Eugene Murphy (Fianna Fail)
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Cuirim fáilte roimh an Aire Stáit and her officials. Before I call the Minister of State, I extend a céad míle fáilte to the students and teachers of Aillebrack in Connemara, County Galway. Céad míle fáilte go léir and enjoy your stay in Leinster House. We love having people here.

Mary Butler (Waterford, Fianna Fail)
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I would also like to welcome my friends from Waterford, five ladies who are up to visit me today.

Eugene Murphy (Fianna Fail)
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The Minister of State, Deputy Butler, wants to extend a céad míle fáilte to the ladies as Port Láirge. They are also very welcome.

Mary Butler (Waterford, Fianna Fail)
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I am glad to have the opportunity to take part in statements on private nursing homes. I will begin by outlining the factual situation regarding the sector before turning to the issue of reform. There are 562 nursing homes in Ireland, which accommodate 31,867 registered beds. Approximately 20% of these are publicly-run HSE facilities or community nursing units, approximately 3.7% are run by not-for-profit organisations funded by the State under sections 38 and 39 of the Health Act, and the remaining 77% are homes run by private providers. The majority of residents in long-term residential care are, therefore, cared for in private nursing homes. The nursing home sector has changed in recent decades from a predominantly State-led service to a situation today where approximately 80% of nursing home services are provided by the private sector.

Approximately 22,500 nursing home residents are supported by the State through the nursing homes support scheme - the NHSS or fair deal - of whom approximately 80% reside in private facilities. Some €1.4 billion has been allocated for the fair deal in 2022, including approximately €350 million of contributions from residents.The net cost to the State is over €1 billion annually, or just under one twentieth of the overall health budget in 2022. This will increase to nearly €1.5 billion for 2023. Private nursing homes received nearly €1 billion in payments under the fair deal scheme in 2021, including contributions from residents. The funding that is allocated per NHSS-participating resident to each private nursing home is agreed between each nursing home and the National Treatment Purchase Fund, NTPF, and prices are renegotiated when agreements expire, which is usually after between one and three years.

The average size of private nursing homes is increasing year on year. This is particularly evident in Dublin, where the average size of new nursing homes is close to 100 beds. There is a trend in nursing home ownership away from small or single-facility operators towards larger corporate groups with multiple facilities. Irish-owned nursing homes accommodate approximately two thirds of nursing home beds. The latest figures indicate that the top 15 private providers, all of whom own or operate five or more nursing homes, contribute 40% of nursing homes beds, which is 10,700 beds.

There are approximately 35,000 people employed in private and voluntary not-for-profit nursing homes across a range of clinical and support roles. The HSE also employs approximately 22,000 healthcare assistants, who work as members of multidisciplinary teams. The agreed cost of care charged to the NHSS for publicly-run HSE nursing homes in 2022 is €1,698 per resident per week, and the latest average price for private nursing homes is €1,073 per resident per week. As expected, this rate varies across the country. Public nursing homes are often staffed at a higher nursing ratio per patient level that allows public HSE-run community nursing units, CNUs, to deliver more complex care where required. CNUs have a higher average cost of care than private nursing homes. The difference between average public and private nursing home costs has widened in recent years and was exacerbated during the pandemic. The difference between average costs of care is kept under review by the Department. Last year, 4,500 residents were in HSE-run community nursing units. The HSE will always step in where a resident's needs are sufficiently complex that they are not able to be cared for elsewhere in the community. That is important. The HSE needs to be staffed to deliver that kind of complex care. It is the Department of Health's aim is to move, over time, towards a needs-based model of funding and pricing for the nursing home sector.

State funding for the nursing home sector is at its highest ever. Despite this increased Exchequer investment in recent years, the sector faces a number of urgent challenges including funding, governance, staff recruitment and retention and the overall stability and sustainability of the market. Looking to the future, it is essential that all future plans for the nursing home sector continue to prioritise the best interests of residents while seeking value for money for the Exchequer. The programme for Government commits to a range of reforms, including integration of the nursing home sector into the wider health service; clarifying clinical governance arrangements; enacting legislation to support fair deal for farmers and businesses, which has been done; ensuring no residents are charged for services they do not use; extending the remit of the patient advocacy service to residents of nursing homes; and enhancing safeguarding within the long-term residential sector.

In response to the acute shortage of care workers against a background of rising demand for care, I established a cross-departmental strategic workforce advisory group in March 2022. The advisory group was tasked with examining and formulating recommendations to address the challenges in front-line carer roles in the home support and long-term residential care sectors. The report of the strategic workforce advisory group on home carers and nursing home healthcare assistants was published in October. It presented 16 key recommendations related to recruitment, pay and conditions of employment, barriers to employment, training and professional development, sectoral reform, and monitoring and implementation. I strongly endorse all of the recommendations and I can confirm that their implementation has commenced.

In 2014, a task force on staffing and skill mix for nursing was established to support the determination of safe nurse staffing and skill mix across the health and social care sectors. Phase 1 of this initiative focused on general and specialist medical and surgical care settings in adult hospitals in Ireland while phase 2 focused on emergency care settings. In February 2021, a task force was established to develop a safe staffing and skill mix framework for residential care, work on which is ongoing. A staffing model based on resident need is being piloted across nine sites, including private, public and voluntary nursing homes, with a view to developing and rolling out on a national basis in 2023.

Looking at the pricing of long-term residential care, the 2015 review of the nursing homes support scheme recommended that a review of the pricing mechanism used by the NTPF in relation to the NHSS should be undertaken. The NTPF review of pricing system for long-term residential care facilities was published last year, and it made four initial recommendations. The first was that the NTPF undertake a formal assessment of the use of a formulaic approach. Second, the NTPF should undertake a formal assessment of the approach to the assessment of the local market price. Third, the NTPF should engage with nursing homes and their representatives in relation to enhancing the internal NTPF review process. Fourth, it recommended the development of an approach to funding that is cognisant of service users' level of care need. A steering group chaired by my Department has been established to oversee the delivery of these recommendations. While the NTPF is advancing the first three recommendations, the fourth recommendation is being progressed by my Department in the context of the development of a resource allocation model that will cover the continuum of long-term care. This work is complemented by the ongoing implementation of the wide-ranging recommendations of the Covid-19 nursing homes expert panel report and the 2021 value for money review of nursing home costs.

I would like to discuss the issue of nursing home closures. The closure of nursing homes can put pressure on other local health and social care facilities and it is vital that the welfare of residents is ensured. As of today, 17 nursing homes have closed or have officially notified the Health Information and Quality Authority, HIQA, of their intention to close since the start of 2022. Over the same period, four new nursing homes have opened, which translates to an approximate net loss of 50 beds. It is important to note that nursing home owners may choose to exit the market for a variety of reasons, for example, due to retirement. I wrote to the HSE in early September to request that it engage with any nursing homes that have informed HIQA of their intention to deregister as a private nursing home and to investigate whether any viable solutions could be found.

In addition to addressing policy challenges in the medium and longer term, the Government has responded to the challenges nursing homes have faced during and since the pandemic. To date, over €145 million in funding has been delivered to private and voluntary nursing homes through the temporary assistance payment scheme, TAPS. TAPS Covid-19 outbreak assistance has been extended to the end of this year. If any nursing home is currently in an outbreak situation, it can claim funds. Private and voluntary nursing homes have also received a substantial package of non-financial assistance throughout the pandemic, including the provision of free PPE, staff accommodation, training, Covid response teams and more. Access to supply lines for PPE, medical oxygen etc. is still provided free of charge by the HSE to all nursing homes, on both a precautionary and outbreak basis. As of 31 July 2022, private and voluntary nursing homes had received €67.5 million of PPE from the State. More recently, the Minister for Health and I launched the temporary inflation payment scheme, TIPS, with €10 million in funding to support private and voluntary nursing homes with their increased energy costs. All private and voluntary nursing homes that have an agreement with the NTPF under the fair deal scheme can apply for up to €31,500 in vouched energy increases from 1 July 2022 to the end of December. Nursing homes will be able to claim 75% of their year-on-year energy cost increases, up to a maximum payment of €5,250 per month.

