Thursday, 20 November 2008
Nursing Homes Support Scheme Bill 2008: Second Stage (Resumed)
Denis Naughten (Roscommon-South Leitrim, Fine Gael)
I welcome the opportunity to discuss the Bill. The majority of Deputies will contribute, as we all must address the issue daily. Each of us has familial and constituency experience of it. As valuable contributions are being made, I hope the Minister of State and her colleagues and officials will take note of points made by all sides of the House.
In December 2006, the Minister for Health and Children, Deputy Harney, announced this proposal. It was just before an election. However, the proposals will not be in place until at least 2010. It is complex legislation and a number of issues must be addressed. The assessment of need and financial assessments are of concern.
As a public representative, I am galled by something flagged by Deputy Chris Andrews, namely, the theory that the HSE is responsible for the entire country. There are greater discrepancies in terms of entitlements than there ever were under the old health board system. The HSE has been an unmitigated disaster and the Ministers in charge should put their heads on the block for their incompetent implementation of the HSE's establishment.
I will cite two examples of care of the elderly, one of which concerns two sides of the same road in south County Roscommon. In Athlone, a white line in the middle of a road marks the county and provincial boundaries and the boundary between HSE, western area, and HSE, Dublin-north Leinster area. The eligibility for an enhanced subvention differs depending on what side of the white line one lives on. At the edge of Ballinasloe ten miles away in HSE, western area, there is a discrepancy between sides of the road despite being in the same region. An elderly person from the County Roscommon side attending hospital is not entitled to step-down care in a nursing home after his or her release, but an elderly person from the other side of the road is entitled to that care because he or she lives in County Galway.
The same pertains to access to the Alzheimer's disease unit in Ballinasloe, which is a stone's throw from my constituents in County Roscommon. However, since they have addresses in that county and live on the wrong side of the road, they are not entitled to admission to the facility whereas patients from 50 or 60 miles away in County Galway are entitled. Greater discrepancies have come about since the HSE's establishment.
To be eligible for a bed, one must need care for a 12-month period. However, the Department of Social and Family Affairs, which is ruthless in its assessment of need, requires that someone seeking a respite care grant must be providing care for a six-month period. There is a discrepancy between the interpretations made by the Departments of Health and Children and Social and Family Affairs. The assessments will be carried out by the HSE and, according to legislation, provisions will depend on available funding. As the year progresses and demand for nursing home beds increases, the HSE will need to curtail its provision by increasing the medical thresholds for eligibility. Someone applying on 1 January will need to meet a lower threshold than someone applying on 31 December. This is what the HSE does. It is dependent on the level of funding, but there is no commitment to long-term funding to meet demand. This provision in the Bill is a significant problem.
The Bill is unclear in respect of the assessment of social need. In my constituency, isolation is a considerable issue because families, relatives, friends and even neighbours may not be available to provide support and care. The most galling provisions relate to assessments of community and home care supports. In County Roscommon, eligibility for home help support requires someone to be, according to the HSE, "actively dying". People who are "actively dying" have their families and friends around them. Likewise, people are not entitled to community supports unless they are "actively dying". Unless someone requires full-time care for a period of at least 12 months, he or she will not be eligible for nursing home care.
The Bill has some winners, namely, those with large capital assets in the form of houses and who may not have been eligible for public beds. The cap has been placed at 15% of a home's value. Nursing homes running on a low cost model will also benefit. However, a significant number of people will lose out. In my constituency, elderly brothers and sisters who have resided in family homes for generations will be rendered more vulnerable. They could have spent 70 or 75 years together. In many cases, one brother owns a farm while another brother maintains the house. The Bill does not make adequate provision for them. They are not considered a married couple for the means assessment because they are not having sex. Were they having sex, they would be eligible for assessment. In many cases of two brothers, a brother and sister, two sisters or so on residing in family homes, one is dependent on the other and does not have his or her own income or has a limited income. Such people will be penalised by the legislation.
The legislation's provision on clawback in respect of property handed over during the previous five years will put another group under serious pressure.
There is a major loophole in the legislation in respect of family-run businesses and family farms. The capital assets relating to such concerns are excluded from the cap set down under the Bill. As a result of this loophole, young family members will hound their elderly parents to sign over property or land well in advance of the age at which they will require care. These individuals will inform their parents that if they do not transfer ownership now or if they contract Alzheimer's or dementia, the property, land or whatever will go to the HSE or the highest bidder, namely, a neighbour, the bank or someone else. Major pressure will be placed on elderly couples throughout the country to sign over their property to younger relatives at a much earlier stage. This will have a damaging effect in many areas, including my constituency.
Part 7 deals with reviews and appeals. I hope the HSE makes a better fist of these matters than it did of those relating to medical cards. When a decision is made in respect of a medical card at present, the HSE does not believe it worthwhile to explain to the applicant how it arrived at a particular calculation. I have been approached by such applicants and I have been obliged to apply to the HSE on their behalf for a breakdown in respect of said calculation. This increases the level of bureaucracy and paperwork involved. When assessments are carried out under the terms of the Bill before us, I hope applicants will be provided with all the relevant details regarding the result of their assessments. They will then at least be in a position to make an appeal rather than being obliged to approach the HSE in search of information regarding how a calculation was arrived at before doing so.
