Rónán Mullen (Independent)

Cuirim fáilte roimh an Aire Stáit. Is as mo pharóiste féin di agus is é seo an chéad uair dom a bheith ag déileáil léi chomh maith.

While I welcome the Bill in parts, I do not believe everything is rosy either. There are fundamental questions that remain to be answered. I knew of a lady who had been worrying for some time because she did not know if she had the resources to pay for her nursing care. Thankfully, someone in the family realised this and relations who had done well in life gave a guarantee to let her enjoy peace of mind that had been missing for some time. It brought home to me that we should not be slow to emphasise that while many of our older citizens are active and fit to deal with the tasks life presents, there are others who experience great vulnerability and fear and we should have them in our minds when we consider this legislation.

I draw attention to an extraordinary scandal from the time of the first nursing homes fees scandal. The Supreme Court in its judgment in February 2005 established eligibility to publicly funded long-term care, whether in publicly funded institutions or HSE funded places in private nursing homes. That was put in place for those who needed it at a cost of 80% of the non-contributory pension. Since that time there has been a conspiracy of silence that the only possible way of exercising this eligibility has been through admission to hospital with a critical illness. The provision of such publicly funded beds is often described as delayed discharge initiative beds in what seems to be an effort to avoid clarifying the eligibility of patients to publicly funded long-term care. In some cases, efforts are made to clarify, to all those who wish to use the subvention route which usually covers a minority of the full cost, that the form will only be signed on the basis the patient and-or family have been made aware of their eligibility for a fully funded bed as per the Supreme Court decision.

Senior HSE officials have criticised the practice of geriatricians clarifying this eligibility to patients and families as a factor in the delayed discharges. When it was pointed out to the HSE officials that this eligibility was the law of the land and that there would be no problem at all if they wished to provide written guidance on any alternative interpretation of the situation, the answer received was that the geriatricians should know the score. It seems there are chilling echoes there of certain aspects of the Ryan report.

Some of the worst suffering occurring in the context of nursing homes has been in the case of families who have not been given access to the information about their entitlements and who have crippled themselves with second mortgages etc. to support an older patient in a nursing home. To add insult to injury, they find their tax relief has been reduced. A further degree of suffering is caused to those who await their eligibility in a general hospital and who may come under the moral pressure of being labelled as bed blockers.

The HSE seems to be petrified by the moral hazard of people's eligibility being made clear to them. The geriatrician or old age psychiatry assessment which, to date, is not standard throughout the HSE converts many requests for long-term to enhanced care in the community. A natural break on the use of nursing home beds is the unwillingness of older people to enter long-term care. If properly assessed and supported, people will choose life at home if that is possible.

The real failure of the Department of Health and Children and the HSE has been the failure to provide for nursing home care in major urban areas, in particular in Dublin. The Prospectus report highlights that although the national average is approximately five per 1,000 older people, it is down to 1.9 or 2.5 per 1,000 older people in parts of Dublin - one third to one half of what is required.

The so-called fair deal draws on a politics of the aggrieved, the increasing numbers who largely through ignorance of their eligibility are crushed by fully funding or part funding with subvention nursing home care and to whom the terms of the new arrangement are presented as an improvement. One must remember the rights people already have. Their rights stem from the Supreme Court ruling. It would appear there are tens of thousands of older people and families suffering seriously as a result of the failure to clarify their eligibility.

The Irish Gerontological Society outlined concerns about this as far back as December 2006 when in The Irish Times, Dr. Cillian Twomey and Professor Desmond O'Neill wrote that no older person objects to a proportion of their pension being used for the board and lodging aspect of this usually reluctant change to a new home where the person's health and social care needs, which are not easy to disentangle, should be met. It now seems older people who can avail of a publicly funded bed will be asked to provide funding for this care over and above their lifetime of taxation and pension contribution. The contrast with cardiac and cancer treatment could not be more stark. In the case of certain cardiac and cancer treatments, tens and even hundreds of thousands of euro are spent without anybody imagining that the patient should hand 15% of their principal private residence to the State after their death.

The debate on funding is also marked by an inappropriate alarmism - a false demographic catastrophism. In fact, older people are fitter and healthier now. Disability is dropping among older Americans at a rate of 1.5% per year. In tandem, nursing home use is not increasing with the increasing numbers of older people, although there are some regional differences. Going back to 2004 figures, the number of publicly funded nursing home beds in the Republic has remained constant at approximately 15,000. Are we dealing with another example of what Theodor Adorno called the cold indifference of the middle classes?

Both the Leas Cross report and the Irish National Audit of Stroke Care indicated grave confusion regarding who provides therapeutic support for people in nursing homes, such as speech and language therapy, occupational therapy etc.

I wish to make an observation in regard to the appointment of a care representative as per Part 4, section 21(11). This is a sad state of affairs appointing a care representative who has only one job, that is, that of deciding whether the incapacitated older person should hand over a proportion of his or her assets to the State but who has no other care or welfare role. The suggestion that it should be a registered medical practitioner or other such health practitioner as appears to the court to be a fit and proper person to make the application should be altered to ensure this care representative is separate from the team treating the person in hospital. There is huge pressure on teams in hospitals to discharge people rapidly and, therefore, there is a conflict of interest which may not allow for a reasoned advocacy role for a very significant decision which must be made.

Senator Ó Murchú rightly used the word "dignity". As we consider this legislation, we need to test it against the question of dignity. I have pointed out some issues which are of major concern. I recall during our debate on the Broadcasting Bill that I proposed we have a heritage channel as part of our suite of television channels to be provided in the new digital set up. I know from my experience of nursing homes and encountering people that thousands of people do not have access to television or radio services which are addressed to their specific needs. Not every older person needs that but there was an opportunity to make a change in favour of older persons who might be in a vulnerable situation. It is too easy to forget sections of the community who are not vocal or particularly influential politically. I hope the sincere concern about the dignity of persons who use nursing home care and their families will guide our consideration of this Bill.