Seán Power (Kildare South, Fianna Fail)

I am pleased to have the opportunity to introduce to the House today the Second Stage of the Health (Nursing Homes)(Amendment) Bill 2006. Government policy in relation to older people has long been to support them to live in dignity and independence in their own homes and communities for as long as possible and to support appropriate long-term care where this is no longer possible. It was for this reason that the nursing homes subvention scheme was introduced in 1993. The aim of this scheme is to provide financial assistance to older people towards the cost of maintenance in a private nursing home. The Bill is designed to ensure that the existing subvention scheme for private nursing home care is grounded in primary legislation, and it will also help the Health Service Executive to implement the scheme on a standardised basis across the country.

Before getting into the detail of the Bill, I want to outline some of the major developments that the Government is pursuing to improve services for older people. It has been the policy of successive Governments to endeavour to help older people maintain themselves in the community — while at the same time providing for appropriate residential care, where living in the community is no longer possible. The policy of this Government as regards the development and delivery of services for older people is to maintain them in dignity and independence at home for as long as possible, in accordance with their wishes.

The last two years have seen an increased focus on services for older people, particularly in relation to long term care, whether residential or community based. Additional funding for services for older people and palliative care amounting to €150 million was allocated by the Government in the 2006 budget — an additional €110 million for 2006 and €40 million for 2007. As part of the budget yesterday, additional full year funding of €170 million — €120 million is for allocation in 2007 with the rest for 2008 — was announced to improve services for older people and palliative care. This is the largest ever annual increase in funding for older people and clearly shows the Government's commitment to improving the quality of service provided to older citizens.

Approximately two-thirds of the money announced in 2006 was allocated to community support for older people. The announcement yesterday will continue this philosophy as the funding will provide for 2,000 additional home care packages, to benefit over 4,000 older people. The number of home help hours will be increased by 780,000 in 2007. An additional €3.5 million is being allocated to further increase day and respite care. This is in line with the focus on keeping people in their own homes, in independence and dignity, with proper health and social support systems in place in the form of home care packages, increased home help hours and increased day and respite care places.

Not every older person can, or wishes to, remain in his or her own home. Of the budget investment that I have outlined, €60 million has been allocated in 2007 towards the provision of additional long-stay care bed capacity, with a follow on cost of €22 million in 2008. This is a significant investment, ensuring that those who can no longer be cared for at home, for whatever reasons, have access to appropriate long-term care.

I now wish to briefly discuss the background to the subvention scheme. The nursing homes subvention scheme was introduced in 1993 on foot of the Health (Nursing Homes) Act 1990 and the subsequent Nursing Homes (Subvention) Regulations 1993, which were made under the 1990 Act. The purpose of the subvention scheme is to provide financial assistance to older people towards the cost of maintenance in a private nursing home. The scheme does not cover, and was never intended to cover, the full cost of private nursing home care. The 1993 regulations provide that a subvention can be paid to an applicant qualifying on both dependency and means grounds. Dependency is assessed according to an applicant's ability to carry out the tasks of daily living, such as washing and dressing. There are three levels of dependency set out in the regulations — maximum, high and medium, which are referred to in the Bill as categories I, II and III.

The maximum rate of subvention that may be payable to a person is determined in the first instance by his or her level of dependency, and the current maximum rates of subvention, as set out in the regulations, are €114.30 per week for a person of medium dependency, €152.40 per week for a person classed as high dependency, and €190.50 per week for a person at the maximum rate of dependency.

Once a person's rate of dependency has been determined, the HSE then carries out a financial assessment of the applicant which takes into account the value of his or her income and assets, subject to certain exclusions as outlined in the regulations. The appropriate level of subvention to be paid is then determined, based on the level of dependency and the outcome of the financial assessment of the applicant, and may result in the maximum level or a reduced level of subvention, as appropriate to that dependency level, being paid, or indeed no subvention being paid. Where a person is married or cohabiting, the means assessment is based on half of the combined means of the couple.