The Government will continue to support the nursing home sector. We remain committed to ensuring that long-term residential care for older people continues to place residents' care, well-being, standards and best interests at the centre of development.

Eugene Murphy (Fianna Fail)
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I thank the Minister of State. I am sure all Senators would join me in acknowledging the great work she does. It is hard to get all things right but she and her officials make a real effort. I think that is acknowledged by the House.

I was to be the lead speaker on this but I cannot be in two places at one time. With the agreement of the House, I will instead call on Senator Dooley to take that slot.

Timmy Dooley (Fianna Fail)
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I appreciate the opportunity to speak on this matter. I welcome the Minister of State to the House and join with the Acting Chair in recognising the tremendous enthusiasm, effort and energy she has put into her brief. I know first-hand the work she does. I have seen her visit a number of facilities in the constituency of Clare, an area I know well.I have seen the way she deals with Department officials, with nursing home owners and with patients. She is universally regarded and liked by all, not only because of her warm approach but also due to her understanding of the detail and her tenacity. She is a shining example of the way that element of her Department should be led and has done sterling work. She visited Ennis some time ago when my mother was recovering from a hip operation. My mother still talks about that encounter and regularly asks how her friend Minister Mary is and I keep her updated.

There is no doubt that the nursing home care end of the health service is probably one of the most complex and difficult areas of the service. This is because it deals with people who are more often than not in the later phases of their lives and there is no easy way through. The Minister of State rightly identified that many complex cases are often dealt with in nursing homes, particularly HSE facilities. She set out very broadly the kind of operators that are there, including the community-led facilities, which are often staffed by tremendous volunteers. All the people who are involved in nursing home care are there not by choice but by necessity, often because there was no facility but there was a huge need and it grew from there. This can put an intolerable burden on the volunteers. They do not have the same economies of scale in terms of their purchasing power and they do not have the same expertise. Many of them are volunteers who come from different walks of life but the one thing they have in their core is a desire to make the lives of their patients as comfortable and as good as they possibly can and they do that to a great extent.

The family-run businesses that started as small nursing homes can struggle because of the requirements of HIQA. They may be providing care in facilities that are not necessarily fit for purpose. They are an important part of the mix, but provide a service that was acceptable 15 to 20 years ago, perhaps. They have done their best to keep up with the standards HIQA requires of them, but often the infrastructure in which they operate does not lend itself to that. There is not enough profit for them to go off and build a new facility. Then you have the larger for-profit companies without which, quite frankly, we would be in real bother. They provide a wonderful formula-driven service with great expertise and they do a very good job.

The Minister of State identified what is provided by the State under sections 38 and 39. Taken all together, it is a hybrid mix of service. It is challenging for all sides to try to have a departmental response on a universal basis. Money is the problem in all situations and it is the answer to some of it. I understand the sector and the way it will lobby. It will identify the weaknesses in some sectors and use that as a benchmark to try to create an equivalence across the service and that has to be taken into account.

There is no doubt that the service has struggled from one crisis to another. It is a fact that all of society suffered during Covid-19. These facilities struggled to keep staffing levels in place. They spent money without thinking or regard in trying to protect their patients. There is definitely pressure on some facilities as a result. We moved from that straight into the energy crisis perpetrated by Putin's war in Ukraine and the impact that has had on energy. We all jostle each other here when we reflect on how great the mild weather is, how good it is that we do not have to turn on the heating at home and how this will take some of the burden from our constituents. The few bob that is being given back in one-off grants will go further than we might have expected three months ago. However, nursing home owners cannot leave the heating off. It is on 24-7 in all these facilities. In fairness, the Minister of State has provided very significant funding to assist that transition.

There are some people in this House who do not like the fact that we live in a free market economy, but it is a fact nonetheless. Some nursing homes, because of their size and scale, are able to do better deals with energy providers. They probably have somebody in the purchasing department who has planned ahead. They are hedging by buying their energy in advance. There are others, including many of the small operations, that are struggling to keep abreast of the situation. If they are keeping in check with HIQA and keeping everything going, they may not have a member of staff available to go around and do a purchasing exercise that gives them best value for money. There is no doubt that there are people struggling in the industry. I know the Minister of State knows this. Due to their size and scale, some nursing homes are doing better than others and that is an accepted fact. The Minister of State understands more than most that there is no one-size-fits-all response. That has been the bedrock of her interaction with the sector.

I am aware from reading certain media reports that things are strained between the representative body and the Department at the minute. That is what it is. It is a feature of the jostling that goes on in lobbying and in government, which is important for keeping all of us on our toes. We have to try to get back to a point where it is more co-operative. Maybe we can do so. There are good people on all sides of this debate whose focus and intention is singularly on patient delivery. There is a role for lobbyists and people on that side. The federations involved are trying to ensure through their members that patients are well looked after. That is absolutely at the core of everything the Minister of State says and does.

I welcome the opportunity to have this debate. There are issues in the sector without a doubt. I am aware of the commitment of the Minister of State, and not just her commitment. We often talk about political commitment, journeys, outcomes in the future and visions. In fairness to the Minister of State, Deputy Butler, she has been in the job a couple of years now and my God, she has made such an impact. She has delivered. She has travelled the journey and walked the walk. She has not really been talking too much as she has been delivering on the ground and behind the scenes. I see this first-hand in my constituency. I have not said this about any Minister in the Cabinet, or anyone in the role that the Minister of State is in, but if there is one Minister or Minister of State who deserves to be retained after the reshuffle, the first one up is the Minister of State, Deputy Mary Butler.

Jerry Buttimer (Fine Gael)
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Hear, hear.

Rónán Mullen (Independent)
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We will check the record to see whether Senator Dooley has said it about anybody else.

Timmy Dooley (Fianna Fail)
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I assure the Senator that I have not. There are others I want to retain, but I have not said it.

Jerry Buttimer (Fine Gael)
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You are Micheál’s man so you have influence.

Rónán Mullen (Independent)
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Maybe Senator Dooley will be there.

Martin Conway (Fine Gael)
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We need someone in Clare.

Eugene Murphy (Fianna Fail)
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Ciúnas. I thank the Senators. The next speaker is Senator Mullen from east Galway who has eight minutes.

Rónán Mullen (Independent)
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I welcome the Minister of State. I also welcome the departing students and visitors from the Gallery because it struck me as I was listening that we are talking about a society that cares for everybody and includes people at all stages at life. People at the other end of life need nursing home care for various reasons. It is not always possible for families to care for elderly loved ones at home. Care needs can be complex and so on. We have a duty as a society to make sure we work to honour the dignity of the nursing home cohort in our population.

On my way to and from Dublin every week, I pass through the small village of Brideswell in south Roscommon. There is, or I should say was, a nursing home there called Tearmainn Bhríde, the closure of which was announced during the year. I think it was one of about 16 closures that have occurred this year. I was reading what the Curley family had to say when they were giving that very unfortunate news. They pointed out that they had plans to extend to a 60-bed more modern facility but they could not find a financial partner. We should think about the consequences of that for the people involved. The family in question would have been working very hard to find suitable alternative accommodation for the population in their nursing home for whom, I am sure, they cared very much. The reality is that the disturbance and the upheaval for people at a time of life when this is the last thing that should be happening to them is very much to be regretted.We must think of the consequences of that for the people involved who worked hard to find suitable alternative accommodation for their population in the nursing home for whom I am sure they cared very much. The reality is that the disturbance and upheaval for people at a time of life when that is the last thing that should be happening to them is greatly to be regretted. We think of the consequence of having to move from a nursing home in the local area to maybe a big town such as Athlone or Roscommon, which are near enough still but far enough to mean visitors will be fewer or the visits less frequent. That is before we talk about the job losses in the community and so on. We have a vested interest not just for the people in the nursing homes but for our communities, particularly in rural areas, to look out for those smaller family-run nursing homes.

