Seán Crowe (Dublin South West, Sinn Fein)
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The purpose of this meeting is to discuss the healthcare and related needs of older persons and the general scheme of the health (amendment) (licensing of professional home support providers) Bill 2024, of which the committee is carrying out pre-legislative scrutiny. To continue our consideration of the matter, I am pleased to welcome from ALONE Mr. Seán Moynihan, chief executive officer, Mr. Frank Dillon, head of communication and fundraising, and Ms Gráinne Loughran, senior policy and advocacy officer. The committee also invited Sage Advocacy to the meeting, but it indicated it was not available and conveyed its apologies. It sent us its views on the legislation, for which I thank it.

I will read a note on privilege. Witnesses are reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity either by name or in such a way as to make him, her or it identifiable or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if their statements are potentially defamatory in respect of an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with any such direction.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable. I also remind members of the constitutional requirement that they must be physically present within the confines of the Leinster House complex in order to participate in public meetings. I will not permit a member to participate where he or she is not adhering to this constitutional requirement. Therefore, any member who attempts to participate from outside the precincts will be asked to leave the meeting. In this regard, I ask any member participating via Microsoft Teams to confirm, prior to making his or contribution to the meeting, that he or she is on the grounds of the Leinster House campus.

I invite Mr. Moynihan to make his opening remarks on behalf of ALONE.

Mr. Seán Moynihan:

I thank the committee for inviting us to contribute. ALONE is a national organisation that enables older people to age at home. In 2023, ALONE provided support to more than 36,000 older people. We have staff and volunteers in all 96 community healthcare network areas. We are also part of the work of the national enhanced community care programme. To make the most of the time allotted to us, we will first speak on the home care legislation and then on the healthcare and related needs of older people in their communities from ALONE’s experience.

To provide context, ALONE is a founding member of, and provides a secretariat to, the Home Care Coalition. The coalition is a group of more than 20 charities, not-for-profits and campaigners, including organisations that work with older people, people with disabilities and people with long-term illnesses, organisations that work directly with carers, and groups that work in the primary care sector. ALONE and several of and our colleagues in the sector believe that the recommendations of the Law Reform Commission's report on the legal aspects of professional home care, which was produced in 2011, still hold some validity. Some of these should be considered as part of the review, if they have not already been considered.

For several years, the Home Care Coalition has met quarterly with the home support reform team in the Department of Health. We have provided input to various areas relating to the statutory scheme through meetings and consultation processes. Recently, coalition representatives also met the Department of children for the first time in respect of disability and PA services.

While ALONE welcomes the Bill as the beginning of licensing home support providers, we acknowledge that Ireland is behind in delivering a statutory home support scheme. We have concerns about the regulations that will be underpinned by the Bill. We have been informed by the Department that the regulations are now largely finalised and out for legal drafting. We hope that the committee can also consider the draft regulations as part of the process of pre-legislative scrutiny.

During the consultation process, the Home Care Coalition raised concerns about the regulations. Wording instating a minimum educational requirement was removed from them. We were informed that the reason for this removal was to allow for keeping the door open in order to future-proof the regulations in terms of new qualifications. ALONE's concern is that this offers a loophole for home support providers to not have a minimum educational requirement in place. Minimum education and training for home support workers to provide an acceptable level of service should be a minimum requirement of a regulated sector.

The regulations do not apply to a home support service provided by a person to three or fewer service users. While recognising the difficulties that regulating this would entail, we believe this will enable the continuation of informal care whereby a carer for one or three people can continue to work unlicensed and unregulated. Such carers will therefore remain open to exploitation in terms of pay and conditions and those availing of this care will also be at risk regarding the standard of care they receive. To the best of our knowledge, and as per the regulatory impact analysis published alongside the Bill, there are currently no plans to regulate home care workers working on a private individual basis in this way.

We have other concerns about the home support scheme and development of the statutory scheme. The work of the strategic workforce advisory group has been hindered by the recruitment freeze in the HSE. No progress has been reported on the group's recommendation that there should be a significant increase in the proportion of home support hours and packages provided directly by the HSE. Delivery of an equitable statutory scheme will not be possible while there is overdependence on private sector providers. In addition, the process was flawed, in that there was no benchmarking of the number of workers at the start of the process versus now, so we do not have accurate information on what the situation regarding workers is.

The commissioning process for home support is problematic in terms of offering any level of security for not-for-profit providers and workers. All not-for-profit providers work under precarious conditions because of how the HSE's commissioning works. As soon as a client goes into hospital or residential care, the provider and, by extension, the worker stops getting paid.

Last year's tender pricing model, by virtue of not funding travel expenses and only partially funding travel time, ensured that private providers were increasingly only taking on clients who were close to where workers were based. Otherwise, the services became loss making. This impacts rural, hard-to-reach and high-traffic urban areas. HSE workers, by virtue of the tender, get first right of refusal of a client, but given they only comprise 40% of the market, those they refuse tend to be the harder-to-reach clients or need support outside normal working hours. The HSE does not provide for weekends or overnights.

The home support service has moved away from traditional "care", such as basic cleaning, changing of bedsheets, etc. This service is vital for older people who are physically frail. We have seen a significant increase in older people looking for support with these basic tasks where they cannot afford private cleaners. This significantly impacts on people’s quality of life, as their housing conditions and welfare decline.

Despite multiple reports by the Department of Health, there has been no progress in identifying a suitable funding mechanism for home support. We are concerned by reports of a fair deal scheme for home support, given the extensive bureaucratic process of the actual fair deal scheme.

Currently, our home support services operate based mainly on trust. There are no regulations, no standards, no independent oversight and very little data, so any progress must be welcomed.

According to the Social Care Institute for Excellence, home care services are often experienced as impersonal, inflexible, underfunded and poorly integrated. They are not designed around the older person, but dependent on organisational structures and who is providing the service.

As we welcome this Bill, we take the opportunity to urge the committee, the Department and the Government to consider health and social care supports for older people more broadly and to support the design of services, with the needs and rights of the older person at the centre of the process. As for the healthcare needs of older people, it has always been our mission to support people to age at home and the health issues I address today are what we see that older people need to age healthy and well at home. The advantages of healthcare being shifted into the community are twofold. First, it will reduce admissions to acute hospitals where it is safe and appropriate to do so and, second, by enabling a “home first” approach, people get to be treated and recover in their own environment.

A core focus of ALONE’s model is linking community and acute services to enable all groups to work together to meet demand. It is strategically designed to bridge the gap between various agencies and services, establishing ALONE as a critical link in the continuum of care. Our evidence comes from a report we produce each quarter that examines what older people need and what their emerging needs are. It is a detailed report and provides a view of what ageing at home in Ireland is like. We have submitted the latest edition from the first quarter of this year and links to the previous reports.

I will move on to the primary healthcare services. Older people experience considerable issues in accessing primary care, including with regard to public health nurses, occupational therapists, GPs and physiotherapists. Of the one in three people reporting to ALONE for GP or primary care issues in 2023, the majority required support engaging with a public healthcare nurse and the second most prevalent issue was support in accessing occupational therapy. While we support older people to engage with PHNs, where available, and access to occupational therapy, both pose a significant challenge. They are pinch points in the system of community care and, for different reasons, are very important. We ask for a review of the staffing levels of these strategic roles and to prioritise recruitment, where and when needed.

Regarding loneliness and mental health, general health issues are the top reasons people look for support from us and, of these, loneliness is the main category. Last year, two thirds of older people who accessed our services experienced loneliness or social isolation some or all the time. The European Commission’s research suggests Ireland is the loneliest place in Europe. ALONE has over 7,000 engaged volunteers who give their time to support and befriending isolated people in their communities yet commitments to develop an action plan to combat loneliness have not been realised.

ALONE is a co-founder of the loneliness task force, a cross-generational coalition working to end loneliness in Ireland. Earlier this year, we launched the loneliness task force research network to provide primary evidence of the issues as they present in Ireland. We call for funding and resources within the Department of Health to deliver the plan to combat loneliness as outlined by the loneliness task force. In May, we welcomed the Seanad motion calling on the Government to live up to this commitment.

