Dan Neville (Limerick West, Fine Gael)

I welcome the opportunity to speak on this Bill and prior to discussing the issues of concern I will put it into context. In December 2006, the Minister for Health and Children announced the fair deal which is the new funding arrangement for long-term nursing home care. People are expected to contribute to the cost of their care based on an assessment of their income and assets. A person is expected to make a contribution of up to 80% of assessable income and up to 5% of the value of any assets in excess of the asset disregard per annum. The asset disregard stands at €36,000 for an individual and €72,000 for a couple.

If the assets include land and property, the 5% contribution based on such assets can be deferred. This means it does not have to be paid during the person's lifetime and may be collected once their estate is settled. In the case of the principal residence only, the deferred contribution will be capped at 15% of the value of the principal residence for a maximum of three years. The charge on other assets is not capped but will apply for the duration of care. However, this charge will not exceed the cost of care. It would not make any sense if it did.

Somebody with a small amount of land valued at €100,000 could have it all confiscated if he or she was in a nursing home for five, six or seven years. This is my interpretation of it and I believe it is the only way it can be interpreted. Many families will be upset if they are forced into this situation.

For the first time, this scheme will offer a uniform system of financial support for individuals in public and private nursing homes. Under this plan, the practise of assessing the income of children will cease. I understood this has not been taken into consideration for a considerable number of years because it was found to be unfair by the High Court.

The Government was woken up with regard to issues for elderly people when it took away the medical card from all those aged over 70. They have presented themselves as a cohort of people who are extremely vocal, many of whom are educated and with great life experience and they will ensure their rights and services will be protected. I sincerely welcome this.

Many of the people who retire at age 65 or 66 have PhDs, masters and other degrees. Many of them served in senior management positions and supervised in industry and commerce or were senior civil servants. Many of them worked hard to rear their children. They have a vast amount of knowledge and experience of life. We must question how this resource is dispensed with when they reach the age of 65. There must be a way to ensure we use the talents and experience of our retired people as much as possible. They have a vast amount to contribute but their life experience, including family life and education, is interrupted and abandoned when they retire. It makes no sense. To put this in context, the number of people greater than 65 years of age has increased by 7.3% since 2002, is expected to increase by more than 800,000 by 2025 and to have tripled by 2050. Life expectancy in Ireland is increasing and now exceeds the European average.

Private and voluntary nursing homes provide in excess of 65% of long-term care beds. By the end of 2007 there were 18,883 private and voluntary nursing home beds in Ireland, an increase of 26% from the 2003 figure. There is one private and voluntary nursing home bed for every 24.8 persons aged 65 years and over. The average weekly cost of a bed nationally throughout all areas and all room types, including single, double and multiple bedrooms, was on average found to be €778. The highest average weekly rate was noted in the north-east coast and the south west. Average rates were found to be €966 in both the north east and the east coast. The lowest rate was in north west where the average weekly rate was €607.

I raise our concerns with the Bill. It is necessary to make changes in this area for the reasons already outlined. The Nursing Homes Support Scheme Bill 2008 stipulates that the fair deal scheme, to which other Deputies have referred, is resource capped. We must understand the implications of resource capping the scheme. This will inevitably lead to waiting lists for support. It is also possible that family members will be called upon to fund the difference.

Income tax relief on nursing home care has been reduced to the standard rate. How does the Minister propose to deal with the inevitable waiting lists? Does the Minister of State at the Department of Health and Children, Deputy John Moloney, anticipate family members will continue to pay up while we wait for funds to be freed up? Perhaps the free up of a bed will come about as a result of the death of a resident in a nursing home. Under the existing system, people receive some contribution to the cost of their care, even if this must be supplemented by the person's family. Under the new proposal in this Bill, older people could be left with nothing and with no certainty about when funding might be available.

The Minister announced that responsibility for contracting beds in nursing homes and agreeing fees will be given to the National Treatment Purchase Fund. The stated purpose of this is to keep costs down. Nursing homes will be required to negotiate with the National Treatment Purchase Fund if they wish to be approved as a provider under the scheme. There is an inherent contradiction between the challenge faced by the National Treatment Purchase Fund of keeping the cost of care down and the role of the Health Service Executive in ensuring high standards are met. Quality must be determined by the prices set by the National Treatment Purchase Fund. If the National Treatment Purchase Fund sets prices, it will probably lead to a race to the bottom as nursing homes cut costs to fill beds. This is a real possibility in parts of the country where there is an over-supply of nursing homes. It is vital that standards of nursing home care are put in place as a priority. This was highlighted again and again by my colleague, Deputy Fergus O'Dowd, following his investigation of standards in nursing homes. There are very good nursing homes and, with my family, I have experience of dealing with very good nursing homes.

Questioning the standard of nursing homes is not a reflection on those who provide top-class care and sometimes these generalisations are applied to those who provide excellent care, which should not be the case. Questioning the standards in nursing homes does not imply there are issues in general, but there may be specific cases and it is very important to address these.

Good nursing home care cannot be provided on the cheap, but it must not become prohibitively expensive. In each January of recent years I have encountered people who say the cost of nursing home care for a parent, brother, aunt, wife or husband is being increased by too much and this creates a problem. We must know what the cost will be of implementing the recommendations contained in the draft standards of residential care settings for older people. This was submitted to the Minister by the Health Information and Quality Authority, HIQA.

It is more than three years since the Leas Cross nursing home scandal was exposed and we still do not have standards for nursing home care. It is important these standards are finalised and enforced as a matter of priority. Will these standards apply compulsorily to private and public nursing homes and, if so, will there be a timeframe for their implementation? When will the regulatory impact assessment be completed? How will the Minister ensure public nursing homes, which are often older than private nursing homes, are able to cope with the cost of meeting new standards? Has HIQA been given adequate funding for 2009 to register and inspect nursing homes? Will the Minister of State outline the funding provided to inspect nursing homes next year? When will the inspection begin? What is the position regarding the recruitment of staff to carry out inspections? Should the scheme go ahead in the absence of standards for nursing home care? Should the Bill be extended to include private care provided in the community?