We live in a time when there is an understandable push towards centres of excellence in all sorts of areas including medicine. It can make sense to have a larger congregated setting for certain things but the human touch must never be forgotten. Many of the family-run nursing homes have been exemplary in the care and individual attention they give to the people living in them.

I have been in touch with Tadhg Daly of Nursing Homes Ireland, NHI, who was very honest in his briefing. He told me there is nothing wrong with seeking to make a profit running a nursing home. Nursing homes are a business and that is how his members get things done. They give employment and so on, he said. Mr. Daly rightly pointed to the discrimination between funding of public beds within the nursing home sector and the funding of long-term care beds. In 2019, there were 23,000 long-term care beds of which about 4,600, or approximately 16%, were public beds. As I understand it, around 30% of the funding was going to the public bed sector. Calculating the spend per person, those occupying a public bed were being funded to the tune of €692 week more compared with the funding of beds in the private setting. One of the arguments that has been made about that in the past has been that there were more complex care needs involved for people in the public beds. This point is refuted by NHI. It cites the Department of Health value for money report. It states:

It has long been assumed that public nursing homes have a larger cohort of higher dependency/high complexity residents than their private sector counterparts. This assumption is based on anecdotal evidence only as there is no single assessment tool used to determine the individual care needs of residents in nursing homes. The study, undertaken as part of this Review attempted to test this assumption, found no discernible difference in care needs between the sectors.

That is the Department of Health’s own value for money report. Why, then, are 16% of the beds getting 30% of the public spend? The argument has been made that sometimes there are extra services available in public nursing home facilities. These extra services, as I understand it, are funded from the community care budget. In fact, the differential in terms of funding available is to the disadvantage of the private sector because private facilities have to pay the capital costs and commercial rates, whereas public facilities do not. They may also be dealing with bank repayments and loans. I cited the example of Brideswell where the inability to get a financial partner for the purposes of developing Tearmainn Bhríde for the future led to the closure of the home. There is a real issue. The question must be asked. There is no doubt as to the Minister’s personal goodwill but must we not ask why the Government appears to neglect smaller private nursing homes at the expense of larger public-funded homes?

Mary Butler (Waterford, Fianna Fail)
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Did Senator Mullen say "neglect"?

Rónán Mullen (Independent)
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In terms of the funding, yes.

Mary Butler (Waterford, Fianna Fail)
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Senator Mullen used the word "neglect".

Rónán Mullen (Independent)
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I am not talking about the neglect of persons. I am talking about the issue of neglecting the financial needs.

Mary Butler (Waterford, Fianna Fail)
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Apologies.

Rónán Mullen (Independent)
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I am delighted to give clarity. I was referring to neglecting the financial needs. By funding one sector advantageously compared with the other, then by definition that is neglecting the financial needs of the lesser funded sector. I am not accusing anybody of neglecting people at a personal level. However, there are consequences to under-funding and there is a funding issue around nursing home care. Looking at the figures another way, the HSE nursing homes receive an average fee per resident that is 60% above that payable to private and voluntary counterparts.

My family experience is that we were fortunate to be able to care for my late father at home and that was very important to us. We benefited hugely from the support of private nursing home care when it came to respite care, where my father was tenderly cared for. I do not speak out of any vested interest other than the interest of personal experience and the observation of what is available to people.

That is the core point. I am conscious that I have run out of time but I ask the Minister of State to continue to consider that funding for nursing homes is not just a matter of treating every patient equally in terms of the envelope of money that is made available by the State. It is also about supporting and protecting community-based facilities in our country for everybody's benefit.

Martin Conway (Fine Gael)
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I welcome the Minister of State to the House. It is good to see her. This can be an emotive topic but it is an important one. I fully agree with the sentiments of Senator Dooley in regard to his reappointment. I wish him well in that regard. Hopefully it will work out well.

Of course, the ambition is always to care for loved ones at home. We should as a society be doing everything we can to ensure that as many people as possible are cared for at home for as long as possible. However, that is not always the case. If it was not for private nursing homes stepping in, many people would not receive the type of care they need. There is no doubt about that. The fair deal scheme is generally fair to the families who benefit from it but it is reasonable to say that what the private nursing homes get under the scheme needs to be looked at. I know the Minister of State is committed to looking at the financial models supporting private nursing homes.

As I said, fair deal is a fair scheme but there are circumstances in which it lacks flexibility. I dealt with a case recently where a family farm had not been signed over in the required five-year period. It had only been done two-and-a-half years before and the payment the family received under fair deal was very small. There was no flexibility shown. Unfortunately, when older people are reticent or slow about signing over a farm time catches up with them. When the family then applies to the fair deal scheme they are challenged as a result. I would like a review of the scheme to provide for flexibility to deal with particular circumstances and accommodate people.

The nursing home sector stepped up to the plate during Covid-19. It was a challenging and difficult time for everybody but particularly for people running nursing homes. Most of the staff were out self-isolating because of Covid-19. Nursing homes did a very good job, by and large. International comparisons show we did very well here. I heard the owner of Marymount Care Centre on the radio with Tadhg Daly a couple of weeks ago.The challenges are immense. Senator Currie regularly speaks to the owners of the Marymount nursing home in Lucan because they are neighbours of ours. There are a lot of challenges and it is important that we ensure the financial structures supporting our nursing homes are sustainable.

Seán Kyne (Fine Gael)
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The Minister of State is welcome to the Chamber to discuss this important area. From time to time, we will all experience family members who enjoy the great care and support of nursing homes. I think of my uncle who passed away in March and attended a private nursing home under the fair deal. I think of all the carers, many of whom came from outside of this country, who are looking after our loved ones. It is important that we acknowledge that because some people have different views about immigration, but when they come to a stage where they need to be cared for they might have a different attitude given the great care and love that immigrants provide in our nursing homes.

The funding inequality between private and public nursing homes is putting a strain on the private system. The HSE has to do a job, but it is poaching staff from the private to the public sector which is putting pressure on the private system. Recruitment is important. There is a requirement under law and HIQA that there are sufficient staff to care for our loved ones up and down the country and we expect nothing less. In terms of visas, can more be done to ensure we have sufficient staff for private and public nursing homes, both of which are under pressure across the country, in particular in more remote areas?

The figures provided by Nursing Homes Ireland suggest the average fee payable under the fair deal scheme since January 2022 for HSE nursing homes is €1,674 and for private and voluntary nursing homes the figure is €1,047. The Minister of State might be able to elaborate on that, and may have done so in her opening contribution. That is putting private nursing homes under pressure.

This year, above any other, energy costs and labour demands are putting pressure on nursing homes. It is a perfect storm. There have been closures and from what we hear there will be more. That is putting pressure on all other providers, public and private. The Minister of State is on top of the issues and I hope for continued Government support for this important sector.

Jerry Buttimer (Fine Gael)
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I welcome the Minister of State and thank her for being here for this important debate. I wish to be associated with the words of commendation to her and her availability. When we meet the Minister of State on her travels, we cannot but be impressed by her warmth, understanding, competency and awareness of the issues pertaining to the nursing home sector. I say this as a former Chair of the Committee on Health. I do not come here to give the Minister of State false praise, but it is an important sector.

