Dan Neville (Limerick West, Fine Gael)

I welcome the opportunity to contribute to the debate. The legislation puts the existing subvention scheme on a statutory footing and aims to assist the Health Service Executive in standardising the scheme. There was no consistency between health boards in applying the scheme and this was unacceptable because people were being treated differently and there was discrimination in how it was applied in different areas. The problems with the nursing home subvention were outlined in the review of the scheme. The manner in which the means test was applied varied and different practices were used in applying enhanced subvention and the use of contracted beds.

The subvention levels set out in the legislation are not the maximum that applies and I expected the Bill to outline the criteria that would apply for the provision of enhanced subvention. The Bill correctly ensures standardisation of practice and rules but where is the standardisation of the enhanced subvention? Enhanced subvention is provided up to a maximum of €680 a week but that amount has never been paid in the HSE mid-western area with €200 a week being the highest amount paid. Will the Minister of State comment on this? The payment should be related to the cost of the nursing home care, given the different charges imposed by nursing homes. There is a wide variation in charges in homes in my area with them costing between €600 and €1,000 per week. At one stage, enhanced subvention was not paid at all but that practice has ceased. Contracted beds are not provided in the mid-west, except under the winter initiative, which provides that people are cared for in a nursing home for two weeks following hospitalisation. Should the use of contracted beds also not be standardised? The number of such beds varies between HSE areas and it reduces the opportunity for patients to avail of public beds in private nursing homes.

The primary legislation covering nursing homes is the Health (Nursing Homes) Act 1990, which provides for the registration of most private nursing homes and for standards to be set and monitored. The issue of monitoring has been debated at length in recent times. It is important and the Minister of State has recognised the need to invest in ensuring proper monitoring of nursing homes. As previous speakers said, 95% of nursing homes provide excellent care and service and they are of great benefit to communities. However, a small number require attention. A proper monitoring system would ensure standards are at an acceptable level.

The rules of the subvention are currently contained in the Nursing Homes (Subvention) Regulations 1993, as amended. Changes in the means test for nursing home subvention came into effect on 14 December 2005. This was the first time the threshold set in the 1993 rules were changed. The Bill does not propose major changes in the rules, but it does provide for some changes. One may get a nursing home subvention from the HSE if one wants to go into a private nursing home. In order to qualify for a subvention, one must be sufficiently dependent to require maintenance in a nursing home and be unable to pay any or part of the cost of maintenance in the home. In other words, a person must pass a means test. The amount of subvention depends on the means and the degree of dependence. The subvention is meant to help meet nursing home costs. It generally does not meet full costs, but there are circumstances in which the HSE may pay an enhanced subvention.

I know of a pensioner who has been refused a public nursing home bed and who lives with his wife, also a pensioner. He is currently in the step-down facility under the winter initiative. He is incontinent and he falls quite often. He will be forced to go back to live at home with his wife, who has serious ulcers in her legs. As they only have the pension, the only option is to bring him home. In a short time he may fall again and be back in hospital. We see these decisions being made all the time. I recently put down a question on the criteria applied to decisions made in granting access to public beds. There does not seem to be consistency in granting access to public beds in places like St. Ita's Hospital or St. Camillus's Hospital in Newcastle West in County Limerick.

Under the current rules, one must apply for a subvention before going into a nursing home, unless there is an emergency. If one goes into a nursing home before one applies, he or she may not be allowed to apply for two years unless the HSE decides otherwise. I do not understand why that is the case. However, I note that this provision will no longer be in the Bill. At any rate, it was rarely applied and it was more honoured in the breach than in the application. People often went into nursing homes shortly after being released from hospital and the subvention was applied a day or two later. It makes no sense that if one failed to apply immediately, one would have to wait for two years. My interpretation is that this provision will no longer apply once the Bill is in operation.

One must be told the result of one's application within eight weeks. If one is refused a subvention or granted less than the maximum applicable to the level of dependency, the right of appeal is available and the person applying must be informed of his or her right to appeal.

An assessment of the level of dependency is carried out on behalf of the HSE, usually by a doctor, nurse, occupational therapist or physiotherapist. The assessment involves interviewing the person and their nearest relatives. The medical condition of the person is taken into account and the assessment also includes an evaluation of the person's ability to carry out the tasks of daily living and the level of social support available. The assessment of one's ability to carry out the tasks of daily living takes into account one's degree of mobility, ability to dress unaided, ability to feed unaided, ability to communicate, extent of orientation, the level of co-operation, the ability to bathe unaided and the quality of memory. This latter task will be replaced in the Bill by cognitive ability. There is a subtle difference between quality of memory and cognitive ability. One could have very difficult short-term memory but very good cognitive ability, and vice versa.