Mental health difficulties remain a significant issue among older people. In total, 2,405 people assessed by ALONE in 2023 indicated they had issues with their mental health. The most prevalent mental health issue was dementia or Alzheimer’s, followed by depression and anxiety. Research published this week by Aware and supported by ALONE has found that 34% of older people experience mild to moderate depression, 41% experience mild to moderate anxiety and 14% considered ending their lives in the last 12 months.

Last year, we addressed the Oireachtas Joint Sub-Committee on Mental Health on the significant mental health difficulties being experienced by older people and we would request an update from the committee on this report. In addition, we have been engaging with the national implementation and monitoring committee, NIMC, in relation to the implementation of Sharing the Vision actions relating to older people. We have been told the decision to establish a specialist group relating to older people’s mental health remains under review pending an update of progress later this year. We call for this specialist group to be established under Sharing the Vision as a priority. Given the levels of mental health issues, some of them unique to older people, we hope to see a similar focus to what we have seen with child mental health. It should not be an either-or but a recognition that all areas of equal importance.

The link between health and housing cannot be overstated. We note that the Institute for Healthcare Improvement states that the different inputs that make a good healthcare system are 40% socioeconomic, 10% physical environment, 30% health behaviours and 20% healthcare. It is a holistic view. I have included the links on health and housing and given this committee’s brief, we want to highlight two specific areas.

The first is housing adaptation grants. At least 50% of all housing adaptation grants that ALONE works with older people to secure are for bathrooms. This is to increase access and ease of use for basic hygiene needs. The recent increases in funding only bring the grants available to 2010 levels. Engagement with the Department of housing revealed that increasing funding for the grants being negotiated with the Department of public expenditure is challenging, in part because the value for money and cost savings provided by the grants are of benefit to the Department of Health in terms of falls, prevention and delay in accessing hospital or nursing home care, rather than to the Department of housing. Any health or social care worker will speak to the need for funding for these grants yet there does not appear to be significant co-operation between the two Departments to advocate in this area. Put simply, these grants prevent falls. In our report, falls were identified as the primary physical health concern among older individuals, reflecting the critical intersection between housing adaptations and mobility challenges. Making homes safer is crucial for preventing falls and maintaining older adults’ well-being.

The second issue is housing with support. The lack of inter-departmental work is also holding back progress on the delivery of housing with support. Committee members may be aware that the first housing with support demonstrator project will be up and running in Inchicore before the end of 2024 because of considerable collaboration between ALONE, Circle VHA, the Departments of housing and health, the HSE, Dublin City Council and others, and is part of Government strategy. It is an example of how housing options between home and nursing home can be provided and offer older people independence and dignity. However, it is not replicable in its current state as the funding mechanisms are not replicable and several elements of the funding are once-off arrangements between the two Departments. Suitable funding structures to enable further developments have not yet been established.

Given the estimated increased demand for nursing home care in the coming years, the findings of the Housing Agency relating to the financial benefits of investing in supported housing for older people and the stated aim to provide care in the community, we call for cross-departmental structures to deliver this, such as were committed to in 2019.

Seán Crowe (Dublin South West, Sinn Fein)
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Thank you. I invite the members of the committee to discuss the matters raised. I call Senator Conway.

Martin Conway (Fine Gael)
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I thank ALONE for accepting the committee's invitation to engage on this matter, particularly the area of pre-legislative scrutiny. I have an initial question. How much engagement has ALONE had with the Department ahead of this legislation? What has been the level of that engagement? Does ALONE feel the engagement has been productive? Does it feel it has influenced the legislation?

Mr. Seán Moynihan:

I will answer first and Ms Loughran may wish to add to that. We are engaging on this with the Department and we have probably been through three principal officers and several Ministers over five years with those quarterly meetings. It has been a process where, as the project in the Department has gone forward, we have tried to produce inputs that the whole of the sector agrees on. We want to be as helpful as possible and to provide people with inputs from the sector to make sure the voice of the older people we all represent is heard from the ground up. In some ways, as we go forward with these things, some elements of the submissions and asks that were there in the first iteration seem to be rolled back because people are concerned that the implementation of policy may be more difficult.

Martin Conway (Fine Gael)
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Overall, then, ALONE has been disappointed.

Mr. Seán Moynihan:

We welcome the fact it is happening.

We have been very dedicated, as an organisation but also as a team player in the NGO sector, to ensuring, acting at a mature level, to speak with one voice to the Department. We feel that there are critical elements regarding quality, training and treatment of the workforce in respect of which more could have been done.

Martin Conway (Fine Gael)
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Yes.

Mr. Seán Moynihan:

We realise that between policy and implementation is when things sometimes get changed. That might be the process we are in at the moment.

Martin Conway (Fine Gael)
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ALONE would welcome that as a start, as I think we all would. If I understood it correctly, the quality of education and training was provided for in the Bill and then this was removed. Is that correct?

Ms Gráinne Loughran:

It was in the draft regulations. The last update that we received was that the regulations were out for legal drafting. We are not exactly sure the point they have reached. We know they were removed partly because of feedback, potentially from private organisations which stated that the need for QQI level 5 would negatively impact the current recruitment challenges, the delays in the QQI certification process and the need to not be too restrictive in the regulations. Apprenticeships and traineeships for home support workers were reported to be on the table, with the possibility of mirroring the process put in place for nursing home care assistants. After a follow-up, we are informed that the reason for the removal was to allow for keeping this open in order to future-proof the regulations for new qualifications that might come on stream.

Martin Conway (Fine Gael)
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Is it fair to say that it was a practical reason and that if this was part of it, they could have a challenge in the context of recruiting staff and, potentially, retaining existing care workers because they might not necessarily have the qualifications?

Ms Gráinne Loughran:

Yes. We want to use nursing home staff as a comparison. In 2018, the role of the healthcare assistant was reviewed by a steering group and a report was published in December of that year. Among the recommendations made by the steering group was a proposal of a QQI FETAC level 5 healthcare assistant would become the minimum required qualification for entry to that role. Also, according to a recommendation contained in the COVID-19 Nursing Homes Expert Panel: Final Report, nursing homes are continuing to implement the recommendation that "All Healthcare Assistants ... should have a relevant QQI Level 5 qualification or be working towards achieving it." This is or is in the process of being implemented in the nursing home sector.

Martin Conway (Fine Gael)
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Being practical about it, in terms of somebody doing a few hours of home help, were this legislation to get over the line, as it will, was that minimum requirement there? There are probably many people who would not have that qualification and who have no intention of getting it but who provide good care to people in their homes.

Mr. Seán Moynihan:

Like any employer, we are all responsible for training and developing staff in such a way that they have the capacity and ability to do the job.

Martin Conway (Fine Gael)
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Yes.

Mr. Seán Moynihan:

In some ways, it is a situation whereby, ultimately, the contracts are for very large amounts of money in some cases. The reality is that we expect people to train staff because they would otherwise be putting untrained people into one-to-one situations.

Martin Conway (Fine Gael)
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I get that. The chief executive mentioned the child care sector earlier. We are in a situation whereby thousands of people who are minding children at home will potentially not be able to benefit from the tax incentives, grants or whatever. I would hate to see the sector over-regulated and, as a result, people would walk away from the profession while hundreds of millions of euro of taxpayers' money are going into this area. It is a difficulty. I can see where the Department is coming from. Let us see how the Department wades through matters to find a solution, because this aspect could be one of the main sticking points.

Ms Gráinne Loughran:

There is also the strategic workforce advisory group whose role it is to improve recruitment and retention in the sector. We believe that the role of workforce improvement and engagement increase should really be the role of that advisory group rather than taking action within regulations for education and training.

Martin Conway (Fine Gael)
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I have some questions on the general work done by ALONE post pandemic. How much has the pandemic impacted on loneliness in this country? We all have examples in our constituencies of people who have not ventured out of their homes much post pandemic. Has ALONE done research on the matter? Is there data on how much people's loneliness has increased following the Covid-19 pandemic?