As Senator Mullen correctly said, the sector is about the people that we care for and love. It is about our neighbours, friends and family and ensuring that people's needs are met in the best place possible, which is in community or home settings where they can be looked after. This debate is important. We also welcome the fact that €1.4 billion from fair deal has been allocated to the nursing home sector.

The backdrop, according to Nursing Homes Ireland and Tadhg Daly, is that we have an emerging crisis. We cannot ignore the elephant in the room, namely that 16 nursing homes, comprising 500 beds, have closed. To be fair to Minister of State, she is not ignoring that and has been battling very hard for the sector.

I hope we can listen to the sector in the context of the fact that we have an ageing demographic. People are being cared for at home and in the community. Our acute hospitals - Senator Gavan will speak about Limerick and I will speak about Cork - are jam-packed. That has to be considered in the context of this debate. I hope, as Senator Dooley said, that the logjam between Nursing Homes Ireland and the Department can be brokered. We have a very good Minister of State who can broker that. She does not have an approach of hiding behind the door. She is has a very commonsense approach.

We have an issue with funding and closures. The Department policy must and should be about ensuring we work with everybody to ensure we have a nursing home sector that is fit for purpose. I asked for this debate on the Order of Business. It is an important debate. I hope we can have a rolling debate on nursing homes because they are an important part of the fabric of our care system and our older and ageing population.

Vincent P Martin (Green Party)
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Cuirim fáilte roimh an Aire Stáit. We all accept that nursing homes play a vital role in our society. They house and provide homes to some of the most vulnerable people in our society. The Minister of State quite correctly reminded us of the significant and important presence of nursing homes in our lives when she said that 562 nursing homes exist in Ireland, accommodating almost 32,000 registered beds. The Minister of State also said that there are approximately 35,000 people employed in private and voluntary not-for-profit nursing homes across a range of clinical and support roles. The HSE employs approximately 22,000 healthcare assistants who work as members of multidisciplinary teams.

Considering the significant challenges, it behoves us to support and protect nursing homes at what is a most difficult time due to demographic changes, including the latest census figures, which I will refer to shortly. We have to ensure that those providing this invaluable service to our society are, first and foremost, encouraged to stay in the business. At the moment, something is wrong because they are leaving, a fact to which I will refer later in my remarks.

The population context is a clarion call to us all because the census figures for 2022 show that there are 768,000 people over the age of 65, and they account for 15% of our population of 5.1 million. The 89,000 people aged over 85 years account for 1.7% of the population, an increase of 20.6% since 2016. By 2031, it is expected that our population of over 65s will be 1 million, an increase of 30%, and 165,000 of them will be 85 years or older, an increase of 85%. It is great news that we are living longer, but those facts require a seismic review. The Minister of State is very hard-working and is respected in the sector. Demographics are a challenge for us all at this defining time.

By 2031, the nursing home sector expects to have a total bed requirement of 45,000. There are 26,561 private and voluntary beds and they comprise 84% of the total stock, with public beds comprising the other 16%. Inflationary pressures are part of this problem. Nursing homes operate on an around-the-clock basis and have experienced an exorbitant increase in costs, principally energy and food, and receive little recognition from the State. That is what stakeholders say; these are not my words.

Approximately 82% of nursing home residents are supported by the fair deal scheme. Ultimately, nursing homes depend on the scheme for how they operate day-to-day and for their survival. The Department of Health's review in 2015 stipulated that pricing mechanisms should be reviewed within 18 months to ascertain their capacity to ensure, among other issues, that residents with a higher level of need and more complex care needs are supported by the scheme. Six years on, stakeholders will tell us that the scheme's faults identified in the 2015 report have not been rectified.

The closure of smaller centres is an issue of serious concern. The nursing home regulator, HIQA, has expressed concerns about the closure of smaller nursing homes for successive years because the fees payable under fair deal are not commensurate with the reality of the costs incurred. The combination of increased regulatory requirements, inflationary pressures and fair deal rates will continue to decrease the bed capacity available to older people in Ireland, predominantly in the private family-owned and family-operated cohort, resulting in local people not being able to access nursing home services in their own communities.Sadly, there have been a number of these closures in the nursing home sector. Simon Carswell, in his piece in The Irish Timesin October, wrote:

Two more nursing homes are closing their doors as rising costs, increased regulatory pressures and insufficient State subsidies for care continue to threaten the survival of smaller care homes.

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Nursing Homes Ireland (NHI), the representative group for private nursing home owners, said the closure of 12 nursing homes in recent weeks was a “wake-up call that can no longer be ignored”.

Tadhg Daly, the chief executive of NHI, said, "It is incumbent upon the Government to finally deliver a long-term strategy to secure the financial sustainability of the sector".

The energy crisis is most acute and nursing homes will feel the energy crisis because they are required to maintain temperatures at a certain level and have medical equipment running 24 hours a day. On a positive note, I am pleased that part of the costs will be met by Government interventions. The additional energy supports were announced as part of budget 2023. A total of €10 million in funding will be made available specifically for nursing homes, drawn from the €100 million once-off fund that has been allocated to support community-based health and social care service providers with 2022 cost increases related to energy. The Minister of State made reference to a number of schemes that will be of assistance to private nursing homes. She referred to the TAPS and TIPS, along with the provision of PPE to nursing homes. Stakeholders would say that it was the absolute necessity to ensure acute hospitals were not overrun with the transfer of residents from nursing homes that drove that generosity, much as it is to be welcomed. There would have been a bigger crisis if those schemes were not forthcoming and there would have been ramifications for the acute hospitals.

As part of the new Government supports for 2022 and 2023, all private and voluntary nursing homes that have an agreement with the NTPF for the fair deal scheme can apply for this additional support for July to December 2022. Each nursing home can apply for up to €31,500 in vouched energy increases. Nursing homes can claim for heating and electricity increases of up to €7,000 per month, with 75% year-on-year cost increases to be reimbursed up to a maximum of €5,250 per month per nursing home, backdated to 1 July 2022. The aim of the new temporary inflation payment scheme is to alleviate the pressures put on nursing homes by an increase in energy prices. It will run parallel to the temporary assistance payment scheme and the Covid outbreak assistance, which has been extended to the end of the year, and which has made more than €145 million available to date.

All this will change utterly due to circumstances beyond the policy of Government, due to demographic changes and census figures. The last thing we want is private nursing homes leaving the sector. We have to have a fundamental review. I know the Minister of State is very hard-working and is respected as a very competent Minister of State. If she cannot do it, I worry who will. We cannot afford to haemorrhage any more private nursing homes from the sector, especially given the population projections and the requirements when we reach the next decade.

Eugene Murphy (Fianna Fail)
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I am sorry for pushing the Senator on but we have a limited amount of time for the debate. I am sure he understands. Before we move on, I note that former Senator Michael Mullins came into the Gallery there. I just wanted to put on the record that he was here with Senator Aisling Dolan and some of his friends from Ballinasloe. I know him very well. He is a gentleman and a former Senator of this House. Some of the Members might meet him around and tell him we wish him well.

Paul Gavan (Sinn Fein)
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It is good to see the Minister of State. I acknowledge her work and her commitment in this area. I will start by painting a picture of the stark reality facing the health system. More than 2,000 nursing home beds have been lost since 2018, with the closure of 64 nursing homes over the last four years. At a time when hospitals are packed full, when we need step-down beds and residential care more than ever, this trend is only accelerating. Some 17 closures have been announced already this year, which is a loss of more than 500 beds in just the last few months. More nursing homes are considering closing. Many of the remaining 550 nursing homes feel they have few options available to them in the coming years if things do not change.

