Thursday, 4 April 2019
Saincheisteanna Tráthúla - Topical Issue Debate
Nursing Home Services
This is an ongoing issue. It was raised by Nursing Homes Ireland, which held a very well attended briefing in Buswells Hotel some time ago. It has followed up with meetings in the Dáil recently in order to highlight the issue. The message it is sending is that unless this issue is addressed in a timely, professional and effective way, the situation is going to worsen, with dire consequences for those in need of nursing home care. We know, from the statistics provided, that Nursing Home Ireland has over 350 nursing homes in the private and voluntary sector in the Republic, with a further 91 in Dublin. That translates into 17,000 beds and over 20,000 staff. It is also the case that 80% of long-term beds are provided through the private and voluntary sectors, with the other 20% provided by the public sector. The former are making a major contribution. The crisis began with a number of closures of smaller nursing homes.
HIQA was very complimentary about these small, homely, family-run services. The nature of service provided is high quality. It is 24-7 and professional, meets the clinical, social and dietary needs of the residents and provides activities. The services play a role in the discharge of hundreds of patients from hospital beds, which is important given the serious situation in that area. There are four areas which need to be addressed, the first of which is the charges levied. The difference between public and private in this respect is astounding. Public rates are €896 at the lowest end to €2,399 per resident per week at the higher end. In the private voluntary sector, rates are between €765 to €1,355 per week. There is an obvious discrepancy there and it must be addressed. A review of the system for setting up nursing home prices under the nursing home support scheme is awaited. A fit-for-purpose model for charges is needed. The review was due in June of 2017, yet it is still outstanding. Replies to parliamentary questions indicate that it will be released soon; perhaps the Minister of State could tell us the date in her reply. There is a discrimination within the fair deal scheme that has to be addressed. A provider informed me that they are not-for-profit organisations, but they are not for loss either.
Staffing is another issue. There is a crisis in the context of recruiting healthcare assistants. The shortage, if it persists, will lead to closures. Nursing Home Ireland is asking that the role of the healthcare assistant is removed from the ineligible category of employment permits list. New categories have been introduced to answer shortages in various crafts and trades; why can this not be done for healthcare assistants? Private and voluntary bodies are training the healthcare assistants, who are then moving on to hospitals.
There is a major issue with regard to what agencies are providing. Agencies are supposed to be for emergencies, but the rates of pay I have seen are €31.50 per hour between 8 a.m. and 2 p.m., €35 per hour between 2 p.m. and 8 p.m., €75 at night and up to €150 if there is an emergency. One can imagine the amount of money that is being spent on agency staff. I am not sure how much goes directly to the staff - I am sure some goes to the agency - but this creates a big problem. Why would anybody work in either the private or the voluntary sector? It was stated that agencies are killing the health system and they have been described as a costly disaster. In a number of nursing homes, nuns provide the services. Their work, of course, is unpaid. Nuns are an ageing breed; they are not going to be available forever, which presents another staffing issue.
Nursing homes have qualified nurses on their staff, yet those nurses are not allowed to put in intravenous drips. That should be looked at. Nurses should be able to do that in nursing homes so that patients do not have to be brought to accident and emergency.
The Minister for Health, Deputy Harris, had certain things to say about the GMS contract - I will not read out his comments - but the current contract means that access to GP services for nursing home residents is constrained. Nursing Home Ireland is calling for a new GMS contract to include specific reference to nursing home residents. This is needed now, not next month. If residents have access to GP care in the nursing home it means that they do not have to go to accident and emergency, which can be a long, difficult process, particularly for elderly people with Alzheimer's or dementia.
I am acting in that capacity at the moment. I thank Deputy Maureen O’Sullivan for raising this issue. The Minister of State, Deputy Jim Daly, apologises for not being here.
The Government’s core stated objective is to promote care in the community so that people can continue to live with confidence, security and dignity in their own homes and communities for as long as possible. There will, however, always be a cohort of older people who require a quality long-term residential care option. The nursing homes support scheme provides financial support for those in need of long-term nursing home care. Participants in the scheme contribute to the cost of their care according to their means while the State pays the balance of the cost. The aim of the scheme is to ensure that long-term nursing home care is accessible and affordable for everyone and that people are cared for in the most appropriate settings.