Mr. Seán Moynihan:

ALONE has campaigned and worked to combat loneliness for several years. The pandemic gave people a real insight into and understanding of loneliness. Evidence based on research indicates that loneliness will shorten a person's life and their physical and mental health. That evidence has existed for many years across many meta studies, etc. The reality is that large number of people did not quite understand the effects of loneliness previously. Unfortunately, the pandemic expanded the rate of loneliness where people who had never been lonely all of a sudden ended up in a world where they were lonely. For us, combating loneliness features in three Government strategies. There is a commitment in the programme for Government to produce strategies to combat loneliness. We lead the loneliness task force and a research network. We want to produce evidence-based proposals for the Government. ALONE has really struggled post pandemic to keep up with the number of older people reaching out to us. The Senator's observation that some people have never re-emerged is probably correct. The evidence from the Institute of Public Health and from our quarterly reports show two things, namely that large numbers of people are coming to us and that many are struggling.

Ms Gráinne Loughran:

ALONE produced the enhanced community care report. I think copies of this were circulated with our annual report for 2023. The report shows that 8.8% of the people who came to us due to experiencing loneliness said they had not been out socially in over a year. That percentage remained consistent throughout the year. We have seen an increase in the number of people contacting us who really have not re-emerged.

Martin Conway (Fine Gael)
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How is ALONE funded? Is it mostly funded by means of State aid? Is it funded by foundations and legacies? How does it keep the show on the road?

Mr. Seán Moynihan:

It is a mixture of three elements. ALONE is an approved housing body, so funding comes from our housing. We also fundraise and we are part of the HSE's enhance community care project.

Martin Conway (Fine Gael)
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I never realised that ALONE is an approved housing agency. How does that in with ALONE's mission statement?

Mr. Seán Moynihan:

It is all about supporting people to age at home. In some ways, the situation predates my time, and I have been there for 15 years. ALONE has always provided housing. Strategically, we have moved towards a situation whereby if people age at home and we provide support, and then to nursing homes. We have really moved into the space of trying to develop housing with on-site support.

Martin Conway (Fine Gael)
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How many housing units does the organisation own?

Mr. Seán Moynihan:

We have around 140 units.

Martin Conway (Fine Gael)
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Does ALONE plan to expand its provision or just to contain it?

Mr. Seán Moynihan:

We have lodged a planning application with An Bord Pleanála for another 40 units. Our real focus is housing with staff on-site support, as an alternative to nursing homes.

Martin Conway (Fine Gael)
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Is the housing provision very specific?

Mr. Seán Moynihan:

Yes.

Martin Conway (Fine Gael)
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Is it group housing in settings where support for older people is provided?

Mr. Seán Moynihan:

Yes.

Martin Conway (Fine Gael)
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That is great.

Seán Crowe (Dublin South West, Sinn Fein)
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So independent living, which is great. Deputy Patricia Ryan is next to speak.

Patricia Ryan (Kildare South, Sinn Fein)
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I thank our guests, whom I have met before in my role as Sinn Féin spokesperson for older people. I thank them for being here.

I wish to follow on from Senator Conway, who asked about the incidence of loneliness. Like the Senator, I want to know whether the problem existed pre Covid or whether it has emerged since.

I have a few questions about the state of mental health among older people. What are the demographics? Is it mostly males or females who suffer most from mental health problems? Will our guests provide an insight in that regard?

Mr. Seán Moynihan:

On the general statement on loneliness, we have given people the language required. The levels of loneliness were always a feature but the pandemic exacerbated the situation. Just as people say it is all right not to be okay when addressing mental health among younger people, we have been trying to destigmatise loneliness and give people the language, ability and strength to reach out, the ultimate aim being to have everybody realise that ending up lonely is not a personal failure but, rather, a feature of life. You retire and may lose a spouse or partner, or your health may be poor. Those over 80 sometimes spend up to 80% or 90% of their time in their own homes. As people age, they sometimes lose social groups, and family sizes change. Really, what we have been trying to do is destigmatise. Some aspects of the loneliness have always existed but I hope we have now given people the language to deal with it. Empirical evidence and research indicate how dangerous loneliness is to people, young and old. Loneliness-----

Patricia Ryan (Kildare South, Sinn Fein)
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What is the mental health services waiting list for our older generation? If they need to see a psychiatrist or other such individual, are they left waiting for a long period? Are there any statistics on that?

Mr. Seán Moynihan:

I will check whether we have any statistics to hand. The reality, even regarding something simple and compared with the position on other conditions, is that there is no NGO for the mental health of older people. It is probably because a generation grew up – I am close to it myself – that did not get the education in school and elsewhere on minding your mental health and did not understand it. In some ways, the language and services never fully developed.

Patricia Ryan (Kildare South, Sinn Fein)
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In that case, should we be requesting that the Department of Health make more progress on advertising services that meet the needs of elderly people with mental health issues?

Mr. Seán Moynihan:

The reason we produce our statistical and ECC reports is to give people a sense of emerging needs. Of the people we assessed in the first quarter of this year, 25% were struggling with mental health issues, including anxiety, depression and loneliness, or dementia and Alzheimer’s disease. A large cohort on the ground is struggling with these. Again, services may not have been developed and there may not have been an understanding that those in old age are as affected as the young.

Patricia Ryan (Kildare South, Sinn Fein)
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What effect is the recruitment embargo having on older people? Are there any statistics on it?

Ms Gráinne Loughran:

We do not have specific statistics. Anecdotally, however, we found that the recruitment embargo has had an impact across the board, be it in terms of home support or otherwise. It is a question of staff across the HSE in general. With regard to mental health, we found that older people must wait for quite a long time to access services such as counselling in their local communities. We have cited a Mental Health Commission report on mental health services that was produced in 2020, and we met members of the joint Oireachtas subcommittee on mental health last year. The report was quite damning in respect of mental health services for older people and, in this regard, referred to the lack of acute beds and the need for further action. There is quite a wide body of evidence in this area. The research carried out by Aware this week and supported by ALONE shows a slightly higher level of mental health difficulties among older women, but an issue we find with data like that is that older men are sometimes less willing to talk about the difficulties they are experiencing. There might be a range of factors that have an impact in this regard.

Patricia Ryan (Kildare South, Sinn Fein)
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Regarding those factors, is the cost of living having an impact on mental health, particularly the mental health of those on social welfare or the pension?

Ms Gráinne Loughran:

We are waiting for the results of our pre-budget survey of this year. Last year, we conducted a survey on the impact of the cost of living on the older people we work with. Much of the feedback indicated that being unable to afford a social outing, for example, was having a significant impact. Being unable to afford to keep the heating on or pay bills, for example, increases stress and anxiety levels. This is all having an impact on many of the older people we work with.

Patricia Ryan (Kildare South, Sinn Fein)
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It was said that the approved housing body has 140 units and that there is a planning application for another 40. Are they rural or urban?

Mr. Seán Moynihan:

Most of them will be in Dublin. Although we are across every community in Ireland, the reality is that the housing is in Dublin. For us, the future is housing with on-site support. We are probably moving away from the current housing model towards trying to meet the emerging need and fill the kind of gap that is filled in other countries. We envisage that some of the stock will change over time.

Patricia Ryan (Kildare South, Sinn Fein)
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Are there many rural houses?

Mr. Seán Moynihan:

We do not have any at the moment but we are part of a pathfinder project to find a way in which the Government and Departments can obtain urban and rural examples of on-site support to create a new housing choice for older people, rather than just nursing homes, and keep them in the community.

Patricia Ryan (Kildare South, Sinn Fein)
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Given that Mr. Moynihan’s organisation does not have many houses of its own in rural areas, what is its view on local authorities regarding housing adaptation? Is the process very slow? Is there a long waiting list?

Mr. Seán Moynihan:

We made freedom of information requests to all local authorities just before Christmas last year and found that roughly 3,500 people are waiting. Some do not keep waiting lists, so the numbers are not fully accurate, and everybody keeps numbers in different ways. The system is slow and cumbersome. We have done a lot of work with other NGOs and have produced reports, dating back to 2017, to help with streamlining and to reduce the number of assessment forms to one. However, the reality, as we all know, is that every increase has just been swallowed up by building inflation in recent years. We are really at 2011 levels but the demand for the grant is so much higher given the nature of things. The system is so worried that people might benefit, that their house prices could be augmented or that somebody else could do well, and that is why we point out that in one of the quarters last year, 50% of all those we were helping with grants were getting them for bathrooms. A disability bathroom will devalue your house because, after a probate sale, the chances are that somebody will have to pay to take it out.

