Olivia Mitchell (Dublin South, Fine Gael)

I welcome the opportunity to speak on this neglected issue and thank our colleagues in the Technical Group for bringing it forward. Already we are sensing a crisis in the area as social trends and the geographical dispersal of the extended family increasingly make care of the elderly something that must be planned and budgeted for in a way that did not happen in the past. One must add to that the fact that there will not only be more of us over 65 years of age; those of us who reach old age will live longer. We will, therefore, have a greater level of dependency, and the challenges for families and the State will grow to crisis proportions.

I want to speak primarily about nursing homes, but I also want to emphasise that they should always be the option of last resort. Home is best, and should always be the focus of investment in maintaining and sustaining independence for as long as possible and developing a continuum of care options for people, including home helps, community nursing, carers in the home and forms of sheltered accommodation as appropriate. The alternative to the nursing home is not just the cheaper but the better option. It is the option of choice that maintains dignity, independence and companionship for the elderly.

The erosion of existing community services and the failure to plan for and provide the paramedics and therapists needed to support people in their own homes, the failure to recognise the role and contribution of the vast majority of carers, and the almost total collapse nation-wide of the disabled person's grant are all symptoms of a lack of commitment to the home first principle and of a Government seeking to make short-sighted savings at the expense of a group that is largely invisible, silent and often very difficult to identify statistically. However, they do not remain hidden or silent, since eventually they turn up at accident and emergency departments in a crisis situation and require long stays in hospital. When they are eventually ready for discharge there is no supportive community and certainly no State supports to discharge them into. That is why we have the phenomenon of medically well people occupying acute hospital beds while their friends and neighbours are at the other end of the hospital seeking acute beds for their treatment.

I want to return to how families resolve that impasse in hospitals later. However, the lack of options for families such as community care, targeted or sometimes even temporary supports in the home is resulting in people going into nursing homes and choosing them as the first rather than the last resort. They are going into nursing homes far too early in many cases when they are well enough — or would be with a little support — to stay in their own homes for much longer. Ultimately, they end up in nursing homes leading far less independent lives than they could otherwise with a little support. At the same time, their resources are drained away, as are those of their families and the State.

The sum of €12 million was recently provided for additional nursing home places, but it had virtually no impact. The effect was once-off, after which the beds simply filled up again. It was because the turnover in nursing homes is extremely low — far lower than it should be. People are spending far longer than necessary in nursing homes. Some people will need nursing home care eventually and there will always be a percentage of the elderly population that will require a bed in a nursing home. It ranges from about 3% to 6% across Europe. As a society we must urgently address how those beds are allocated to people and how they are paid for. The crisis is developing rapidly and will get worse. Already spiralling nursing home costs are putting appalling pressure on families as the gap between the State subvention and the cost continues to grow.

Equally, I do not deny that the cost of subventions on the State is also growing. In 2001, the State paid €52 million in subventions. A scant two years later, the ERHA alone paid out €70 million in its area. Every year that burden, both public and private, will continue to grow. Already what was forecast in the review of the nursing home schemes completed in 2001 shows that we have completely underestimated the growth in costs and numbers of those requiring nursing home care. It shows the immediacy and urgency of the problem and the need to address it before the entire system collapses in tatters.

The debate that has taken place so far has been about who should pay in future. I regard that as secondary to establishing who is paying now. Unbelievably at present, we do not know who is paying, how much they are paying or why. Bed allocation and subvention decisions are chaotic, arbitrary and grossly unfair. The only determinant now of whether someone gets a free bed is luck. It is not a question of income, wealth or even knowing the local Deputy. It is not family or insurance but luck. That luck can, of course, be influenced by such things as geographic location. For instance, there is a far greater preponderance of public beds in the North Western Health Board area than in the eastern region. However, even within those regions, it comes down to luck.

That can be improved by timing, for instance, if there is a winter initiative or a crisis in hospital beds which results in money going into nursing homes. It may also be a matter of who is making the decision on the day. People with exactly the same circumstances and means are treated differently depending on where they live or what week they apply. Some get a free bed, and some get a totally inadequate subvention, even though their means may be exactly the same. Sometimes the only difference is the degree of determination of families to preserve their inheritance and keep their relatives in a hospital bed until they get a free public bed. They know that they either pay out or tough it out. The toughest people get the best deal. Others equally — and sometimes even more — entitled have to beg, borrow and steal, mortgaging their own homes and those of their families and generally making themselves into beggars to pay the costs of a private nursing home.

The Ombudsman says that everyone over 70 is entitled to a nursing home bed. The Government says that the entitlement is only to what can be provided within existing resources, and that those must be rationed out. That is reasonable, but let us do it according to some rules and a framework. The whole system at present lacks clarity, certainty and consistency, so that families are left floundering in crisis situations, not knowing what their choices are or even if they have choices. They are often without any information about what is available. Most people are responsible. They want to plan and budget, making choices within the options open to them. They do that in all other areas of their lives — education, insurance, their holidays. They want to do the same about their nursing care, and particularly regarding nursing home care at the end of their lives. They cannot, however, because there are no rules or framework. They cannot figure out their entitlements, and there is apparently no one to tell them what they are. They do not even know their own responsibilities.

We know that nursing home costs can wipe out the work of a lifetime for inmates — and not only theirs, since it can pauperise their children and their families too. The very least that we owe to the elderly is that they know their entitlements and what they are obliged to provide. The debate has focused largely on responsibilities for families, who have a moral responsibility to parents. In the vast majority of cases, people do not need to be told that. They know, and it is a labour of love for them. Most will go to enormous lengths to ensure the very best care for their families. That is as it should be.

However, that should not be their legal responsibility. Young couples with mortgages and children have enough problems, legal responsibilities and calls on their resources. If they can afford it, they will do it, but it should not be a legal requirement. Responsibility for care of the elderly should be shared by the State, to which the elderly have contributed all their lives, and where an income or asset is not being used, that should be shared with the patient.

Inheritance is a hugely emotive issue in this country, but nevertheless, the patients have first call on their assets, and their first responsibility is to themselves. People save all their lives to ensure some comfort in their old age. We would all like to think that we will do that, and we would also like to think that we will be able to pass on something to our children — the fruits of our own labours — at some point in the future. There is no reason that shared responsibility could not enable that. For instance, in many countries where assets exist, an imputed rent is calculated, and the patient pays for that for a defined number of years — three, five or whatever we find appropriate. If the patient lives beyond that, the State should take over the cost of his or her care. Such a back-loaded system would also encourage governments to develop community care services to ensure people stay out of nursing homes for as long as possible.

The important issue I wish to raise is that clarity and certainly in respect of entitlements and responsibilities is an absolute necessity. However, it is completely absent and is causing crisis situations in our hospitals. People are inappropriately placed and are not receiving good nursing care in hospitals when they could be in their own homes supported by community facilities. If an individual needs a nursing home bed, they should be able to get one but he or she must know their entitlements and responsibilities. If we do not have clarity, we will never resolve this situation.

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