Frances Fitzgerald (Fine Gael)

I welcome the Minister of State. This legislation is very important because there will be more than 800,000 people over the age of 65 years by 2025. Thus, many elderly people will need care at various levels, be it in the community or a nursing home. We spend 0.6% of GDP on the elderly. The current spend in the United Kingdom is 1.9%. There is no doubt but that this area will require further investment in the years to come. It is very clear that many families are stressed and under considerable pressure because of the lack of supports, be it in the community or residential care.

I want to raise a range of issues associated with the legislation about which Fine Gael has concerns. Will the Minister of State review the points made in the Dáil and on Committee Stage by Deputy Reilly and determine whether it will be possible to address some of them by way of amendment on Committee Stage in the Seanad? It is clear that this legislation will require more amendments before we will be in a position to support it. In principle, if people cannot make a contribution towards the cost of their care, we must accept it as reasonable. However, the devil is in the detail.

There are many matters I want to raise with the Minister of State. Let me begin by considering the community care packages available. The Bill caters primarily for those who require high dependency care. Traditionally, nursing homes dealt with persons with a range of needs, but increasingly they are dealing with patients who need high dependency care. However, there may be people who, for a variety of reasons, might not be classified as having high-dependency care needs but who may need some form of residential care. Will the Minister of State outline the degree to which the assessments will take social factors into account? There are big questions about community care packages. The issue of standards will increasingly come to the fore. We hear about standards in nursing homes but no public nursing home has been inspected. That will come in on 1 July and I welcome that move. We have all just come from the solidarity march for victims of abuse today. There were no inspections in the homes discussed in the Ryan report. Inspection is a critical issue and whether the Health Information and Quality Authority, HIQA, will have the appropriate resources to carry out the necessary inspection is a key question.

Standards will be a question of the future because people will depend on quality community care packages in which there is huge variation. We all want older people to receive support that enables them to stay in the community. The level, quality and quantity of community care packages will be critical to that support. People do not yet get the kind of support they need to stay in the community. Many who have fairly high needs do not get the wide range of care necessary to remain in the community. There are approximately 750 people in acute hospitals who need placement in nursing homes. I am somewhat concerned about that because there are vacancies in nursing homes. Will the Minister of State and her Department say what the barrier is to placing those people appropriately in nursing homes?

The most important question is what resources will be allocated for the implementation of this legislation. What will happen if, for example, €55 million is allocated in a current year and that money runs out? Will we put pressure on people to go into a nursing home early before the money runs out? How will we deal with that difficult issue? What is the Government approach to the key issue of funding?

A total of 62% of nursing home costs goes on staffing yet there are no criteria for the ratio of nurses and care assistants and so on for public or private nursing homes. The Government needs to address that if this legislation is to be successful. Other issues arise about the detail in the Bill on how assessments will be made. What is the future of public nursing homes? This legislation does away with universal provision. What do the Minister of State and the Government envisage as the future of public nursing homes? Section 5(5) refers to (a) relevant facilities and (b) approved nursing homes. Why is it necessary to separate the two? Section 5(4) raises questions about the criteria for rationing and who will do it.

Under this Bill everything is done within the Health Service Executive, including the appeals mechanism and the care assessment. Surely we need to bring independence into the procedures whether in respect of an appeal or having a second assessment of need or the setting of nursing home fees. Is there not room for a more independent procedure in the various arenas that the Bill addresses?

Section 7 of the Bill "enables specified individuals to apply to the HSE for a care needs assessment and allows the HSE to make arrangements for care needs assessments to be carried out". Obviously the goal of this is to ensure that quality care is provided to the older person. Section 7(5) of the Bill, however, allows the HSE as the service provider to operate also as the body which determines whether the person is in need of a service. Surely some assessment should be conducted by a multidisciplinary group of professionals, independent of the HSE and the Department of Health and Children. There is no guarantee that once needs are identified the resources will be put in place to ensure they are met. Will the Minister of State consider that point?