Patricia Ryan (Kildare South, Sinn Fein)
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I will conclude because I am conscious of the clock. I thank Mr. Moynihan for his response.

I have been made aware of instances where significant numbers of carers are caring for one person, based on a rotation of perhaps three or four carers in a week. I have an issue with this, particularly where the person cared for has dementia or Alzheimer’s disease and will not be familiar with the carers coming to them. Is ALONE coming across that?

What is the position on fundraising?

Ms Gráinne Loughran:

I will take the question on home care. There are generally changes in care throughout the week. At weekends and overnight, for example, it is likely that there will be agency staff or private providers. We find it depends on the person in that some prefer to have different carers looking after different needs, while others prefer consistency in care all the time. The latter is probably more common but there is a range of preferences. Carer consistency and knowing who is going in and out of the home are really important to older people, their families and others involved in the care.

Mr. Seán Moynihan:

We might send the committee a note on that. We have done some research and evaluation on this. Obviously, consistency is a desire. Other countries have done some work on this. I just do not have the details in front of me, but we might send a note to the committee afterwards about what other countries have done to alleviate the problem.

On the question on fundraising, we are an NGO, so we fundraise, the purpose of which is to meet emerging needs, as the Deputy will see from our reports. We operate in the gaps in the system, usually addressing loneliness and such conditions. We fill the gaps until statutory bodies get to them.

Ultimately, we use the funding to invest in innovation and change, whether that is use of technology for older people, the volunteer programmes and all those types of things. It is to ensure we have the ability to respond as we see the changing needs while then working with all the Departments and all our partners in the NGOs to try to fill the gaps or create models of services that can be rolled out nationally to ensure those gaps get closed over time.

Patricia Ryan (Kildare South, Sinn Fein)
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I thank the Chair.

Ms Gráinne Loughran:

We have been engaged with the Department for several years. We meet with it quarterly and throughout that time we have found it to be quite proactive in engaging with the coalition in offering opportunities to provide feedback and input, whether that is through the meetings we have with them or the various consultation processes. As for input on the particular heads of the Bill, etc., that is slightly separate. It has more been on the regulations as that has been ongoing. There has also been more verbal, I would say, feedback on the licensing process of home care providers.

Mr. Seán Moynihan:

That is a really good question. We have drawn on our experience, but because we sort of provide the secretariat and the relationship with the Department of Health for the coalition, a lot of what we have presented are the position papers of the coalition. That is on the basis we realise that for TDs, Governments and public servants our sector is sometimes described as very fractured or having too many NGOs. In reality there are levels of co-operation where in matters like this we come together to try to produce one voice in what we are saying so there are not mixed messages.

Ms Gráinne Loughran:

In saying that, there are other members of the coalition with various areas of expertise. There are providers, for example, whereas ALONE is not a provider. There are organisations that work with people with disabilities that have higher levels of expertise than we might in particular areas. It is just to recognise that too.

Mr. Seán Moynihan:

The Deputy is probably already seeing it. There is data available that has been published by the Department of Health and the HSE. Obviously, in high-density, easy-to-move-around areas a lot of private contracts are awarded. As per our submission, the HSE then also has first choice. In more rural or more hard-to-reach places we are going to have a situation where the NGO providers are left to do that and some of that may be done at a loss or possibly not at all. Ultimately, there must be something here that levels the playing pitch. Our fear around the privatisation of this is a situation where people may cherry-pick what is very profitable and not go into a situation to ensure there is community access. With things like VHI in the past there have been measures like community rating to ensure there is equal access. Something like that needs to be looked at to ensure we do not end up in that situation.

Ms Gráinne Loughran:

That is a challenge raised by many members of the coalition that are home care providers. The difficulties caused include how the new tender has set an overnight hourly rate of €5 per hour below the daily hourly rate for what is a premium, awake, overnight service. It is unsustainable for a lot of not-for-profit providers to deliver overnight services for almost 20% below daily services. That is not something that is delivered by the HSE. It is outsourced, so it exclusively affects the not-for-profit and private providers. That causes difficulties with many of the smaller providers that are in a lot of ways already on the breadline, to put it like that, when it comes to maintaining sustainable funding for their services.

Ms Gráinne Loughran:

Yes, but there is differentiation in what is done with the income that comes through.

Ms Gráinne Loughran:

Yes.

Ms Gráinne Loughran:

I believe it has.

Mr. Seán Moynihan:

It has been by those in the Home Care Coalition that are providers. I am not aware what the answer was, but if we have it we will send it on.

Ms Gráinne Loughran:

We wrote to the Minister with that information as well.

Mr. Seán Moynihan:

The wider point the Deputy brings forward is a bit like with the privatisation of the nursing homes and the health system in general in that sometimes we end up in places we did not intend to end up, if that makes sense. It happens by stealth because we are not watching out for what could happen. We feel that if we have a strong NGO system, a strong healthcare system and absolutely a private system then older people will benefit from quality and choice rather than having a situation like we have ended up with for nursing homes where around four private providers around 10,000 beds. That leaves us with motivation matters and the restriction of the services that are provided.

Mr. Seán Moynihan:

Both of them are probably covered by the current recruitment freeze. While we would welcome the implementation of Sláintecare and the likes of enhanced community care, where more people have been employed in the community, these gaps are going to lead to people needing more care, possibly needing higher levels of home support or possibly needing to go into nursing homes prematurely on the basis of the provision of some of the basic practical tasks of health and hygiene having been reduced, given we do not provide basic home care tasks. On top of that, without occupational therapists and primary healthcare nurses, the critical links to the healthcare system are not really there in the community if they are not equitably available throughout the country.

Mr. Seán Moynihan:

There is a slight irony in that we live in a world of data, phones and everything else but every time we try to plan something, there seem to be huge gaps in data, and that has been our experience sometimes when we push back.

Neasa Hourigan (Dublin Central, Green Party)
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I welcome our guests. Am I right in thinking that sometimes, when there is an issue with home care support, a relationship breaks down or there is some kind of difficulty, their organisation supports its service users through that process?

Mr. Seán Moynihan:

We operate in the gaps. As we say, the older person positions our service, so we go in and assess what the support needs are. We might go in to deal with loneliness and then learn there is something wrong with the roof, so we fix that, or there is something wrong with the heating. We operate in those gaps. If someone has a difficulty in accessing home care, we will act as the advocate to get that and, ultimately, help them through the system. There are multiple complex systems within the Government. In the Department of Social Protection, for example, older people can get eight means-tested benefits, all of which use different forms with different criteria and so on. Ultimately, they are about getting people the finances they need to remain at home, and it is the same in the case of home care. If something breaks down, we may end up in the middle of that with support from colleagues.

Neasa Hourigan (Dublin Central, Green Party)
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I think all the politicians on this side of the room will recognise the need to help people with the myriad long forms they face.

What are some of the ways ALONE has come across those relationships breaking down? What issues are coming up for people? Is the home care support that is offered not enough, is it offered at the wrong time or is there interpersonal relationship breakdown? What are the issues ALONE comes across?

Mr. Seán Moynihan:

I will speak in general terms and Ms Loughran might wish to speak to specifics. The purpose of the Bill relates to the fact that prior to this, there has been a funding-led model. There is a certain level of funding and it is a matter of loaves and fishes, with everybody trying to get things, rather than determining what one person's needs are, whether that is 20 hours a week, while another person's might be 14 hours, and so forth. It is a very difficult job, in fairness to people throughout the country in healthcare, discharging and other parts of the system. It is about how we decide who gets what number of hours. Somebody in the system will probably have worked hard to get these people any hours, so in some ways, even if they are not suitable hours or suitable connections, people are nearly stuck with having to maintain a provision that is below what they would want or what their clinician would want for them, just on the basis of people working hard to divide up what is currently available.

