. The irony is that the way policy is going threatens to strangle that care and reduce it instead of helping it.

We are encouraged by the emerging themes which the Department of Health has abstracted from the first phase of its consultation. However, there are a number of issues which are causing real concern, mainly because they are not being discussed as opposed to there being a lack of consensus on them or that they are going in the wrong direction. The nature and purpose of home care will have to be defined in the legislation. We believe the legislation will seek to place primary responsibility on the family, with the State in a supporting role. We agree that is the right way to go and would command widespread support. Unfortunately, the HSE recently seems to have set its face firmly against this approach. I do not have time to develop this point in my opening statement, but I would suggest that there is a real prospect that the State will end up spending several hundred million euro extra because of the direction this is taking, with no increase in home care services.

There has been much talk about a funding model. In the initial stages, when the legislation was being proposed, there was almost a rush in the direction of co-funding. Our position is that we recognise that co-funding will be required in some shape or form. We are not willing to talk about co-funding the current system; it is completely unacceptable. The debate must focus on what we are trying to fund. Standards for home care must be defined and a model for home care found before we discuss how it is to be funded. A lot of current discussion centres on wonderful models from overseas. There has been quite a lot of discussion about the German system, for example. It is excellent, and is based on a very sophisticated insurance model. For example, if one does not have children one's insurance premium is higher, on the not unreasonable assumption that when a person is older there will be nobody to look after him or her, whereas if a person does have children they are required to under the German system. An insurance based system was first floated in Ireland decades ago. There has never been evidence of a political appetite to address it. We believe it is an interesting model to explore, but the reality is that good systems cannot be delivered without a proper funding model. Trying to fund this by way of means testing via taxation is never going to work.

As HCCI has said, there is a crisis in the staffing of home care. That crisis is going to get worse. We absolutely do not accept the ESRI and Department of Health-HSE projections because they are based on a steady-state situation. Over the next ten years, as part of the demographic shift, unless the ratio of family carers is increased from one in ten to one in five, we will have to provide massive numbers of extra paid care. That has to be built into a policy and thought about carefully, but it is not being mentioned or discussed.

The other elephant in the room is that the HSE itself is massively conflicted in terms of the delivery of home care. I do not say that as a cheap shot at the HSE. Many of the problems are not of its making, but rather are failures of policy. We should consider that. The HSE is a major direct provider of home care services throughout the country. It delivers services on the basis of historical funding patterns, meaning that consistent service planning and delivery is problematic. The current CHO system, where each CHO has an independent accounting officer and therefore a degree of operational autonomy - which the new regional integrated care organisations, RICOs, will also have - means that it is still practically impossible to achieve a consistent framework across the system.

The HSE places an emphasis on home care, yet I would argue that when it comes to service delivery the priority is secondary to the priority it accords to its own internal industrial relations. That must be named, acknowledged and discussed. I am happy to be proved wrong, but I do not believe I will be.

An effective system for dealing with grievances and complaints is essential to ensure quality home care services. We are dealing with individuals who are at the front line, with enormous independence and autonomy who usually work unsupervised in someone's home. HSE systems in this regard are unfit for purpose, which is a direct result of arrangements set by the Government, not by the HSE.

As I understand it, the HSE wrote to the Government two years ago asking for those policies to be changed. That does not relate just to home care; it relates across the system. There has been no movement on that but there needs to be movement in that regard. In our case, if we have a complaint it is signed and sealed within 30 days. That can include either the rejection of the complaint, the person is dismissed or anything in between. We have seen cases in the HSE where a similar situation has dragged on for years. There is no reason for that to happen. Furthermore, because of differential arrangements mandated by the HSE regarding working conditions for its own directly employed staff and for the staff of commission services, the hourly cost of direct provision is up to twice the cost of commissioned services at current rates. That is a major discrepancy and potentially, if we want to look at it that way, a total waste of money. That is worth discussing as well but I do not have time to develop it now.

In terms of commissioning, Family Carers Ireland would contend that since commissioning was introduced in 2010 there has been a steady reduction in baseline quality indicators. When the shift to a lowest common denominator home support specification is put beside the increasingly complex cases now being assigned to the home care system, it looks to us like a serious accident waiting to happen.

Far from saving money, we believe this year’s tender for home support services has resulted in avoidably higher costs of service because of the extent of gaming of the scoring system that was allowed in that tender. To be clear, I am not suggesting anything that happened was unlawful. I am just saying it was very bad policy.

On regulation, the Health Information and Quality Authority, HIQA, was originally scheduled to have assumed responsibility for regulating home care by 2016. There is not even an alternative date in place. The implications of failing to adhere to this timetable are not even being discussed or addressed, possibly because a HIQA survey in 2017 showed that 76% of people responding to the survey thought there was independent regulation in place. I am sure the HSE would rather not be the regulator but if one is the regulator, the commissioner and the direct provider, one has a massive conflict of interest.

This is, inevitably, a very high level review of issues, with five minutes to do it, relating to improving home care. I will be happy to discuss any of the points later.