An applicant's means will be assessed at 50% of a couple's combined income and assets. While that is fine in many cases, it does not take into account the real costs incurred by couples on low incomes. The cost of running a house will not be reduced by 50% because one member of a couple goes into a nursing home. While I accept that the costs relating to food will decrease, those for heating and electricity will remain the same. The figure of 50% in this regard is not accurate.
A significant number of people will lose out as a result of the implementation of the provisions of this legislation. At present, those in public nursing homes only pay 80% of their assessable income. These people will lose out under the new scheme.
Would it be possible for someone to investigate what I believe to be a financial scandal, namely, the lack of accountability and transparency regarding the massive nest egg relating to patient accounts that is being stored in Tullamore, County Offaly, by the HSE? For the next of kin or families of, for example, Alzheimer's or dementia patients, trying to discover how much money is stored in one of these accounts is similar to attempting to uncover the third secret of Fatima. It is not possible to access such information. It would be an improvement if statements were issued to families or next of kin regarding the amount held in patient accounts by the HSE at present. Everyone is aware that a new stealth tax is being introduced in the context of the service charge. However, there must be transparency regarding the contents of patients' accounts.
Among those who will also lose out are people who enter nursing homes but who may not be regarded as being highly dependent in medical terms. These individuals will lose out in respect of the tax relief available to them. The average cost to stay in a nursing home is approximately €50,000 per annum. This means that the tax relief proposed in the budget — I presume it will be underpinned by the provisions in the Finance Bill to be published later today — will be slashed from €20,000 to €10,000. For many families, €10,000 is a significant amount of money.
Nursing homes with a higher cost base will also lose out under the Bill because the resources available to fund this scheme will be capped. The National Treatment Purchase Fund, NTPF, will negotiate on behalf of the State in respect of the new contract beds and will seek the cheapest possible beds. The standards relating to nursing homes have still not been placed on a statutory footing. I refer here to the standards for residential care settings that were drafted by HIQA. We must ensure that such standards are put in place. If proper standards in respect of the care of the elderly are put in place, we can then proceed to examine the position with regard to the costs relating to nursing homes. Some nursing homes will not be able to continue to charge the rates they are charging at present and meet the standards laid down by HIQA. If the NTPF is exerting pressure in that direction, standards will drop and there will be a race to the bottom. In such circumstances, it will not be a case of trying to obtain quality care for the elderly in facilities that are as close as possible to their own homes.
There are those who provide care on a private basis in the community. I refer to facilities that are not funded by the HSE but rather by the fund-raising efforts of local community organisations. Such facilities are excluded from the legislation. The fair deal does not refer to care in the community. There is a gaping hole in the legislation in this regard. While there will be assessments in respect of the care that is available, the reality is that care in the community varies from month to month and year to year and is dependent on the level of funding that can be accessed.
As soon as the HSE begins to tighten its belt, care in the community will be the first area to be affected. As a result, elderly people will become ill and will be obliged to enter hospital. They will then not be able to re-enter the community because resources will not be available to allow for the provision of home-care packages. As stated earlier, they will not be able to access home help services either. Funding will not be available for these individuals to enter private nursing homes, except in circumstances where they require care for 12 months.
Let us consider the case of an elderly person who has a hip replacement operation and who, with intensive support, can return to his or her home and live independently. Due to the fact that there are no community physiotherapy services — posts have been created but appointments have not been made as a result of the ban on recruitment — and because home-care packages and the necessary home help structures are not in place, persons such as the individual to whom I refer are obliged to remain in acute hospital settings or enter nursing homes.
What happens to elderly patients who only require care for a number of weeks in order to recuperate and who do not require it for a 12-month period? At present, they can apply for a nursing home subvention and if they are eligible under the thresholds, they will receive it. Under the new scheme, however, they will not be eligible for the fair deal. As a result, there will be a significant increase in pressure on acute hospital settings.
There is an extremely high dependency ratio in my constituency because of the large elderly population living there. The county hospital in the area is the only facility of its kind between Roscommon and Galway which does not have a step-down facility to allow patients to move from acute hospital settings to nursing homes. I refer here to the beds provided under the winter initiative. A person admitted to Portiuncula Hospital or to University College Hospital Galway will receive two to three weeks' extra care. It is in the interests of family members not to send their elderly relatives to the local hospital, namely, the Roscommon County Hospital, but to send him or her to one of the most congested hospitals in the country, namely, University College Hospital, Galway, because a person admitted to that hospital can avail of up to one month's care in a private nursing home following their release from hospital. A person admitted to the local hospital will not get even one hour of respite care once they leave that setting. This causes an incentive to be put in place that will put further pressures on the acute hospitals setting.
The theory behind this legislation is good. I welcome that we are at last having this debate on the fair deal. While I acknowledge many will gain from it, there will also be many who will lose as a result. In the future, vulnerable elderly people and siblings in family homes will be left high and dry as a result of this legislation. Also, elderly people will be brow-beaten into signing over their assets at a much earlier stage than they intended.
What chance will an elderly person willing to sign over, say, a corner store, to a son or daughter wishing to expand or develop the business, have of raising loans with the banks if the State has a claw-back on that asset for five years? Banks will not release money and this will cause stagnation in regard to the development of small businesses in rural communities.