Ms Gráinne Loughran:

Much of the advocacy work relates to advocating for additional hours or larger packages. Moreover, where an older person might be living in a cluttered or hoarding environment, a home support worker will not and cannot enter, for the sake of their own health, so it is about advocating for all the services around that to try to engage with cleaners, get grants and so on to re-engage. We might support somebody to apply for home support but often they cannot get it because of the nature of their situation, but the nature of their situation might mean they need it all the more, and that is another challenge.

Neasa Hourigan (Dublin Central, Green Party)
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That is interesting. The issue of hoarding has arisen at the committee previously in the context of the lack of supports, given people often need a great deal of complex mental health supports to address the issue of hoarding.

One matter that arose in last week’s meeting with representatives of the Department related to the appeals procedure that might be appropriate here. What would ALONE like to see in the form of a robust procedure for service users that they would find easily accessible? One point I put to the representatives was that there was a focus in the proposed wording on working with the providers to improve their service, but that there was not necessarily corresponding language relating to a remedy for someone who has received improper care. What would ALONE like to see in the form of a complaints or appeals procedure that would serve those users and make them feel as though there was a remedy if they were not getting what they needed or wanted? I accept Mr. Moynihan's point about loaves and fishes, whereby some people are just taking what they can get, but I refer to a procedure that would work to enhance the system but also make people feel as though their rights were being vindicated?

Mr. Seán Moynihan:

Again, on the general point, to which Ms Loughran may want to add, in a lot of cases relating to healthcare, even going back to housing, landlords and so on, there is a power dynamic in the background. People have to complain to those on whom they are dependent, in a lot of cases, and in some cases for personal care, for the ability to remain independent and so on. Any complaints procedures in these areas, therefore, have to tilt the bias towards the individual because making a complaint is difficult. The individual should be believed initially while we wait for the outcome.

Neasa Hourigan (Dublin Central, Green Party)
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It is about balancing the power dynamic.

Mr. Seán Moynihan:

Yes, because otherwise there will be no complaints. As an organisation, we spend a lot of time looking for complaints. Because we provide people with services, they tend not to complain and, instead, just feel grateful, but we do not want that. We do not want any older person to end up, in our case, feeling as though they rely on a charity. In our view, we run a service for older people. We may have to be formatted as a charity, but that is not necessarily the way we want people to view us. There are some key principles we need to adhere to in setting up a complaints process, whereby we realise who the complainants are and what the dynamic is between the complainant and the service provider, and produce safeguards in such a way that people will feel as though they have the right to complain and will not lose out for doing so. That will be the most important part of it.

Ms Gráinne Loughran:

I would echo that. It is the major point. Of course, there are roles here for HIQA and the HSE, but it is about enabling older people to engage with that process, whether through the universal design and the accessibility of the language and the process, whereby people can lift up the phone rather than go online, for example. A range of elements will need to be built into that process, but the power dynamic is the significant one.

Mr. Seán Moynihan:

As I said, not all the members of the Home Care Coalition agree with the Law Reform Commission, but some do and that is why we mentioned it.

One of its recommendations is that there be a contract between the service provider and the person receiving the service on the basis that they have entitlements. The service provider is saying it will provide them, such as going back to training and so on. The recipient can challenge the provider on the basis that it said it would provide something and has not. It is not an interpersonal thing, but a case where, like any other service, someone did not get what was promised.

Neasa Hourigan (Dublin Central, Green Party)
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There is a logic to that, which would mirror other services. From what Mr. Moynihan describes there is some work to be done to centre the person receiving the service and not the system, whether that be the Department of Health, the HSE or the public or private service provider.

The organisation also mentioned regulations not applying to those providing a service to persons below a certain number, which I think was three. It was said that the standard was the main concern. Will they expand on that? Are there also concerns about encouraging what is almost a contract system where everybody is a self-employed contractor? Could such a cut-off point have unintended consequences around the structure of service provision?

Ms Gráinne Loughran:

We recognise the challenges with that. Regulating services for fewer than three people is difficult but leaving that cohort without plans for further measures would enable the continuation of a lot of the informal care whereby carers who might provide live-in care, for example, would continue to work unlicensed and unregulated. As it is, there is no data, but that would continue as it does now in the background, without fully recognising that. Those carers would therefore remain open to exploitation in terms of pay and conditions. Those availing of the care are also at risk with regard to the standard of care they might receive. To the best of our knowledge there are no plans to regulate in that way on a private individual basis. It was considered as part of the impact analysis, and the role of Coru was looked at in the context of providing individual regulations. Part of the challenge outlined was that the lead time to introduce a mandatory registration process for home-support workers would require a minimum of five years and a maximum of ten years. It also states that international evidence indicates best practice is to first introduce regulations for providers and only then is the requirement introduced for individual workers to register. We see the benefits in a tandem approach where the sector is regulated followed by a process for individual workers. The Migrant Rights Centre of Ireland, the Great Care Co-op and a lot of those organisations are strong on the role of migrant workers in particular in providing domestic and home care on a private basis.

Bernard Durkan (Kildare North, Fine Gael)
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I welcome the witnesses and thank them for their input over a number of years. I go back to the discussions we had with the founder, which was more than a couple of years ago. It was a satisfactory exchange of views. I will put it that way.

Seán Crowe (Dublin South West, Sinn Fein)
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Was that Willie Bermingham?

Bernard Durkan (Kildare North, Fine Gael)
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The one and only.

A couple of questions come to mind. The object of the exercise has to be to provide the highest quality of service possible to the widest community, and to do that effectively and efficiently. How many organisations are in the coalition and how does it operate? Does each member of the coalition, for example, have to fight for funding in its own right? Is there a central body that adjudicates and advocates for them, and how does it work? How broadly is management in contact with the wider organisations representing the coalition?

Mr. Seán Moynihan:

ALONE takes a sort of sectoral approach to change whether in models and scales of services, or in campaigning. For us and other members the coalition is where NGOs get together themselves. The funding of how it is done is among the members. We ultimately come together because we have the connection with the older people. The voice of a lot of the people we represent may not come up through the system, and their needs may not be heard. The Home Care Coalition is self-funding and where we have come together for more than a decade to track, with the Department of Health, so we know this is a vital thing in the gap between the needs of people and their preferences and what was being provided by the State. We have advocated as a group and tried to produce one voice. While we may have slight disagreements, it is where we come together to align, thrash those things out and put forward things that we all agree would make a good system.

Bernard Durkan (Kildare North, Fine Gael)
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Does that coalition encompass those involved in providing private care?

Mr. Seán Moynihan:

No, our coalition would literally be-----

Bernard Durkan (Kildare North, Fine Gael)
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What about public providers?

Mr. Seán Moynihan:

-----NGOs. It would be a mixture of service providers, advocacy organisations and general needs support organisations.

Bernard Durkan (Kildare North, Fine Gael)
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The NGO concept is fine and good. I am curious as to how all of the organisations relate. There are NGOs on one hand, but the private sector provides home care in a lot of cases and should be under the umbrella of the coalition to co-ordinate the level and quality of services that could, should and might be available. It should also be recognised that there is a vast difference between the requirements of some householders as against others, some of whom who may need a friendship call daily, weekly or whatever the case may be. There needs to be ongoing contact. In the same way, for those who require a higher level of attention, that that is possible regardless of who is dealing with it, NGOs or whoever. There needs to be an organisation that has overall responsibility. We dealt with this back when I was a member of the Eastern Health Board. The gaps that existed then are still around, unfortunately.

Mr. Seán Moynihan:

In the design of all this, the most important thing is we realise that whether it is younger or older people with disabilities or health issues, the majority of people's desire is to age and live in place. The system ultimately needs to be designed in such a way that their healthcare, social and practical needs are met so they can remain as independent and active citizens as possible.

Bernard Durkan (Kildare North, Fine Gael)
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The levels need to be laid down by the HSE or the Department of Health, and all of the organisations should converge from that point. However, in terms of meeting the financial requirements of all those organisations, to what extent is Mr. Moynihan satisfied that they all receive equal and fair treatment, and that some are not ignored or in a better position than others for whatever reason?

Mr. Seán Moynihan:

As a group, the Home Care Coalition does not campaign around funding for itself or its individual members. That is left for people to deal with themselves. It comes together really to propose the right to a home-care scheme, and to make sure there is an equitable and fair system that is well regulated. In some ways we have never discussed funding for our sector. I will speak of a different case, as CEO of ALONE.