Will the Minister of State define what is included and excluded? What does "specified services" mean? What does one get in return for 15% of one's income and a proportion of one's assets? Does one get a basic service or access to the other services that an elderly person might need, such as occupational therapy and various ancillary services? It is very important to spell that out. The Minister indicated on Committee Stage that she would introduce regulations to outline to some degree what would be included. Will the Minister of State say in her response to this Second Stage debate how it is intended to address that issue? Otherwise people will have fewer services than they have now. Provision in this area is inadequate.

Many involved in farming and in small businesses are extremely concerned with the implications of this Bill for their livelihood. They are particularly concerned that there is no cap on the deferred charge and other fixed assets such as land, farm buildings, commercial and investment property and small businesses that may not be highly profitable. This situation is not fair because a person with a very valuable residence would relatively speaking be undercharged but the Bill does not take account of the sustainability of farms and small businesses in rural areas and gives preferential status to principal private residences. The Bill does not address this and the Minister of State needs to outline how she intends to deal with it. She needs to deal with the absence of a ceiling on farms as a priority.

I welcome the changes made in the repayment of ancillary State support but I would appreciate clarification from the Minister of State on amendments made to the definition in section 20(4)(a)(ii) whereby a child who remains in the home and is over the age of 21 will be eligible for a further deferral if the aggregate of his or her cash assets is not greater than the general assets deductible amount. Will the Minister of State give information on the general assets deductible amount, how it is calculated and what it amounts to? If a sibling over the age of 21 has inherited the assets, cash or land will the Minister of State clarify how this will impact on the ability to apply for deferred payment? These are important issues. This is in many ways a technical Bill but it will have a serious impact on individuals, their futures and their ability to continue in business or stay on their farms.

The role of the National Treatment Purchase Fund, NTPF, also needs to be addressed. Will people be able to choose a nursing home that is close to their home or will the NTPF choose a nursing home at a certain cost that is 100 or 200 miles from their homes? We must build in criteria for the community that enable elderly persons to have access to a nursing home that is close to his or her home and family.

The HSE used to deal with this but it now appears the hospitals make the payments under the delayed discharge initiative. To minimise the cost to the hospitals, older people are being offered places in nursing homes which are at a distance from their family homes and communities. That needs to be addressed. Many people are being placed in nursing homes far away from their homes, as is happening in Dublin where there is a shortage of such accommodation. One understands why this is happening but in terms of the development of this scheme, this issue needs to be given further thought.

The National Treatment Purchase Fund will be given responsibility for contracting beds in nursing homes and agreeing fees. Nursing homes, both public and private, will be required to negotiate fees with the NTPF if they wish to be approved providers under the scheme. There are some contradictions in this respect. The NTPF is being given the challenge of keeping the cost of care down while the HSE wants to ensure high standards are met. Quality should not be determined by the prices that are set by the NTPF. We must ensure quality is maintained in residential nursing homes and that there is not a drive down by nursing homes to the lowest standards to ensure they become approved nursing homes. How will that be ensured?

The means assessment aspect is dealt with in section 10. Under the terms of the Bill, the HSE is entitled to seek an assessment of means, which will be conducted by a suitable person of its choice. From the legislation it is not clear what is meant by a suitable person or who will conduct the assessment of means. Will the means test be carried out by the HSE, State officials or an independent third party? We believe the financial review should be conducted by an independent third party in order that a fair and reliable estimate can be established in which both the applicant and the HSE can have faith. A person's right to avail of care through this scheme should not be jeopardised by obstacles in seeking a financial review and such people are entitled to seek a financial review if and when they need to. The Minister of State might consider this issue on Committee Stage.

We have seen in recent months how the values of assets can change very quickly. In terms of an allowable deduction, will the Minister of State take into account in the development of this scheme the changing value of assets when somebody has been assessed? Is there a review mechanism in this respect?

I also raise the question of extending the nursing homes support scheme to private care in the community. That is a matter the Minister of State may want to examine.

This is an area that deserves the highest attention and the highest investment because it determines the quality of people's lives in their later years. It is critical that we get this legislation right. I commend the Government's attempts to move in this direction but there are many serious questions in this area. I urge the Minister of State to take note of the points that have been made on Committee Stage in the Dáil and the points I have made. I will communicate with her privately on a range of other concerns we have which I have not had the opportunity to put on the record because of time constraints.