At the same time, more than 7,000 patients, which is a staggering figure, have been delayed in hospitals for longer than necessary because we do not have the capacity in home care or step-down and recovery facilities to discharge them on time. The Minister of State will know that is a particular problem where I live in Limerick. We lost a fine nursing home in Castleconnell earlier this year, one that provided a key service for local people. It is sadly missed. This is a major driver of delays in hospital admission from emergency departments. There are, on average, between 400 and 600 patients in hospitals every day who could and should be discharged. Greater availability of step-down, recovery and convalescent beds would take pressure off our acute hospitals.

Sinn Féin, if in government, would prioritise investment in the public system. Over-reliance on the private sector was never going to be sustainable. The Minster of State said, rightly, that 80% of nursing home sector is covered by the private market. There was never a national conversation about that. Some 30 years ago, it was 80% public. We must recognise that we need a much greater role for the public sector in the future. I will have more to say on that towards the end of my speech. That is not to say we do not value the role voluntary and private nursing homes play in providing care. What we need is a sustainable funding model. We also need to have a conversation about the fair deal scheme, the pricing mechanism and a sustainable funding model based on the changing nature and dynamics of care, which is happening and which will continue to happen.

I will deal with the issue of inflation costs. This winter, nursing homes, like so many other businesses across the State, face rising costs and inflation across the areas of energy, food and beverages and justifiable pay demands from workers. It is very clear that voluntary and private nursing homes will need to be supported through this unprecedented crisis with total cost certainty. To that end, I would respectfully say that €15 a week per resident falls far short of what is needed when it is clear from independent analysis that costs have already risen this year by more than €190 per resident per week. This increase equates to an uplift of less than 1% in public funding for nursing homes. Nursing Homes Ireland has pointed out that the temporary inflation payment scheme may lead to more closures. This is a challenge for smaller nursing homes in particular, including those run by families, which are essential to their local communities. We cannot countenance losing them or forcing them to turn down the heat. I heard a horrific story about a very cold nursing home in the middle of Limerick just this morning. We cannot afford to have more staff laid off or cut back, or cutbacks in the quality of service offered to residents. While the Minister of State has confirmed that the new TIPS or a separate scheme will allow nursing homes to claim up to €10,000, Sinn Féin does not believe this is the right way to go about it. We need a fit-for-purpose bespoke arrangement that recognises the additional burdens the nursing home sector carries. In the short term, we need support that will keep beds open and keep the heating on.

I make no apologies for highlighting the issue of workers in the sector. Further challenges for nursing homes are staff shortages and retention. There are, on average, five vacancies in every nursing home because of the lack of qualified carers and healthcare assistants. The Government has spent years expecting carers to pop up out of thin air. I acknowledge the difficulties that the sector, especially the workers, experienced during the pandemic. Years of under-resourcing, on top of the health emergency, was a recipe for disaster and the toll on workers and families was horrific. In light of the sacrifices made by workers in this sector, it is beyond a joke that they have yet to be paid their pandemic bonus more than a year since it was first promised. In recent weeks, some of these workers have been contacted regarding making the payment. That is welcome. I hope it will be paid in time for Christmas for all these workers.

We must deal with the issues of low pay and poor working conditions once and for all in order to address the recruitment and retention crisis in residential care. The previous solution of just stopping the HSE from hiring workers from private homes did not work. It was never going to work. The funding model going forward must be underpinned by a collective pay agreement that ensures a common pay standard for workers across public, voluntary and private organisations, from the smallest care home to the largest.I acknowledge that the Minister of State has sought to have the living wage be the new minimum wage in the new HSE tender authorisation model for home care. That is progress and I acknowledge it. We need to go further.

I will not be popular for saying this but it has to be said that one reason there is a problem with recruitment in this sector is because of the poor terms and conditions. Underpinning that is the fact that the vast majority of private nursing homes refuse to recognise trade unions. How can that possibly be justified? How can we have workers in the public sector, who rightly have unions and people to come out and defend them, when the private sector denies those rights? I know this personally. I was a union organiser before I was lucky enough to get in here. Whenever I organised workers in a nursing home, whether in Tipperary or Limerick, they were immediately fired for choosing to join a trade union. I will read out a standard contract from the sector. It states that the company will require workers to work a variety of shifts, which include days, nights, evenings and weekends as part of the workers' normal working week. It states that as the company's primary function is the care of its residents on a 24-hour basis, workers are required to be flexible in their hours of work, as from time to time they may be asked to provide cover for other shifts. It states that their rate of pay includes an additional 3.5% premium which is paid for working a shift pattern, which includes working unsociable hours and Sunday work, for example, night duty, weekends, and so on.

Would the Minister of State work under such a contract? This is the elephant in the room. Private, for-profit nursing homes do not pay their staff enough. Fundamentally, they do not recognise their right to be represented by trade unions. My key request of the Minister of State, in the difficult work that she has in future, is to raise that difficult question with private nursing homes. We need an employment regulation order to be put in place. That can be done by getting trade unions to negotiate with private sector employers. We can then have a basic level of decency in pay and conditions that will lead to less turnover of staff and build a more solid future for workers and the sector. That is the only way that this can happen. Unfortunately, the biggest roadblock to that is nursing home private sector employers. That sector needs to be tackled.

I am calling for much greater supports for these nursing homes because of the crisis that we face. It has to be coupled with recognition that the workers in that sector need to have their voices represented. In the past couple of years, we heard plenty of voices from trade unions in the public sector about what workers faced during the pandemic. We never heard from a private sector trade unionist in the nursing home sector because they had not been given that voice. For me, as a trade unionist and as republican, that is a key issue that has to be tackled. I wish the Minister of State well with that task.

Frances Black (Independent)
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I warmly welcome the Minister of State to the Chamber and thank her for the work she has done in this area. I acknowledge the great work she has done. I am aware that she is passionate about this. I am glad that we are having these statements on the nursing home sector. Caring is the future of work. While Ireland remains one of the youngest European populations, our demographics are changing as we live to greater ages and birth rates fall. Our ageing population means that we need to think about how we make jobs caring for old people now and in the future attractive, fulfilling and well-compensated. Currently the nurses, healthcare assistants and home helps that provide this care are, without a doubt, significantly underpaid. I know the Minister of State is aware that they do work that is physically, mentally and emotionally taxing for low wages, often in difficult working conditions. Care workers are often women and the sector employs a significant number of migrant workers. The low wages that care work commands reflect the low levels of trade union membership and the prevalence of precarious work. They also relate to historical trends of the work undertaken by women and by migrant workers being undervalued.

As a member of the Joint Oireachtas Committee on Health and as chair of the Sub-Committee on Mental Health, I hear constantly about how recruitment issues due to high costs of living, inadequate pay and housing problems, especially in Dublin, are negatively impacting our ability to provide people with the healthcare they need and deserve. Similar shortages of teachers and bus drivers are impacting the provision of other essential public services. These jobs are essential. The pandemic brought that fact into sharp focus, yet they are rendered increasingly unattractive due to inadequate pay and working conditions. These jobs are the low carbon jobs of the future. To create a just transition to a carbon neutral economy and society, we need to empower workers to enter these sectors. We must face the reality that privatisation has facilitated a decline in working conditions and worse outcomes for workers and consumers.

I welcome the report of the strategic workforce advisory group on home carers and nursing home healthcare assistants that came out last month. It had 16 key recommendations relating to recruitment, pay, conditions of employment, barriers to employment, training, professional development, and so on. I am happy to hear the Minister of State endorses all the recommendations and can confirm that their implementation has commenced. I would love to hear more about that in the Minister of State's concluding remarks.

