Joe Costello (Dublin Central, Labour)

I am pleased to have the opportunity to contribute to the debate on this Bill. Not many of us on this side of the House agree with the Minister that the so-called fair deal lives up to its name. The Labour Party has major concerns about some of the unfair aspects of the scheme.

The purpose of the scheme is to provide for those requiring long-term institutional care. The legislation is explicit in stating that it is intended almost exclusively for the care of the elderly. Individuals will be assessed on the basis of their care needs and also on a financial basis, and the scheme will be administered by the Health Service Executive. As Deputy Kehoe observed, the legislation envisages a funding allocation of €103 million, but only half that amount will be made immediately available. In total, the estimated funding requirement is €820 million. Therefore, the scheme is labouring under a negative equity before it is even operational, despite the fact that we have been examining this issue for a considerable time.

Section 5 of the Bill includes an enigmatic reference to the capping of resources, with the implication that the scheme will come to an abrupt end if there are insufficient resources to fund it. This is a strange way to put in place a scheme that is designed to deal with long-term institutional care and has many far-reaching implications for the individuals concerned and their assets, ancillary services and so on. It is a strange statement to include in the legislation. Will the Minister offer reassurance in terms of the viability of the scheme, with reference to how the subvention is being put together and the issue of resources being capped?

The provision of long-term residential care is a critical issue. All Members frequently encounter constituents who are experiencing difficulty in accessing long-term care, respite care in their homes and so on. Families are doing their best to provide support and to finance the care needs of their elderly relatives. In fairness to the Minister, she has at least made an effort to deal with this issue. However, it is ironic that virtually everything the Minister has touched has turned to dust. She has not been successful in dealing with any of the issues she identified as requiring action when she assumed her Ministry almost six years ago. Her first action was to produce a ten-point plan to deal with the crisis in accident and emergency services. After six months she said the crisis could not be resolved in such a short timeframe and that she needed another year or two to address it. Six years later, she is still addressing the problems with accident and emergency services. Reports in yesterday's newspapers indicate that the situation has deteriorated substantially.

The basic issue of management has not been addressed. Accident and emergency services continue to operate in a dysfunctional fashion. I am well aware of what is happening in my local hospital, the Mater Hospital, where the situation is worse than it was when the Minister came into office. If, after six years, a Minister is unable to address what is essentially a management issue, we cannot be confident when she attempts to address something as complicated as long-term institutional care. There is little hope of her devising a solution that will be adequate in this case. All that is required in regard to the accident and emergency situation is to provide proper access to hospitals, proper treatment therein and proper discharge mechanisms. Patients are entitled to that but they are not getting it. This is not rocket science, it is merely a question of management.

The Minister made her first fundamental mistake in introducing the Health Service Executive in the manner in which she did before finding herself unable to modify it in a manner that might allow it to become a functional entity. Every effort she has made has worsened the situation. It is amazing to comprehend that in 2009, some 30 to 40 people are on chairs and trolleys in the Mater Hospital on a daily basis. In 2008, on average, 80 people were waiting to leave the hospital but could not do so because the Minister has done nothing to provide for step-down facilities, adaptation grants and so on. The Minister talks a good talk but she does not deliver.

The situation is similar in regard to the Minister's plans for co-located hospitals. She has made reference to 1,000 private beds being taken out of the public sector, thus increasing capacity for public patients. However, today's report by Goodbody Economic Consultants indicates a further 25% increase in the cost of private health insurance, which is expected to pay for the Minister's co-location plans. That is combined with a 23% increase since last November. In the space of four months there has been an increase of almost 50% in voluntary health insurance and very little to show for it, as well as the enormous annual budget given in this House to the health service. The situation regarding co-located hospitals is turning into a mismanaged exercise that will not provide extra beds but will simply mean that the subsidy goes to the private sector and ordinary patients in the ordinary hospital will lose out.

I would like the Minister of State to answer whether the private sector will pay the full costs of private health care in private hospitals. Will co-located use remain as a major subsidy to the private sector? Does the Minister of State mean what she says or is this another guise for tax breaks to the private sector in terms of property and profit that the Progressive Democrats ideology is so good at providing? An example of this is in legislation concerning the pensions levy. It is amazing that the private sector, in the form of private schools, will not be subject to the pension levy. The State provides the subsidy but staff will not be subject to the pension levy. An anomaly exists that the State has not bothered to address whereby the private sector receives a State subsidy that should be considered for pension purposes but is not being treated in the same fashion.