The Health Service Executive has the discretion to pay an enhanced rate of subvention, over and above the rates I have just outlined, in a case, for example, where personal funds are exhausted. This discretion regarding individual cases is a matter for the HSE. The average rate of subvention paid by the HSE generally exceeds the current approved basic rates.

As previously stated, the subvention scheme is provided for in the Nursing Homes (Subvention) Regulations 1993 at present. These regulations, which are made under section 7 of the Health (Nursing Homes) Act 1990, outline the scheme in detail, including such matters as how an application should be made or determined, how to appeal a decision made under the scheme and so on. Legal advice received from the Attorney General has indicated that new primary legislation is needed to underpin sufficiently the principles and policies of the scheme.

Sections 6 and 7 of the Health (Nursing Homes) Act 1990 were amended by section 3 of the Health (Miscellaneous Provisions) Act 2001. The purpose of this amendment was to incorporate principles and policies into the 1990 Act that would facilitate the making of new subvention regulations under the Act. However, the available legal advice indicates that section 3 of the 2001 Act does not adequately provide for the making of regulations under that Act. Consequently, section 3 of the 2001 Act has not been commenced and this section will fall on the enactment of this Bill.

The Ministers for Health and Children and Social and Family Affairs established last year an interdepartmental group to examine the entire subject of long-term care for older people. The group included senior officials from the Departments of the Taoiseach, Health and Children, Social and Family Affairs and Finance and was chaired by the Department of the Taoiseach. The group had a number of reports available to it, including the Mercer report on the future financing of long-term care in Ireland, which was commissioned by the Department of Social and Family Affairs. The group also considered Professor Eamon O'Shea's report, Review of the Nursing Home Subvention Scheme, commissioned by the Department of Health and Children. Both reports were published in 2003.

The group reported to the Government earlier this year and, consequently, the Government is considering policies on long-term care for older people. Several principles underlying this policy were agreed with the social partners in Towards 2016. For example, these principles specify there should be a single standardised national needs assessment for older people who need care. Moreover, the use of community and home-based care should be maximised. When required, residential care should be of a high quality and there should be appropriate and equitable levels of co-payment by care recipients based on a national standardised financial assessment. The level of support for residential care should be indifferent as to whether such care is provided in a public or private facility. The financial model to support any new arrangements must also be financially sustainable.

Consultation has taken place with the Departments of Finance and Social and Family Affairs, the Office of the Attorney General, the Office of the Taoiseach and the Health Service Executive in respect of the provisions contained in the Bill. There will be ongoing discussions with the relevant Departments regarding any developments or changes made in the area of services for older people, including any regulations to be made under this Bill. Naturally, discussions have taken place throughout the drafting of the Bill with the Health Service Executive, which has responsibility for the implementation of the subvention scheme.

The purpose of this Bill is solely to put the existing subvention arrangements on a sound legal footing and to underpin sufficiently the principles and policies of the current subvention scheme. I now propose to outline briefly the main provisions of the Bill.

Section 1 contains a minor drafting provision and simply will insert a heading into the Health (Nursing Homes) Act 1990. Section 2 of the Bill will amend section 2 of the Health (Nursing Homes) Act 1990 to specify that subvention shall only be paid to a person maintained in premises in which a majority of its residents are members of a religious order or priests of any religion if the premises are a registered nursing home.

Section 3 is the main section of the Bill. It will replace section 7 of the Health (Nursing Homes) Act 1990 by inserting the provisions of the 1993 Nursing Homes (Subvention) Regulations into primary legislation, after which those regulations will be revoked in the Bill. Given the length and amount of detail contained in this section, I propose to go through it subsection by subsection.

The new section 7 will define the various terms used in the Bill. Subsection 7A specifies that all dependent persons may make an application to the Health Service Executive, HSE, for a subvention. It specifies that making an application to the HSE is required and outlines the manner in which it must be made. It also provides for an offence in which false or misleading material is provided in a subvention application.

Subsection 7B provides that once the HSE receives an application for subvention, it shall arrange for an assessment to be carried out regarding the degree of dependency and the means of the applicant. The assessment to be carried out in this regard will be based on the applicant's ability to carry out the activities of daily living, such as walking and dressing. Other factors affecting an applicant's ability to care for himself or herself will also be taken into account, such as the receipt of medical services and family support.