We all know we have an ageing demographic and we all know the benefit this brings to our society. Every report we have ever seen shows that older people are net contributors to the community. There are, however, times and places where older people face either housing, health or financial challenges. The reality is that our sector - and I will just concentrate on the aid sector - is very small sizewise. In my time in ALONE, we have gone from around 75 volunteers to close to 7,000 and from three or four staff to 220 across the country. Considering the number of older people and given the data we provide every quarter on the demand for support among the ageing demographic, our sector is a little like that grant scheme in that it is probably stuck with regard to its ability to respond to a much lower population of older people than we currently have.

Bernard Durkan (Kildare North, Fine Gael)
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We can accept that. I still feel there needs to be an overall mechanism for identifying need. Mr. Moynihan said that €85 million needs to be assigned just to housing supports for older people. I agree that money is required but there needs to be some overall co-ordination of the system operating in the local authorities. I dealt with the first one in the country way back when it was a novelty. It was very successful because there was an agreement and there were plenty of people around prepared and willing to carry out the works. The works then were a much bigger requirement then than they are now because adaptation of a bathroom is a major issue for a lot of older people. It requires removal of the bathroom and replacing it with a floor-level shower tray. We are working towards one but there is no co-ordinated way for things to move into place. For some unknown reason, it becomes really expensive for all of the materials involved. I cannot understand that. Perhaps it is accepted practice that this is the level that must be paid for this. The renovation may require a shower, an electric shower and a ground-level shower tray. The removal of the existing structure is the first thing that takes place. It is not rocket science and is quite simple to do. The occupational therapists must also get involved and the scheme is very strict in the way it operates. That part is done privately and the application and older person applying must await the completion of that. I believe there is a need for continuation in the home of the level of service that is available in nursing homes or hospitals for as long as possible and practicable. We must not try to force older persons to remain in their home if they are not capable of surviving in that kind of environment because it then becomes a burden for them. There is a need for some overall body to take that responsibility, set out the requirements and make an easier reference, so that people will know straightaway that it is going to cost X, Y or Z. They will then know if they have to borrow, beg or whatever the case may be but at least people will know where they are going.

Bernard Durkan (Kildare North, Fine Gael)
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It is all very fine to come back to the Government for everything. Those in opposition have a tendency to do that. I realise it is a ready avenue for people to divert-----

Bernard Durkan (Kildare North, Fine Gael)
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No, that is for one element of the support services we need in the country at the present time. I did not interrupt the Deputy when she was speaking, even though I am not slow to interrupt when necessary.

We have to consider the overall nature of this, not one element of society at a time. Nobody is doing that. We need to recognise that we have overall responsibility. The Government and the Opposition have responsibility as well. I hope we can stick to it and avoid going down culs-de-sac and saying afterwards that we thought that was the way.

I will make a final comment. I realise that forward planning is necessary, as I believe the witnesses do, in order to identify the extent of the problem and the degree to which we propose to resolve it. It can be very easy for all of us to abdicate our responsibilities and say that someone else should do it or the Government or the private sector should do it. It will cost money, whether it is done by the public sector or the private sector. Nobody is willing to work for nothing. While many people give voluntary contributions for a long number of years without complaint, we should not have to depend upon that forever.

Mr. Seán Moynihan:

I will give a short answer to the higher level point. As a sector, we have called for a commissioner on care for the older person, similar to an ombudsman, so that, ultimately, we can hold all Governments to account over the years to implement the policies, procedures, practices and strategies that are there for older people. The experience of the age sector is that while the national positive ageing strategy was launched around 12 years ago, it never had an implementation plan, it never had any funding and around 2017 it went from a strategy to principles. Once something goes from strategy to principles, Government Departments are no longer under an obligation to respond to what is in a strategy document. Ultimately and bit by bit, it fell away. After losing 12 years, the conversation around that is restarting. I am a great believer that in the political system, the public service and the NGO sector a large number of great reports and strategies are done but we need to have the ability to hold people accountable and deal with whole-of-government issues. Having an ageing population is a bit like global warming; it will change every Government Department because every Department's customer base is changing, including the needs and designs of every service. We usually talk about pensions, health and housing and we stop there. We are barely included in the housing debate. We need to get better at those whole-of-government issues. We need to do that and sometimes this requires holding up a mirror and holding people accountable.

Bernard Durkan (Kildare North, Fine Gael)
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I thank Mr. Moynihan.

Seán Crowe (Dublin South West, Sinn Fein)
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I will make a couple of points. On behalf of the committee, I thank the witnesses for their submissions and the work ALONE does on behalf of the 36,000 older people it supports to age at home through the whole concept of independent living. I congratulate ALONE on its initiative in relation to a loneliness task force and pulling together a coalition. This is very important work. While we talk about charters of rights for people, older people probably need a charter of rights. I look forward to engaging with ALONE at some stage on how that could be pulled together. That would be a really important step forward. The point was made that, thankfully, people are living longer but there are responsibilities in relation to that right across Departments. There are also societal responsibilities. If we signed up to such a charter, it might be much easier to move forward.

The opening statement noted that home support services operate mainly on trust and there no regulations, standards or independent oversight and very little data so any progress is welcome. I made this point last week when the Department officials were before the committee. Why is there no regulation? Why are there no standards in this area? What is Mr. Moynihan's sense of why this has been left for so long? Is it because no one is speaking up for or advocating on behalf of older people? Is it just an oversight?

Mr. Seán Moynihan:

I will make a general point on that and then perhaps Ms Loughran will add something. I will go back to the point about the national positive ageing strategy. Sometimes older people are presented as if they are one homogeneous and hugely powerful group. In reality, it is a very diverse group with very different interests.

There is a huge number of older people working or running businesses, some of whom are helping out with childcare and everything else. Some people need support but it is hard to regulate or go after. If people have poor housing, health or access to finance and they are marginalised, it does not matter what age they are. Our ability to support those who need means that it has been left for a long time to be dealt with.

Ms Gráinne Loughran:

In addition, on home support, going back to 1968, the interdepartmental report on the care of the aged recommended placing home care on a statutory footing. That highlights the challenges but also should cause us to reflect on why it has taken so long and why we have gone through successive Departments and Governments, yet we are still not at the point at which we said we wanted to get to in 1968. That should be reflected on. The broad range of requirements and policy needs for older people often get left aside. Many of us do not think about what we will want for ourselves as we get older and what we want for the population as we all get older is put on the long finger. That is on a personal basis for many but also on a national basis and it is something that needs to be addressed.

Seán Crowe (Dublin South West, Sinn Fein)
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It is increasingly common that we hear of people dying in their home and they are found three or six months later or even 12 months. That was one of the driving influences behind ALONE, where Willie Bermingham came across people in various situations as part of his work and had the foresight to establish the organisation. It is a challenge. Instead of things improving, it seems like society is getting worse in many ways and there are so many people who do not have human contact on a daily basis. The point was made about the change in carers. When the Department was in we were making the point that it is not unusual for the carers to be changed on a daily basis and that has an impact on the individual. There is no continuity or no relationship built up and so on.

The witnesses mentioned the traditional tasks that would have been done such as changing sheets and basic needs like that. One would imagine that as part of well-being and health. Where did that come from? The point was made that it is more about the needs of the organisations that are delivering this rather than the individual for whom the service is being delivered. Is that where the changes came about? It seems like a basic thing. It is not just changing sheets but there is also a change away from shopping and all those other tasks. Someone might be living in an urban setting and can send off to one of the supermarkets and have it delivered but people cannot do that in rural Ireland. They depend on their neighbours and friends. If they are isolated, they are in huge difficulty. Is there any insight on why that changed?