Social support is assessed by one's housing conditions, such as the number of people in the household and the ability of household members to care for the person. The extent of support from one's community and the services received are also taken into account. The Bill does not specifically mention the elements of social support, but states the family and community support available, as well as any other issue which affects one's ability to care for oneself, will be taken into account. There should be room here for more guidance and standardisation. There will be more variation from different inspectors and assessors on this issue.

An assessment team, appointed by the Health Service Executive and which includes people with professional experience in the care of dependent people, decides whether or not a person meets the dependency requirements for a nursing home subvention. There are three levels of dependency. Medium dependency exists when one's independence is impaired to the extent that one needs nursing home care because the appropriate support and nursing care required cannot be provided in the community, and the mobility of the person is impaired to the extent that he or she requires supervision or a walking aid. This is known as category III in the Bill. High dependency exists when the person's independence is impaired to the extent that he or she needs to be in a nursing home.

The following assets may be taken into account: household property, excluding household furniture and goods; stock, shares and securities; money on hand, in trusts, lodged, deposited or invested; interest in a company or business of any kind, including a farm; interest in land, life assurance and endowments; and current value of business equipment or machinery, excluding a car. A farm is a livelihood and I would like to see the reference to farms in the Bill developed. How is the ownership of a farm calculated? Many difficulties may arise in families if a person in a nursing home was forced to sell the farm. The person who makes such a decision may be the person in the nursing home. Such a decision could cause much stress to the person.

If one disposed of assets in the previous five years, the value of those assets may also be taken into account. The first €11,000 in value of any asset is disregarded. The Bill does not clarify whether disposal of one's assets to help a son or daughter build a house, or to help the child of a married son or daughter, will be taken into account.

How can a parent seek repayment of the money he or she spent on buying a site for a newly married child? That, however, is implied by the provision that the disposal of assets will be taken into account when assessing nursing home subventions. Such assets may comprise stocks or shares, cash or mature life assurance or endowment policies. Parents may divide their assets with their children only to be asked to recover the money the money four years later.

The principal private residence is not taken into account if it is occupied immediately prior to the application and continues to be occupied by the spouse, a child under the age of 21 or in full-time education or a relative in receipt of disability allowance or a blind, disability, invalidity or old age non-contributory pension. A person may leave work to care for an elderly person but, if he or she leaves the carer's allowance scheme to receive unemployment assistance, the house will have to be sold because its value is taken into account in calculating the nursing home subvention. According to my understanding of the Bill, it does not take account of carer's allowance or unemployment benefit or assistance.

A neighbour of mine left work at the age of 35 and spent the following 20 years caring for her parents. When she turns 65, she will not be entitled to a contributory pension but, as a matter of principle, she refuses to accept the non-contributory pension. Having cared for her parents for more than 20 years, she feels entitled to the same rights as somebody who remained in full-time employment. A committed and intelligent person, she made the choice of caring for her parents. People leave work and, for example, move back to Limerick from Dublin to care for somebody for two or three years. An in-law of mine could no longer continue to provide care in the home because of serious health problems and will now be forced to sell the house because it will be taken into consideration when the nursing home subvention is calculated.

Under the current rules, if the house is not occupied by any of the aforementioned categories of people, its value may be taken into account. If the value of the house is taken into account, it is assessed at 5% of the estimated market value, net of mortgage, loan, rental or purchase repayments. Variations existed among health boards in terms of how houses were treated for the purpose of means tests. The Health Service Executive cannot require a person to let or sell a house but a subvention can be refused on the basis of the value of a house. If the house is sold, the proceeds are taken into account in the assessment of means. Houses now cost at least €200,000, so somebody on social welfare will have no choice but to sell it and join the local authority housing list. The Bill provides that the house must be taken into account unless it is occupied by the aforementioned categories of people.

The HSE may refuse to pay any subvention if the assets, including the house, are greater than €36,000, the principal residence is valued at greater than €500,000 in the Dublin area or €300,000 in the rest of the country and income is greater than €9,000. People earning €200 per week will therefore be obliged to sell their houses, even though it is barely possible to survive on €10,000 per year. They must pay for nursing home care because they inherited their residences. Houses in my area which cost €5,000 when first built are now worth up to €200,000.

See this speech in context