The subsection provides that the person carrying out the assessment must be suitably qualified to do so in the opinion of the HSE and may or may not be an employee of the HSE. This will allow the HSE to arrange for suitable medically-qualified professionals, such as, for example, physiotherapists who are not employed directly by the HSE, to carry out such assessments. An amendment will be tabled on Committee Stage to reflect the change of names of the social welfare payments mentioned in this section.

Subsection 7B also provides that the HSE shall arrange for the means of an applicant to be assessed, either by an employee of the HSE or a person nominated in writing by the HSE. It provides that the financial assessment shall take into account all of the applicant's assets and sources of income, such as, salary, pension, savings, etc. It also provides that certain assets and income shall not be taken into account, including the applicant's principal private residence, where occupied by certain relatives as prescribed in the subsection, as well as the first €11,000 of the applicant's assets. When an applicant is married or cohabiting, the means assessment will be based on half of the combined means of the couple.

As for an applicant's property, where an applicant's principal residence is not continuously occupied by a relative as prescribed in the subsection, such as a relative whose sole income is the old age pension or a spouse, the HSE shall exclude 95% of the estimated market value of the principal residence from the financial assessment of the applicant. This means that an imputed income of 5% of the market value of the principal residence shall be taken into account.

The subsection further provides that the principal residence of the applicant will not be taken into account if that could give rise to destitution or homelessness of a person with a close connection to the applicant. This provision is to allow for exceptional circumstances and will generally apply in the case of a relative who does not fall into the categories prescribed in the subsection.

Subsection 7C outlines the basis on which the HSE will determine subvention applications, the amount of subvention payable and the grounds on which it may refuse to pay a subvention. This subsection also provides that the HSE may pay an enhanced rate of subvention, referred to in the Bill as an alternative subvention, when a person cannot meet the costs of care without undue hardship, the amount of alternative subvention having been decided after taking available resources into account.

The section also provides the HSE with discretion to refuse to pay a subvention if the value of the applicant's assets exceeds a certain threshold, or the applicant's principal residence exceeds a certain threshold and his or her income is above a certain level. Such thresholds were recently increased by way of the Health (Nursing Home)(Amendment) Regulations 2005 and the following thresholds apply at present. The threshold for assets to be disregarded for the purposes of subvention assessment is €11,000, the asset threshold above which subvention may be refused is €36,000 and the income threshold above which a subvention may be refused is €36,000. The threshold of principal residence value above which subvention may be refused is €500,000 or more when the residence is located in the Dublin area or €300,000 or more when the residence is located outside the Dublin area, when the income of the applicant is above the threshold of €9,000. The Dublin area is defined as Dublin city and county.

Members should note that while the threshold regarding income was not included in previous regulations, it has been added to this Bill for consistency. This section also provides that the HSE can, at its discretion, pay a subvention to the proprietor of the nursing home in question instead of directly to the applicant himself or herself.

Under subsection 7D, the HSE can arrange for a review to be carried out on the degree of dependency or means of a person who is in receipt of a subvention. When the HSE is satisfied the person no longer qualifies for subvention or qualifies for a different rate of subvention, it can arrange for the payment to stop or be altered appropriately and for notice of same to be sent to the applicant and the nursing home proprietor, if appropriate. When a person's subvention payment is being stopped or decreased, the HSE will not implement this decision for 60 days to give the person time to get his or her affairs in order.

Subsection 7E allows for an appeals mechanism against decisions made by the HSE in respect of an application not being considered because some condition of the application has not been met, the level of subvention to be paid, or a decision to pay a different level of subvention following a review.

The HSE must appoint a person to consider the appeal who may be, but is not necessarily, an employee of the HSE. The person must consider the appeal based on guidelines issued by the HSE. He or she must make his or her decision as soon as is reasonably possible and must send a copy of that decision in writing, together with the reasons for the decision, to the person making the appeal. A further appeal is also possible regarding the decision of the High Court, whose decision is final, except where a further appeal is made to the Supreme Court on a specific point of law.