The review of the nursing homes support scheme, NHSS, published in 2015, identified a number of issues for more detailed consideration, including a review of the pricing mechanism used by the National Treatment Purchase Fund, NTPF, with a view to ensuring value for money and economy, with the lowest possible administrative costs for clients and the State and administrative burden for providers; increasing the transparency of the pricing mechanism so that existing and potential investors can make as informed decisions us possible; and ensuring that there is adequate residential capacity for those residents with more complex needs. A steering group was established to oversee and manage the pricing review. The steering group is chaired by the NTPF and includes representatives from the Departments of Health and Public Expenditure and Reform. As part of its work on the review, the NTPF sought various inputs including external expertise and stakeholder engagement to inform the review. These inputs are being considered in detail.
This report is significantly overdue, however. I understand that the NTPF is close to completing the report and it is expected that the steering group will be provided with a final draft very shortly. Once complete, the report of the review will then be submitted to the Department of Health. It is recognised that any change to any part of the scheme must be considered in terms of the short and long-term impact on the viability of the scheme and accessibility of long-term residential care in general. It is important, therefore, that the relevant issues are considered thoroughly through this review process and that we ensure that support for people who require it remains on a sustainable footing.
The nursing home sector has also raised concerns in relation to staffing, particularly in terms of securing access to appropriately qualified staff. On foot of these concerns, nursing home providers have requested the removal of healthcare assistants from the ineligible list for permits issued by the Department of Business, Enterprise and Innovation to bring in workers from outside of the European Economic Area, EEA. These permits may be issued for occupations in respect of which there are labour or skills shortages. The results of the most recent review of the employment permits critical skills list and ineligible lists of occupations that come into effect on 22 April 2019, as set out on the website of the Department of Business, Enterprise and Innovation, contain no changes to the grades of care worker arid healthcare assistants.
There needs to be a clear demonstration that recruitment difficulties are solely due to shortages and not to other factors, such as salary or working conditions.
Both Departments met sectoral representatives and considered their business case. The sector has been advised that more evidence is required of the labour shortage and that they must demonstrate full engagement with the Department of Employment Affairs and Social Protection. On provision of this evidence, the matter will then be reconsidered. The Minister of State, Deputy Jim Daly, acknowledges the significant role of private and voluntary providers in residential care provision. I assure the House that he and the Department will continue to engage with the nursing home sector.
There is a danger of shooting the messenger because I must acknowledge that reply was very disappointing. To go back to the review and how long it is taking, it is acknowledged that it is significantly overdue but we are not too sure why it is taking so long. The report is close to completion but we still do not have a date as to when the review will be available.
What must also be considered is that we need a system whereby when a satisfactory rate is struck, it will be proofed against inflation in relevant areas of cost for a number of years. We hope inflation will decrease as well as increase but that proofing must be included also. There are concerns about the appeals mechanism and this needs particular consideration. With regard to the price review, is there professional and independent costing and other technical and relevant expertise?
In the context of staffing, the Minister of State's reply stated it must be proved there is a genuine labour shortage and it is not due to other factors. I have given the facts about the work and the rate that can be paid when going through an agency. How can agencies offer so much when the funding is from the State? This is leading to shortages in the private and voluntary sector. Somebody has to join up the dots and look at the matter in a much more holistic way. Earlier, I spoke to my colleague, Deputy Pringle, and he told me there is a very good system in Donegal where there is close co-operation between hospitals and community nursing homes but there is a fear this could be subject to change.
The voluntary and private sectors are providing much-needed care for long-term residents in particular. We must acknowledge that there is an increasing demand for the service. We want to keep people in the community but it will not be possible for everybody. Further closures will have serious consequences so these issues must be addressed. I could not get over the difference between the average public and private rates, which ranges from a difference of 40% to 163%. This needs to be looked at as well as the other issues I have raised.
I do not have a closing statement on this. I acknowledge Deputy Maureen O'Sullivan's frustration, particularly with regard to the report that is significantly overdue. I would like to revert to the Minister of State, Deputy Jim Daly, on some of the questions the Deputy has raised and ask for a more specific response. I am not in a position to give Deputy O'Sullivan specific answers. I hope she will bear with me while I raise the issues with the Minister of State, Deputy Jim Daly, and ask him to respond. I acknowledge Deputy Maureen O'Sullivan's frustration about the clear fact that I am not in a position to answer some of the questions she has asked. I will go to the Minister of State and ask him to provide specific answers.
A Cheann Comhairle, I have been asked to take the next matter but I do not have a script. It was not brought; I just received a short note.
Whoever might attend, I have to say it is most unsatisfactory to find ourselves in a situation whereby we have only been able to proceed with two of the four Topical Issues selected. This is becoming something of a habit. I am afraid that we cannot lay responsibility entirely at the door of the Government because frequently people who submit Topical Issues then withdraw them as soon as they have been selected. That is not acceptable either.