Privately provided care in the community enables people to live in their own homes for as long as possible. Care services may include assistance with trips to the doctor, reminders to take medication at the correct time, meal preparation, house-keeping, errands, shopping and companionship. Most important, these services allow people to maintain independence while they age in the home in which they have lived all their lives.

I am interested in the home care package scheme, which is a very effective intervention to assist elderly people who would otherwise be in a very expensive nursing home. I have seen some of my family leaving a public nursing home following a stay of six, eight or ten months, returning home under the home care package and some three or four years later these people are still at home. Without the package, such people would still be in a public nursing home. Will the Minister of State and the Department of Health and Children seriously consider how this cost effective, socially beneficial scheme can be extended? The scheme allows people to remain in their homes for the latter days of their lives and continue to interact with their neighbours and family. The alternative is to stay in a private or public nursing home with additional costs for the State.

There are occasions when a person's medical needs and level of dependency would not normally warrant admission to a nursing home. Nevertheless such a person may opt for nursing home care, because the person may not feel safe in the home and seek increased security or may even seek companionship. This is especially the case in a rural area, such as my constituency, where people feel more and more isolated for many reasons, such as changes in society, changes necessarily introduced which make it difficult to travel to the bar and others on which I could expand. When I was a young person, there was no such thing as a letterbox in the door in rural areas. The postman knocked at the door and interacted with people. This implied a relationship among remote and rural people who had contact in a general way. That is all gone now, as the Minister of State knows. The post-box at the top of the road and all the services that were there, as well as the neighbourliness and social connections, are gone. Society has changed dramatically in rural areas. Sometimes we do not know our neighbours, although everybody knew everybody else in the past. The Minister of State, who comes from a rural area, understands what I am talking about. People will go into nursing homes for companionship. If something happens in an area, such as an old person being broken into, beaten up and robbed, elderly people around the area will want to leave for safety's sake, whether they are 80 or 85 years of age. They will not feel happy or safe. They want to be around people and thus they will decide to go into a nursing home.

Under the new scheme, the care needs assessment criteria for admission to a nursing home will become much stricter, which means that only highly dependent older persons will be admitted to nursing homes. Although there is some scope for taking social factors into account, it is not clear, considering the possibility of resource capping, whether such people will avail of the scheme. Perhaps the Minister of State will inform us of the Government's approach to this. It is important that this assessment is flexible and responsive to people's medical and social needs, and that the scheme is adequately funded to cater for those who wish to avail of it. I would sincerely like the Minister to put this on the record. We may have to refer to this in future when we are dealing with very serious social cases in our own areas, and we would like to have a record of the attitude of the Minister in the House when the issue was debated.

Older people whose treatment needs have been met in an acute hospital are being discharged to nursing homes under a scheme known as the delayed discharge initiative, DDI. This generally applies to persons who have spent reasonable lengthy periods, sometimes months, in acute hospitals. I welcome this because it frees beds to be used by people on waiting lists. Some of the nursing homes are very well equipped, while others are less so. I appreciate that only selected nursing homes have been approved for such admissions. Approval is generally based on the capacity of the nursing home to provide suitable care for high dependency residents. In previous years, funding for such beds was provided by the HSE. It now appears that payments under the DDI are being made by the hospitals. In order to minimise the cost to the hospital budget, older people are being offered places in nursing homes which are at a distance from their family homes and communities. Again, this has social implications for the elderly. Many older people from Dublin are being placed in nursing homes in other counties. There have been cases in which older persons and their family members have not accepted the places offered. This is perfectly understandable in certain circumstances. It is not appropriate to place older people in nursing homes which are distant from their friends, their families and their communities and in locations without public transport, making it difficult for people to visit.

A further complication is that at least some hospitals are refusing to make any payment where the older person does not accept the nursing home chosen for them by the hospital. This places the full burden of the costs on the older person and his or her family. If this is a precursor of what we can expect when the fair deal scheme is implemented, and the National Treatment Purchase Fund is negotiating contracts with nursing homes, then it is to be deplored and opposed. Older people must not be deprived of their right to go to nursing homes which are close to their families. While some limitations may need to apply to a hospital, the NTPF must not have a veto on this matter.

Assets that have been transferred at any time over the five years prior to the date will be included as means. With regard to assets transferred prior to 9 October 2008, the person may make an application to the executive to recalculate the means on the grounds that it is necessary to do so to avoid undue financial hardship. According to section 16, the amount of ancillary State support paid back shall be paid back with interest. Moneys advanced by the executive shall be aggregated and the consumer price index for mid-December in that year shall be taken to be the base figure.

If nursing home promoters and developers continue to seek economies of scale by building bigger and bigger nursing homes it will only serve to further diminish the quality of personalised care to which an older person is entitled. There is no overall strategy for the nursing home sector. Many nursing homes have been built over recent years with the aid of significant tax reliefs. The free market economic philosophy allowed many of these to be built in isolated areas or areas where land prices were cheap. Too many of these nursing homes are far from services such as GPs, pharmacies and physiotherapists. They are far from churches, shops and other amenities, even if there are diminishing numbers of nursing home residents who can avail of these.

In general, I welcome the Bill. Many questions have been asked during the debate and I look forward to the Minister's response. If the Minister intends to respond this evening, I will be at the Oireachtas Joint Committee on Health and Children with the Minister, Deputy Harney, and Professor Drumm, so I will read the response afterwards.

See this speech in context