Subsection 7F states that a nursing home owner must inform the HSE in writing of the death, discharge or permanent departure of a resident within 48 hours. This is to ensure that subventions do not continue to be paid in respect of persons no longer in the home. When a nursing home proposes to discharge a person, its proprietor must inform the HSE in writing 14 days in advance and must outline the reasons for so doing. The Bill provides for an offence where a nursing home proprietor does not fulfil his or her obligations in either of these situations. This subsection also provides that where a person in a nursing home starts or ceases to be paid a subvention, the Health Service Executive will inform that nursing home proprietor of this fact as soon as possible.

The new section 7G provides that the HSE may recover all or part of any payment or overpayment if the HSE is satisfied that an overpayment occurred or that the payment was procured through fraud or misrepresentation. The new section 7H allows the Minister to make regulations, with the consent of the Minister for Finance, on the rates of subvention payable, the amount of assets to be disregarded when assessing a person for subvention, the thresholds above which subvention may be refused, the percentage of the family home to be disregarded and the percentage of the spousal income to be assessed, as required. It provides that, when making regulations, the Minister will take into account the cost of living and nursing home care in the State and the rate of inflation, as appropriate.

The rates of subvention payable relative to a person's degree of dependency are also laid out in this section. This section provides that the Minister will only make regulations on the rates of subvention after taking into account available resources and the prevailing cost of nursing home care for persons falling under the various dependency categories. It also provides that the maximum rate of subvention that may be payable to a person, based on his or her level of dependency, is reduced by the amount by which the person's means exceed the weekly rate of the old age non-contributory pension, or State pension as it is now known, payable at the time of assessment. This represents no change from current practice. This section outlines the basis on which it is decided whether a person falls under one of the categories of dependency — category I, II and III of dependency, otherwise known as maximum, high and medium dependency — based on such factors as the person's degree of mobility and the extent to which he or she is confused or disturbed.

The new section 7I provides that where a person is in receipt of subvention immediately before the passing of this Bill, he or she will continue to receive a level of subvention equivalent to what he or she received prior to its enactment. However, the HSE may still carry out a review of the degree of dependency and means of any person in receipt of subvention at any time and may discontinue paying subvention or pay a different level of subvention if the review shows that he or she is not being paid the correct level of subvention. The new section 7J provides for guidelines to be issued by the HSE to provide practical guidance in respect of the provisions of the Bill and how the subvention scheme will work, for example, the process to be followed to decide the amount of subvention to be paid to an applicant.

Sections 4 and 5, like section 1, are minor technical provisions which insert a heading into the Health (Nursing Homes) Act 1990. Section 6 replaces section 14 of the Health (Nursing Homes) Act 1990 with a new section, which provides that regulations will only be made after a resolution approving the regulations has been passed by both Houses of the Oireachtas. At present, regulations are made before being laid before both Houses of the Oireachtas, which can subsequently annul them.

Sections 7 to 10 also contain minor drafting and technical provisions. Section 7 repeals section 3 of the Health (Miscellaneous Provisions) Act 2001. Section 8 amends Schedule 7 of the Health Act 2004 by deleting item 6 in Part 4, as this item updates a section of the 1990 Act that is being replaced under section 3 of this Bill. Section 9 revokes the 1993 Nursing Homes (Subvention) Regulations, as the provisions contained in those regulations are now contained in the Bill. Section 10 amends section 2 of the Health (Repayment Scheme) Act by replacing section 3(10)(c) with section 3(10) in the definition of "spouse". This is a technical provision. Section 10 also contains a provision relating to commencement. Section 11 cites the Short Title of the Bill and cites the Health Acts of 1947 to 2006 collectively as the Health Acts 1947 to 2006.

At this stage, I want to speak briefly about the Health (Nursing Homes)(Amendment) Bill in the context of other developments and legislation ongoing at this time which are related to services for older people. The Health (Repayment Scheme) Act 2006 came into effect on 30 June 2006. The repayment scheme was launched publicly by the Health Service Executive, HSE, and the scheme administrator, KPMG/McCann Fitzgerald, on 14 August 2006. A national advertising campaign and a helpline also commenced on this date.