I support the efforts made by this Government to advance the vision of Sláintecare, which I think is a brilliant strategy. We need to think ambitiously about the framework of a public healthcare system. We also need to think about how that idea of universal access and public provision relates to the care of old people. Our response to the closure of private nursing homes and the resulting loss of beds should not just be about giving more money to private operators. Research has shown that carers employed by the HSE make more money, enjoy better working conditions and have much higher rates of trade union membership than those working for private companies. In the US, research has shown that the acquisition of nursing homes by private equity firms increased the short-term mortality rate for residents by 10%. That is fantastic. Private equity firms are snapping up nursing homes all over Ireland. This should be a source of major concern. I agree with Senator Gavan on this issue. We must take decisive action. Privatisation has failed. We need a national care service that can provide the kind of comprehensive, high-quality care people deserve, delivered by well-paid, unionised care workers who are treated with the respect and the appreciation they deserve.

Paul Gavan (Sinn Fein)
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Well said.

Frances Black (Independent)
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We must also speak about the protection and empowerment of older people living in nursing homes. People living in residential care communities often need support in asserting their autonomy and expressing their desires and concerns. This requires robust regulatory, advocacy and decision support frameworks to operate in tandem with one another. It is vital that the Assisted Decision-Making (Capacity) (Amendment) Bill be enacted as soon as possible to facilitate the long-awaited operation of the decision support service and the abolition of wardship. This must go hand-in-hand with increased supports for the provision of advocacy services for older people, particularly those in residential care settings. I know the Minister of State knows about the recently published annual report of Sage Advocacy, which noted that it is receiving an increasing number of referrals. Those people are coming to Sage Advocacy with cases of increasing complexity. It is vital that advocacy services for people in residential care facilities receive adequate support. We must ensure that the voices of residents are heard in the running of these institutions and in the political decisions that are made about them.

I also want to use this time to highlight the calls from the Irish Association of Social Workers and others for adult safeguarding legislation. I recently attended the virtual launch of the association's position paper on safeguarding legislation. It has done vital work sketching out what adult safeguarding legislation should look like. It must be human rights-based, include mandatory reporting for certain circumstances, facilitate inter-agency data sharing and co-operation, and provide for real sanctions for care providers which neglect their duty of care to residents. This legislation is long overdue. My Civil Engagement Group colleague, former Senator Colette Kelleher, introduced such a Bill in 2017. It was mired on Committee Stage when the Government insisted that research from the Law Reform Commission was needed for the Bill to advance. The commission has not been able to deliver the report so far and I am dismayed at the lack of legislative progress in this area. I was really heartened by the Minister of State, Deputy Rabbitte’s, comments at that event that she would see to the introduction of legislation if there are further delays.

The people living in Irish nursing homes are people who have provided this country with decades of work, both paid and unpaid. They played their part in building a modern, economically prosperous country and they deserve the highest standard of care. I believe that a national care service would be best placed to provide that care.I believe that a national care service would be best placed to provide that care. If we pay workers what they are worth, we get better results. In the meantime, we must make sure that nursing home staff are paid wages commensurate with the difficult and essential nature of their work, and that residents are protected and empowered by effective and complementary regulatory, decision support, advocacy and safeguarding systems. Protecting the comfort and dignity of nursing home residents needs to be a central priority.

I would like to echo what others have said around the Minister of State's work in this area. I know how hard she works in this area and I know it is something she is extremely passionate about. I would also like to see her retained in the role going forward, particularly around mental health. I hope the Government honours its commitments to introduce and enact long-overdue legislation in the area of adult safeguarding. I thank the Minister of State again for the work she is doing in this area.

Eugene Murphy (Fianna Fail)
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I thank Senator Black. Her co-operation is always first-class. The next speaker will be Senator Fiona O'Loughlin, to be followed by Senators Maria Byrne and Aisling Dolan, who are sharing time. Senator Sharon Keogan then has five minutes. If there is two minutes left at the end of the speaking time of the next Acting Chair on the rota, who is Senator O'Loughlin, she can give it to me. If not, that is okay. I call Senator O'Loughlin.

Fiona O'Loughlin (Fianna Fail)
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I appreciate the opportunity to speak on this and I thank the Minister of State, Deputy Butler, for joining us. It was great to see her this morning at the launch of the Samaritans report. I acknowledge the tremendous work the Samaritans do throughout the country. Both the Minister of State and Charlie Bird were inspirational. I know it is an area the Minister of State is passionate about and cares about. Within a few hours, we are discussing two elements of her area in regard to mental health and older people.

We are all extremely conscious of the excellent work that is going on in nursing homes, where people are looking after vulnerable people. We are relying on an element of trust because when people go into a nursing home, they are vulnerable and rely on others to give the appropriate care and support to them. We are conscious of the financial challenges that are faced by the nursing home sector in terms of the cost of living and the inflationary cost increases. It is important there is an appropriate response. Obviously, it is a priority for all of us that nursing homes that provide care to residents under the fair deal are helped to manage the temporary energy inflation costs and that the residents’ lived experience and comfort are not affected. For these reasons, the Minister of State, Deputy Butler, and the Minister, Deputy Stephen Donnelly, announced a new scheme last week, with €10 million to support the private and voluntary nursing homes with the costs of energy inflation. That will certainly do a huge amount to alleviate the problems that are there.

It is worth repeating that every nursing home can apply for up to €31,500 in vouched energy increases. The fact that nursing homes can claim for heating and electricity increases of up to €7,000 per month is important, with 75% of year-on-year cost increases to be reimbursed up to a maximum amount. That can be backdated to 1 July 2022, which is very fair.

I have heard comment and received emails in regard to the add-on charges or discretionary charges in nursing homes. It is important to clarify that the nursing homes support scheme covers core living expenses. Obviously, residents need to have an element of choice in how they spend their own money on extras, such as social programmes and getting a daily newspaper or a hairdressing service. That is very important for quality of life. It is important that there are systems whereby the nursing home can provide that service but that is obviously an add-on cost, an additional charge, and there needs to be complete transparency around that. At the moment, there seems to be a lack of transparency around these charges and also, unfortunately, we hear anecdotally that clients are being charged for services they do not avail of. I use the word “anecdotally” because it is something we hear about, and we also sometimes hear about a flat charge being levied due to the increased costs associated with Covid. It is important that we bring that sense of reality into the debate we are having. I note it is important that there are extra services.

I had reason to visit a nursing home in Listowel last week. I was visiting a friend of mine, a fabulous man from Athlone who was living in Dublin but at the age of 58 he has had to move to a nursing home, which is very sad. He is in Listowel because he has a great community supporting him there. He had lived in Newbridge at one stage of his working life, and that is how I got to know him. It is an old nursing home but the staff are fantastic – they are absolutely amazing. I know Paul has brought great life to the home. I had a great conversation with him. I have to applaud him as he had just graduated with a master's degree in climate change the day before. It was incredible.

People sometimes go into a nursing home because they are incapacitated in some way but they still have so much life to live, so much to offer and so much capacity. We have to ensure that where they have that capacity, our society and community, including the work the Minister of State does, enable that living and support the people who are there, in this instance, to support Paul in what he wants to do with his life and to ensure he has that quality of life to enable him.

I wish the Minister of State continued good work in her advocacy and her support.

Eugene Murphy (Fianna Fail)
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Before I leave the Chair, I welcome Councillor Sarah Kiely and all of the nice people from Limerick. I know Senator Maria Byrne is particularly pleased to have them here today. All I can say is that when I am in the Chair, Senator Byrne is a lady to deal with. Enjoy your day. You are very welcome.

I ask Senator O’Loughlin to take over the Chair.

Fiona O'Loughlin (Fianna Fail)
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I call Senator Maria Byrne, who is sharing her time with Senator Aisling Dolan.