The Minister's grand plan for private health is fundamentally flawed because it exists on ideological grounds, which is part and parcel of the overall Thatcherite and Reagan economics and thinking. Everything private is good and everything public is bad. This results in the denigration and degradation of the public sector. The idea is that there is no such thing as society or social solidarity, therefore, everything that can be privatised is privatised. The concept of free education and universal free health does not come within the Minister's ambit. That is the fundamental flaw in her thinking. There is nothing in the Minister's book about a caring social order that requires universal health care to be provided by society.

This is why it is particularly inequitable that the current proposals single out the elderly. The elderly were singled out in the 2008 budget in terms of the loss of the medical card to those over 70. That was the Minister's first step towards balancing the books. The elderly have been targeted to an inordinate degree by this Minister as if they are a burden on the State that she is not prepared to tolerate. The Health Act 1970 makes provision for free health care but it is more honoured in the breach than in its implementation.

The elderly in need of long-term care are the new pariahs in our society. This includes the over-70s and the elderly who are in hospital, who are bed blocking as it is put by the HSE, and those in need of long-term institutional nursing home care. These people will be treated in a different fashion to any other sector of society in need of health care. Anyone else who requires health treatment is treated in the normal fashion but the elderly must be dealt with in terms of their means and their assets. That is the fundamental flaw in this argument.

However, from the Minister's point of view this is the strength of her position because she can avail of the assets before or after the death of the patient in institutional care. Let us imagine how cold and calculating this is. Anyone facing long-term care is also facing the family home being taken from the person, either before or after death, in deferred payment and the assets must be dealt with in such a way as to make payments according to the assessment of the HSE. In a caring social order this should not be part of the solution to a difficult problem.

The elderly have been singled out and it imposes an extra burden on them. They are now seen as problems and pariahs in society. They are a burden on their children and on their inheritance. Elderly people who want to see how this legislation will operate and what they will leave behind as their children's inheritance and legacy in their final days will see themselves as depriving their children the longer they live. This is what long-term institutional care will do under this legislation. It will make the elderly, in their own eyes, a burden on their families. Their health will deteriorate because they see themselves as part of the problem. That is the uncaring aspect of this legislation. It has a negative impact on the elderly, who see themselves as part of the problem rather than part of the solution. This is why Age Action Ireland and the Senior Citizens Parliament have expressed concerns about this legislation. On the one hand they see the benefit of it but on the other hand, they also see the human imposition and the damage that might be caused by it.

How is the scheme resource to be capped? There was an initial contribution of €103 million, which dwindled down to half that amount. The Government is reneging on its resource commitment. Is it possible that the scheme will run out of money? It seems that under the terms of the legislation the HSE is in a position to recoup sufficient funds from the estate of the patient through its financial assessment. However, the State does not provide further subvention. Is the State admitting that the capping is as a result of scarcity of resources and that it can pull the plug at any time if it does not wish to make a contribution? What are the implications for the HSE assessment and what are the parameters of the assessments of the individual's means? There are criteria and there is a formula. How far can they go and how far can they meet the failure of the State to fulfil its side of the bargain? There is a major question over this part of the scheme currently. If the money runs out, does the care run out? How robust is the scheme from the Department's perspective?

The question from the other side is what happens to the people who do not qualify for the scheme when they are not sufficiently dependent to meet the criteria. There are very few health care packages in the community currently as all that funding has dried up. If one operates with a local authority, one may find it very difficult to find one that is prepared to put any adaptation package together for a home, whether it is to adapt a bathroom or toilet or install a ramp for somebody who is seriously ill or in need of any kind of long-term care. The HSE does not seem to have the funding to provide the service either.

This is part of the reason there are so many bed blockers, as there is no integration of services for people coming out of hospital. The term "bed blocker" is terrible as it implies it is the patient's fault for blocking a bed. It is in the best interest of everybody to get out of hospital as quickly as possible after treatment. There are no step-down facilities in the community or adaptation grants available. There is no integration of services either — the biggest issue — because there is no line of communication between the HSE and any of the community-based services. Nobody bothered to establish it so the health service operates in a limbo.

Tax relief relating to nursing home care, as I understand from the latest budget, is now at a standard 20% rate rather than the previous rate of 41%. That will be detrimental to the earner's finances in providing care. All the nursing homes which come within the ambit of this legislation must be approved separately by the HSE. This will be a major issue because we have had so much fall-out from so-called approved nursing homes, which were not very well approved. We need a strong code of conduct, criteria and standards in this area. There are no provisions in the legislation dealing with approval, the criteria for the HSE to assess all the homes that will be approved and how to ensure that in the future, the level of supervision and monitoring will be up to the required standard for a service that is not currently provided.

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