The HSE has informed the Department that more than 22,000 forms have been submitted to the scheme administrator applying for repayments and these applications are being processed at present. The timeframe for payment is predicated primarily on whether the applicant is alive or whether the application is being made by a family member or the estate of a deceased person. Priority is being given to pay those who are still alive, of whom it is estimated there are 15,000. The HSE has advised that the first payments have now commenced. It is expected that the bulk of payments to estates will commence in the spring of 2007. Provision has been made for applications to be received up to 1 January 2008.

The Health Bill 2006 will establish the Health Information and Quality Authority, HIQA, and will put the social services inspectorate, SSI, on a statutory basis within the HIQA. The intention is that the SSI will be required to monitor residential services provided to older persons against standards adopted or set by the HIQA. This is in accordance with the commitment in the health strategy, Quality and Fairness — A Health System for You, to extend the remit of the social services inspectorate to other social services, including residential services for older people. As previously stated, my Department is in discussion with the interim HIQA on standards for residential care for older people.

The fundamental objective of the Health Bill 2006 is a health and personal social services system which has quality and safety embedded at all levels and in all settings. The registration and inspection system for residential services will provide a quality assured residential system for persons in receipt of these services. The inspectorial system in the Bill will take account of situations where centres are not in compliance with regulations and standards and provide for attaching conditions to registration or cancellation of registration, if appropriate. This will ensure that, ultimately, only services which are provided in line with the regulations and meet the standards set by the HIQA will be allowed to operate. It is, therefore, a priority to establish the HIQA and the Office of the Chief Inspector of Social Services on a statutory basis. The Department has been working very closely with the Office of the Parliamentary Counsel and work is at an advanced stage on the draft provisions. It is intended to have the Bill published before the end of the year.

The HIQA's main role will be to enforce internal quality assurance practices at all levels within the health delivery system and at the same time bring external quality assurance to bear in an objective manner. To that end, the Bill ensures that quality of services will be monitored and evaluated against transparent standards on an ongoing basis. Safety is the most fundamental aspect of health care quality.

The Minister established a working group last year to produce draft standards for all long-term residential settings — public, private and voluntary — in conjunction with the relevant bodies. My Department is in discussion with the interim HIQA on a consultation process on these draft standards. The standards are based on legislation, research findings and best practice. While broad in scope, the standards acknowledge the unique and complex needs of the individual person at the centre of care and the additional specific knowledge, skills and facilities needed for service providers to deliver a person-centred and comprehensive service that promotes health, well-being and quality of life.

The standards are set out in two parts. The first part focuses on the standards concerning the resident as an individual, and includes personal identity, social connectedness, rights, and health care. The second part focuses on the organisational aspects of the residential care setting and includes management, staffing, care environment, and health and safety.

The Department is also preparing legislation to update and clarify the current legislation on eligibility for services. The main aim is to make the system clearer and to bring it up to date with developments in service delivery and technology that have occurred since the Health Act 1970. The legislation will define specific health and personal services more clearly, define who should be eligible for what services, set out clear eligibility criteria, including for older people, and establish when and in what circumstances charges may be made. It will also deal with an appeals framework.

I reiterate that this Government has made services for older people a priority by supporting older people to live in dignity and independence in their own homes and communities for as long as possible and, where that is no longer possible, by supporting the provision of quality long-term care. The significant progress that has been made in terms of the growth in funding available for this sector in recent years and, in particular, the investment package put in place in the 2006 budget is indicative of the Government's commitment to the ongoing development of health-funded services for older people.

This Bill will ensure that the existing subvention scheme for private nursing home care is grounded in primary legislation and will also go a long way towards helping the Health Service Executive to implement the scheme on a standardised basis throughout the country. Further announcements about the subvention scheme will be made shortly. These will have implications for the Bill and I intend bringing forward amendments at a later stage.

I commend the Bill to the House.