Maria Byrne (Fine Gael)
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I want to add to the Chair's remarks in a welcoming Councillor Kiely and the guests from Limerick. It is lovely to see them in the Gallery.

I thank the Minister of State for coming to discuss this all-important issue. I acknowledge the work she has done in this area and also the staff who work in nursing homes. Given the situation with Covid, we are coming out of a very difficult time and we must acknowledge the work that staff put in with regard to nursing home care and looking after people. Many people were perhaps bedridden so staff needed to go that extra mile.

Nursing homes went through very difficult times, which I acknowledge. I also compliment Tadhg Daly and his team in Nursing Homes Ireland as I know they have been very much to the forefront in highlighting the different issues that nursing homes are facing. It is frightening to think that at least 18 nursing homes have closed down since 2019, and Senator Gavan referred to one closing in Limerick recently. Nursing homes, especially smaller, family-run nursing homes with less than 40 beds, create a great community and as they are family-run businesses, they develop a relationship with the people who are in their care.

It is not just older people who are in nursing homes. A friend of mine ended up in a nursing home for almost five years before she passed away, and she was in her 30s. She had a very rare form of dementia at the time. I used to go out to visit her every week and I saw the care and attention that she and her family received. It was very sad because she had very young children and her husband and family would not have coped only for the care and attention she received in the nursing home. It was a smaller nursing home and she was like part of the family there.

I understand that extra supports are not available in some situations. Some people need more care than others, in particular people with dementia. My understanding is that extra funding is not given to nursing homes to look after people who, unfortunately, end up with dementia.

I see my time is up. I compliment the Minister of State. As a final point, there needs to be equality in terms of the payment to public and private nursing homes.

Aisling Dolan (Fine Gael)
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I thank the Minister of State. I welcome her to the House, along with the councillors who are present. We also have representatives from Ballinasloe who are part of that group, Séamus and Cathal, who have joined us and represent business groups in Ballinasloe.

The HSE came to the fore during the Covid crisis to support nursing homes with personal protective equipment for staff and oxygen. I know those supports continue but we have had nursing home closures in my area, including the 25-bed Stella Maris nursing home in Athlone and Tearmainn Bhríde nursing home in Brideswell. The family running the Tearmainn Bhríde nursing home had planning permission to expand it to 60 beds but could not get a financial partner to allow them do that. The nursing home in Kiltormer closed but is now being used for families fleeing Ukraine. In regional and rural areas, where the Minister of State is from, people want to stay close to home, the reason being they can have visits from their family. How can families visit if it is all going to be private nursing homes that are major providers with 100 or 200 beds in the middle of Galway, Dublin or Cork cities? What happens to all the people who are living in rural areas when their families cannot visit them? Is there any way that we as a State can look at how we can support networks of smaller private hospitals to come together for greater volumes and efficiencies in costs? We could look at supporting them to maintain their premises in local areas, while allowing cost efficiencies through their coming together and working together around recruitment.

So many of our rural nursing homes offer supports in the form of step-down facilities for our hospitals. If the Minister of State talks to the general manager of Portiuncula University Hospital, the majority of patients there are probably in their 70s and 80s. They are staying there because there is nowhere else for them to go. If beds are closing, and we are losing beds in 17 nursing homes that are closing, we need Sláintecare to support our hospitals, step-down facilities and primary care. We need to look at ways the HSE can think in a smart way about supporting these smaller nursing homes. Otherwise, we will lose them. We are losing them in our rural and regional areas and we are left with these major and, I know, very necessary larger nursing homes but these are, more than likely, in city centre locations. That will not benefit anyone in rural or regional areas. From that perspective, I ask the Minister of State to look at ways we can support smaller nursing homes.

Sharon Keogan (Independent)
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I, too, wish to be associated with the previous remarks and to welcome Councillor Sarah Kiely and her guests to the House.

There is a story about the anthropologist, Margaret Mead, who when answering the question about what she considered to be the first signs of civilisation in a culture, her answer was a femur or thighbone that had been broken and healed. In the animal kingdom, a broken leg signals death as it means the animal cannot walk to find food or drink and cannot escape from predators. No animal survives a broken leg. The existence of a healed femur meant that someone had taken the time to stay with the injured party, had set and bound the wound, carried the person to safety and tended to that individual during his or her recovery. That selflessness and care for others, the sense of community and duty beyond the self, is where civilization starts.

The people being cared for in these nursing homes we are discussing are among the most vulnerable in our society. They deserve the highest level of care we can give. I have spoken with people involved in the private nursing home sector and asked them what the main challenges facing Irish nursing homes are today. Their answers were definite and unanimous. The hike in energy prices is impacting these homes greatly. As one can imagine, a nursing home is not exactly the type of place where a few machines can just be switched off, so many of the tips that work for homeowners cannot be applied there. The €10 million allocated across private nursing homes is, I am afraid, a drop in the bucket when spread across the more than 500 nursing homes we have in the country.

Recruitment is a constant struggle. So many representations have been made to the Department of Justice by industry representatives regarding the stringent restrictions on employing healthcare workers and assistants from abroad. I am told that the threshold of €27,000 for a healthcare assistant, HCA, to be allowed into the country is a massive barrier. HCAs will earn this in Dublin, but not outside it. Could this be examined? Perhaps a lower threshold could be introduced for workers to be employed outside Dublin, àla the Department of Housing, Local Government and Heritage’s first home scheme. However, this points to a wider issue in respect of salaries. According to an independent review conducted by an economist for the NIH, the private nursing home sector requires €65 million in funding to bring its healthcare workers’ salaries into line with the HSE pay scale.

The nursing home sector, like all healthcare sectors, is facing into a tough winter. Bed capacity is the primary concern. The sector lost 474 beds last year due to homes shutting down, mainly smaller ones in rural areas. The service has become financially unviable. While lost bed capacity is often made up for on a national level by large new builds, these are rarely in the same areas as those that close down, which puts pressure on families and other homes. This lack of bed capacity will have a knock-on effect for our hospitals. Often, a hospital patient is approved for a home care package, but there is no capacity to deliver that service, as the HSE similarly lacks HCAs. In order to free up a hospital bed, the HSE will contract a nursing home bed as a step-down until such time as a HCA becomes available to make good on the offer of home care.

It is very much the case that the feeling on the ground is this will be a particularly tough year. The staff retention crisis is not that hard to wrap one's head around. It takes a full year of full-time training to complete the necessary Quality and Qualifications Ireland course in care of the elderly in order to work as a HCA and, in return, most of these workers are earning in the region of €11 to €12 an hour. Is this really how much we value this essential work? At the end of the day, HSE nursing homes are getting a 60% higher fair deal rate than private homes, and so can pay higher wages and pensions. Private homes want to do that too but simply cannot; the maths does not add up. Industry representatives have stated that the fair deal is being unequally managed and is unfit for purpose, and the vital services being provided by private nursing homes cannot continue if the State does not offer the necessary support. A major review is needed and major changes must be the result.

I wish the Minister of State well. She has been very good in her portfolio. I have no idea where the reshuffle will take her-----

Mary Butler (Waterford, Fianna Fail)
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Neither do I.

Sharon Keogan (Independent)
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-----but I am sure that no matter where she goes she will serve that Department very well.

Eugene Murphy (Fianna Fail)
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I will keep my contribution brief because I chaired this debate up to a few minutes ago. Whatever the reshuffle is, I hope it is right for the Minister of State. Many comments were made in her favour. I will refer to when, some time ago, she visited the Roscommon-Galway region. I saw the respect she has for older people from watching how she engaged and sat down with them. We spent a day on the road and met so many groups. The feel-good factor for everybody involved was fantastic. I hope that she is allowed to continue that work for a long period because she is very good at it.