Mr. Seán Moynihan:

That has narrowed over the years. Other Deputies pointed this out. We have strategies around healthy Ireland and it is about health and social care. It seems counterintuitive, whether it is practical tasks, cleaning or access to food, that we would narrow something in such a way as it would damage someone’s health while going in to the help them. It probably comes down to people being under pressure with the time they have to do the tasks they are given. In England, they have a terrible phrase, which I hope we do not fall into, of “care cramming”. Basically, carers come in and they have a certain amount of time and they run in trying to do the basics they can do because they have to run to their next appointment. Part of this, as we pointed out earlier, is that people are getting lower hours than those they applied for and carers have shifted from domestic to personal where they used to do some of the domestic work. People need access to both. The system needs to work from older persons outward. Older people are their own best resource. In the context of an enablement and reablement world, in some ways we are trying to get older people to maintain the skills and capacities they have to continue doing certain things they want. There will be certain tasks that they cannot cope with and that people have to come in to support them around but there should not be a rigid system where someone is given a particular amount of time to do a particular task. That might not be relevant for one person but be perfect for somebody else. When someone comes in, what they provide should be for the person’s health needs and what their clinicians and the people around them assess they need to have provided. The restricted nature of what is involved means that we will have to return to this. History resonates and we go around in circles until we resolve these things.

Seán Crowe (Dublin South West, Sinn Fein)
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ALONE made the point in its submission about safer homes and basic provisions such as the housing adaptation grant. Again, when the officials were in, the point was made that it would not be unusual for ourselves as public representatives to make an application for a housing adaptation grant and that kind of simple stuff. I gave the example of a man who was looking for a ramp to get a scooter in so that he would be able to get out of the house and live independently. He died before he got that. I am dealing with a man at the moment who is dying. He was released from a step-down facility after getting operations done. He cannot get into the bath and there is no shower. The local authority will say that it does no longer has facilities so it does not do that. These are all things that are not necessarily tied to the legislation but holistically we are talking about care for older people and these are the issues. If someone cannot get into a shower or a bath, what do they do? Do they wash at the sink? That is something many of us of an older generation will remember but -----

Mr. Seán Moynihan:

The Chair’s point is well made. Sometimes we are almost caught between centralising and decentralising. I do not know if it is still true but at one stage I was involved in something and we had case studies and so on. To get a set of grab rails, there were two different systems in County Meath alone. For grants, there are 31 local authorities. We get caught where people say they want to empower people to make local decisions but then there could be 31 different sets of variations on who gets what and how. We are a relatively small country. In some ways, we do not have strong views on the politics of that but it is about systems. Usually when we purchase a service, the system is designed to our needs. In some ways, that is all we are asking for here and that the system is designed for the older person’s need. What can be delegated locally, where it works for the older person, should be delegated locally and what does not serve that need should be prescribed by the relevant Department.

Seán Crowe (Dublin South West, Sinn Fein)
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There is a challenge of trying to get an OT to come out and look at a house. This also impacts on the health system. We visited Limerick and I was asking about people being discharged from beds and what the relationship was like with the local authority on that. Yesterday, some of us were in the North and, again, there was the same problem. If those basic facilities cannot be put in place, how can someone be released from hospital care into their home or community care?

Mr. Seán Moynihan:

In many cases, that is why we exist, where someone is getting discharged or referred for support.

We work with all the other NGOs in an area or the local authorities and we build a package for the individual to stay at home, outside of a healthcare package. There can be blockages for someone being discharged when the house is no longer suitable or there are cluttering issues. Sometimes when people are going home, they need new access to food or an adaptation made to go home. This is the type of thing that we do. We try to pull that together because ultimately, it is very hard for people to do that unless they know the system or are in the best of health, never mind if when they are in a health situation.

Ms Gráinne Loughran:

I might add, in respect of housing adaptation grants, that 13,000 grants will be funded in 2024. That is lower than the 13,500 grants that were funded in 2010. Since then, the population of people aged 65 and over has increased from approximately 515,000 to 806,000 people. The number of grants being funded is not keeping pace with the population. While it has been reported that there was an increase in Exchequer funding for the grants in budget 2024 to €75 million, that is not the case in reality. Several local authorities applied to the Department for additional funding last year, which resulted in a €75 million spend by the Exchequer on the grants. The funding for 2024 only replicates this. This goes back several years, in the context of waiting for local authorities to come knocking on doors to look for additional funding for those grants. In the meantime, as the committee will be aware, last year several of the local authorities closed access to the grants at several points during the year. They implemented spending restrictions and a broad range of ways to dampen down applications. Our support co-ordinators on the ground find that at times, when somebody needs a grant, it is more beneficial to wait and apply on 1 or 2 January. This is because the funding runs out midway through the year in some cases. It is incredibly difficult to access them in all cases, despite the various advocacy work that our support co-ordinators do locally.

The reason the housing adaptation grants are so important is because they are funded by the Department of housing. They are extremely relevant to health needs and there is a need for significantly more co-operation on that than is currently happening, that we are aware of. We are still waiting for the review of the grants. There was a commitment to publish the waiting lists for the housing adaptations by the end of 2019 but that has not been completed. We recognise that the Department of housing has a lot going on. This is, however, something we see as a health need. We recommend that members of this committee would perhaps consider looking at that too.

Seán Crowe (Dublin South West, Sinn Fein)
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I am way over time. The witnesses made the point in their submission about considering the health and social care supports for older people more broadly and to support design of services and the needs of the rights of older people. This point has been made. Last, the Bill again talks about education of the carers. I will repeat a question that was asked when the previous group was in. How important is communication between the carer and the person receiving the care? If a carer is going in and the person is deaf and the carer cannot communicate with him or her or if the person who is doing the caring does not have English or Irish as his or her first language, how important is that as part of this legislation? Do the witnesses believe it should be part of this legislation and that those needs, in addition to the educational needs, should be one of the priorities?

Mr. Seán Moynihan:

This is why, with the workforce group set up by the Department with the coalition and why, even in our own submission, qualifications matter. Whether it is domestic tasks or personal care, people must have these skills and abilities to relate to the individual and to deliver the care. Obviously, we want people to go into this area and feel valued, because it is a difficult, emotional and physical job and they need to feel trained and supported. On the other hand, we do not want to put either the older person or the staff into unsafe situations, where somebody has been asked to care for somebody and they lack knowledge of dementia, complex cases or other issues going on. It is not safe for either party, and that is where the training comes in. This would include cases where the older person may have challenges around sight or hearing. There are all types of training and support that staff need. It is vital that we keep the people that we care about in the community supported at a time when they need us the most.

Ms Gráinne Loughran:

Regarding communication, there is a line in the regulations that notes the need for the home care worker to be able to communicate effectively with the person he or she is working with, so that is noted.

Seán Crowe (Dublin South West, Sinn Fein)
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Again, I accept the point that it is an extremely difficult job. It might not be financially rewarding in many cases but it is rewarding in so many other ways for those who are involved in it, and that is the story we get. I will move to other members who are looking to come back in. Senator Kyne may go first.

Seán Kyne (Fine Gael)
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I apologise as although I heard the opening statement, I had to go to the other House. I welcome Mr. Moynihan, Ms Loughran and Mr. Dillon. First, I was surprised to see the statement that Ireland is the loneliest place in Europe. I am aware that we have a lower density of population, but is that particular to older people or is that a general statistic? Is it based on the model of housing in other jurisdictions, where there is sheltered or clustered housing? There is the odd case in the newspapers regarding the use of the rent-a-room scheme, where those living alone might rent out a room to a student. Obviously, this has a financial benefit but there is also some socialisation and someone there during the term. The witnesses might comment on that initially.

Mr. Seán Moynihan:

Unfortunately, that report on loneliness is a European report and it is a heat map that goes across the whole life course. To take the loneliness task force, which we supported and led, this had everybody from ourselves and Jigsaw to everything else, both young and old. I spoke earlier about the fractures of life, for example, retirement, bereavement or poor health and how they can lead people into loneliness. It is also that some of the services and interactions we had daily, have disappeared. Some of the supports have moved online and the digital age has affected younger people, who are less connected. I noted that primary schools produced a report two weeks ago indicating that children under ten have fewer friends now than they had a decade ago. We are seeing that loneliness come through in all age groups. Unfortunately, it is something that is again, recognised in the programme for Government and two Government strategies. Ultimately, we need to try to get plans and actions in place. For us, we are trying to set up a research network. All the NGOs, both young and old, are trying to be part of that conversation to produce evidence-based information and to try to produce the movement that we need.