I will make a few very brief comments. I will not repeat much of what has been said except to say that we all acknowledge staff and what they do. Senator Kyne brought up a very important point about workers from abroad who work in this sector, who are very caring and very good with people. I hear this over and over again. Sometimes, a challenge for private nursing homes relates to older buildings and HIQA. We have to acknowledge that HIQA does a very important job but when improvements have to be made to an older building, it is more difficult. That is a challenge for some private nursing homes.

I will return to a point that was mentioned already. Three nursing homes have closed in my area. Tearmainn Bhríde, near Athlone, was mentioned. There is another at Ballyleague, Lanesborough, which is right beside me, that is now occupied by other people. At the same time, we have another difficulty, because there is now a planning difficulty at the Sacred Heart Hospital and Care Home in Roscommon, which has been a fantastic centre for older people and to which this Government has committed another 50-bed unit, including financially and otherwise. There is an issue with the building and bat flight paths, and the project has been held up as a result.I just hope that a way around this will be found and this matter can be sorted out. If we cannot get this unit up there, then it is going to be very difficult for the older population in County Roscommon and in the Galway region.

Generally, however, I compliment the Minister of State and the Government. Help has been provided to this sector in many respects. The nursing homes know that although they still face many financial challenges, without the financial support they would not have got as far as they have now. The battle is still ongoing. I again thank the Minister of State for coming in. This has been an important debate. Let us hope that at all times we are committed to doing the very best for our older population. They have served our country and done their duty and surely it is up to us now, because we will get to this stage as well, to give them every support.

Mary Butler (Waterford, Fianna Fail)
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I thank all the Members who contributed. I am looking forward to being able to respond on some of the issues raised. It is a great opportunity to be able to come into the House. I always find that the contributions are balanced and measured. They differ, but at the same time this is a great opportunity. I wish to clear up some points because I do not agree with everything said regarding the private nursing home sector. I am making every effort to support reform in and to improve our nursing home homes to ensure everyone who needs residential care enjoys a good quality of life. The one thing we must remember in this regard is that nursing homes, whether they are public, private or voluntary, are our loved ones' home from home. This is more than likely where they will end their day and must be acknowledged.

Fair deal is the budget I will get from 1 January 2023 to 31 December 2023. It is my job to ensure that budget will be sufficient to look after the 22,500 people who live in nursing homes next year and that it does not run out. Some of the Members might remember that a few years ago this budget did run out and people were waiting for up to 12 weeks to get into a nursing home. I will not allow this to happen. The turnover from a successful fair deal application to entering a nursing home is four weeks. I have kept this time steady for the past two years.

The private nursing home sector is very different. For example, €2.3 billion has been invested in the private nursing home sector by European investors since 2020. In August 2022, Bartra Healthcare sold four nursing homes to a Belgian real estate investment trust, REIT, in a deal worth €161 million. On one side of the equation then, we have the nursing home sector being seen as a viable process for some investors, while on the other side we have the voluntary and small, family-run nursing homes that are struggling. It is a complicated issue.

Senator Martin quoted a comment suggesting there was little recognition by the State. I must say I am disappointed in this. I know that it was not the Senator's comment but something said to him. A total of €145 million was allocated through the temporary assistance payment system, TAPS, in the past two years. This is still ongoing for any Covid-19 outbreaks. Some €67 million was provided in personal protective equipment, PPE, and oxygen supplies in the past two years, and this is also ongoing. Last week, the Minister, Deputy Stephen Donnelly, and I announced funding of €10 million, backdated to 1 July 2022 and running until the end of this year, to support inflationary costs. We will review this aspect again. The private nursing home sector was paid €1 billion in fees last year. If this is little recognition from the State, then I am at a loss. One-twentieth of the health budget was paid to 22,500 nursing homes last year. I just want to make those points.

Senator Mullen also referred to the value-for-money report. It is possible to look at reports and pick the bits we like. I am therefore going to pick the bits I like. The value-for-money report clearly shows that there is a higher level of staffing in public nursing homes, with a higher nurse to health care assistant ratio. The conclusions of the value-for-money report referred to by Nursing Homes Ireland relate to an examination of a small sample of five nursing homes. The report itself cautioned against relying on those results. We can, therefore, take different parts of the report and decide which piece might suit us the best.

To return to what I said at the start, there has been much talk of discrimination between public and private nursing homes. Last year, 4,500 residents were in HSE-run community nursing units. The HSE will always step in where residents' needs are sufficiently complex that they are not able to be cared for elsewhere in the community. The HSE needs to be staffed to deliver this type of complex care. This is a fact. I have spoken to people in the community nursing units and visited them. I have also spoken to the head of the older persons' section in the HSE. I was interviewed on the radio last week and I had only just come off when I got a text from someone managing one of the community nursing units saying it has residents that go into hospital from a nursing home but, unfortunately, those patients deteriorate and then they go to the community nursing units. This is because of the standard of nursing supports available to support them.

I agreed with a great deal of what Senator Gavan said. Planned sectorial reforms must happen. I am not one bit happy that I inherited a situation where 80% of nursing homes are private. There should be much more public provision. One of the things I am working on now is a new funding stream for nursing homes that are dementia-specific. Like Carebright in Bruff in County Limerick, which I visited, and St. Josephs in Shankill, 70% of people in nursing homes may have a diagnosis of dementia or be showing signs of dementia. This is a huge number. We certainly need dementia-specific facilities across every CHO. There are currently two streams in the fair deal scheme, the public and the private. I am putting a stream in the middle of those which is only for dementia-specific places to support people to come into the community. Many have looked at the situation in Carebright in Bruff but felt it was not financially viable. I want to make it financially viable to support people and to have these dementia-specific places. This is important.

Paul Gavan (Sinn Fein)
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Well said.

Mary Butler (Waterford, Fianna Fail)
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To touch on the temporary inflation payments scheme, TIPS - we have TAPS and we have TIPS - for nursing homes, it has been bandied about that this amounts to €15 per person. This payment was not per person but per nursing home. If any of the Members wants to get out their phones and look at their calculators, this payment is for 433 private nursing homes. They have 18,000 residents and €10 million has been allocated. If everybody were to draw down this funding, then this scheme would actually amount to €13 million. If anybody wants to take out their phone and do the calculation, it will be found that the amount is not €15 per person. I will say no more, but this figure has been bandied about in the public domain for the last two weeks. To be honest, I am disappointed that a scheme brought forward to support private nursing homes facing financial challenges in the context of inflation was torn apart before it even got the chance to start. Some nursing homes, however, have contacted me and welcomed that they will be able to claim €31,500 from 1 July 2022 to the end of December 2022. We will review this situation again. Again, I have a budget to work within and I must try to do my very best in this regard.

Another thing I wish to say is that I was disappointed in Senator Mullen's comment regarding neglect. I do not wish to be associated with any comments regarding neglect. All the people in the nursing homes sector are doing their best. I refer to the work done by the staff during Covid-19, through the most difficult of times. Covid-19 bore down hardest on the nursing home sector. We have an ageing population and this is something we should celebrate. Older people will never be a liability. They are an advantage to us. Their lived experience can never be forgotten. We must do the very best we can in this regard.

This is not a black and white issue. I meet many healthcare workers and I was delighted to adopt the strategic workforce advisory group's recommendations. The three most important of those are: that healthcare workers will receive, as per the next tender, the living wage; they will also receive mileage; and that we will also move to a situation where we can bring staff into the healthcare system from outside the EU. Some 17,000 people have come in on work permits from outside the EU to work in the nursing home sector. I got these figures during the week. I hope there will be a big difference when we do this in respect of home care.

I once again thank everyone. I appreciate that some of the Members sat here throughout the entire 90-minute debate. I again thank the House for giving me the opportunity to address the issue of the nursing home sector.