I will take a step back for a second on things like the rent-a-room scheme. In our submission, we identified that ageing at home is about more than just health. It is the physical environment and the social connectivity, as the Chair has highlighted in respect of-ALONE. In some ways, again around housing, we do not necessarily include the needs of older people in the housing conversation. Housing is an issue that is affecting the economy and home care workers coming into the country. It affects everything and is expensive. Traditionally, there has been a high level of house ownership, so we leave aside what the housing needs and choices are. As a result, and we mentioned this earlier, we are trying to produce housing with support in that gap. That is, where people can remain in the community and choose alternatives. When we talk about rightsizing, we talk about how older people should rightsize but we never talk about what types of houses we are going to build for them in order that they can rightsize in their community.

What are the targets to build them? We have rightsizing policies within the Department without any numbers to back them up to say we will build those units. With regard to building those types of units, 15% of older people say they would rightsize if there was a choice within 1 km or 2 km of where they live, which would be a wonderful opportunity for them to move into high BER-rated housing that is cost-effective. We created the policy without turning around and saying we will build any of these units so ultimately it will not happen. The only people who will rightsize are those who have substantial value in their housing because then the gap between the cost of buying an apartment or something that is big enough makes sense. Other than that, for most people who are living in a three-bedroom semi-detached or terraced house it just makes no sense. It will never happen.

Grant schemes relating to housing were mentioned and also housing with support. Ultimately, we have a whole generation of older people. The percentage of older people in private rented accommodation went up by 86% since the latest census. How will we pay the rent when people retire? What will happen? In some ways, that is as big a question. It has been proven we will be able to pay the pension for a wider cohort but a deep dive has not been done into the numbers to see whether we will be able to meet the housing needs of people. Schemes such as rent a room have a part to play. We need more programmes that are intergenerational across that. There is a huge level of older people who can still contribute wisdom and knowledge to younger people. There are also situations where there is under-occupancy and if we can provide for that in a safe way, we should provide and encourage it. It is part of the wider cohort of the housing needs of older people. For older people it can sometimes sound like what can be done to solve the problems of younger people's housing. We all know that most parents and grandparents would do anything to get their children, nephews, nieces or grandchildren housing but most people just own the house they live in and would nearly need to make themselves homeless to help out any more than they have.

Seán Kyne (Fine Gael)
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I thank Mr. Moynihan. There is no one-size-fits-all approach to this because every family unit is different. Some people have children living nearby. Others have one child or three children or five or six children. Some people have a number of children but they live in different parts of the country. I have come across cases where daughters are living in Dublin but their mother is living at home and that creates difficulties. It might work in terms of remote working depending on the type of jobs the daughters have. There is no one-size-fits-all approach and family units are getting smaller in general and people are getting older. That creates longer-term issues. People are living for longer, thankfully, and where five or six years ago the issue was funding for hours now the issue is getting people to deliver the hours.

When Mr. Moynihan speaks about the fair deal scheme bureaucracy, obviously he agrees with the statutory right to home care but is concerned in case it becomes bureaucratic like the fair deal scheme is. Does he think it can be a simpler model?

Mr. Seán Moynihan:

Our clear message is about trying to build it out from the individual who is in receipt of care, whether practical or healthcare. The strategic workforce implementation group report is sitting there and there are 22 recommendations but if we are to attract people to work in this sector cutting requirements or education for them, or cutting job satisfaction or psychological safety in doing the job, will reduce the number of people who will stay in the sector. For us, it is about trying to make it a sustainable role and job that people will be attracted to.

Ms Gráinne Loughran:

In addition, regarding the fair deal-style funding that has been referenced at various points, a funding mechanism for home support has not been decided on. It is currently funded through general taxation and, as many of us will be aware, the fair deal process is complex. It is bureaucratic. We anticipate a process of that nature would likely dissuade people from going that route and instead potentially looking for support from that unregulated care sector. The ESRI report that looked into the various funding models that could be considered for home support found that once the value of somebody's home was take into consideration almost every outcome was regressive. It would increase poverty among older people and there were a range of other issues. The ESRI report did not go into that particular option in detail but those were the findings.

People use home support for significant periods. They might start on a lower level of support and increase it over a period of months or years, or they might not increase it. Home support is not the same as nursing home support and the funding model has to consider the expansive nature of home support and people's experiences of it. As Mr. Moynihan stated, it has to work from the older person out to be effective.

Mr. Seán Moynihan:

There is a slight principle that needs to be considered in some of this as well. For the fair deal scheme that means going into a nursing home, older people are making a contribution towards their care. Then, if that is being made a home care situation and possibly for people with disabilities, etc., we are creating a whole system and it possibly will end up being complex by the nature of trying to make it fair and equitable in the different situations people are in. Everybody's financial journey is very unique. Does that make sense? The challenge here is the principle for the 1,000 people who are aged under 65 and if they went home with enough home care, will they have to contribute to that? Is that what we are saying about healthcare in general? In some ways, it would be regressive. With regard to the people we are talking about and that we service, we are at 98% employment so the vast majority of people who will retire after 40 years of service to the State, working and contributing to taxes. We feel home care would probably be better paid for from taxation or a contribution and finding a way to fund it that way rather than a situation of means-testing at another end. As we said earlier, the Department of Social Protection has eight means-tested grants all with different criteria and hence we all get lost in them. Maybe those who need the grants most lose out because it gets too complex and people are resistant to apply for the grants at all.

Seán Kyne (Fine Gael)
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I thank Mr. Moynihan.

Bernard Durkan (Kildare North, Fine Gael)
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It is not strictly relevant to this committee but the wider scheme of things. In the changing housing situation I - and I am sure we all - have come across whereby there can be apartment blocks that cater very well for people - and approved housing bodies are central to those - but we get a lot of antisocial behaviour complaints. How those people get into the apartment blocks I do not know but whatever they do to get in there, they create havoc for other people who want to go about their business - whether it be older people or people who are at work all day and find that when they come home at night for a rest they cannot. There is loud music, banging of doors, and in many cases a continuous stream of people calling to one or two houses all night long with the consequence of doors banging and all kinds of noise. That reduces the quality of life for older people and the people who are at work all day. This results in people looking for a transfer out into a very congested market within a very short period. It makes life extremely difficult. I had three people from the one location just last weekend who all had the same problem. Their lives are being made intolerable and they want to go back to wherever they were. It was quieter and that is what they were looking for. We need to keep that in mind and the approved housing bodies need to tighten up on who gets through the system and if they are vetted, what way they are vetted, or not. We have to house everybody but at the same time while doing that we should try to maintain - insofar as possible - a regime that does not militate against people who just want to be left alone and do not want to have the attention of noisy neighbours and the kind of thing that goes with them.

It dramatically reduces the quality of life for people who feel vulnerable.

Seán Crowe (Dublin South West, Sinn Fein)
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The options for older people were mentioned. South Dublin County Council has a scheme for over-55s which is very popular and heavily subscribed. It has only been rolled out recently and there is huge demand for it. That is the way to go for other local authorities. It gives local authority tenants the option to downsize and there is also a scheme for those in private accommodation. It is in South Dublin County Council but not throughout the State. It is popular, it responds to the needs of people and all local authorities should do it.

Is there anything else in regard to the legislation that has not been touched on this morning that the representatives believe needs to be included? Are they happy with how things went this morning?

Ms Gráinne Loughran:

In regard to the legislation, we found the difficulties are less to do with what is in the legislation and more to do with what has been left out. That might be echoed by some members of the committee. We are concerned that the regulatory impact analysis states that the fees to home support providers as part of the licensing will not apply until the system is operational, which is expected to be from 2027. It does not clarify whether that timeline relates to statutory home support in full or just the regulatory system. If it is the latter, we would be concerned about that timeline. The lengthy process that has been gone through in establishing the scheme is something that has been raised.

On the broader area, there is much to be taken into account in regard to personal assistant services and disability services. Our members of the home care coalition would speak with expertise on this. Personal assistant services are not covered under this legislation. It is important that services for older people and people with disabilities are progressed in tandem and we are not leaving gaps in either area. There was a consultation earlier this year on the national policy on adult safeguarding for health and social care services. We recognise there are many moving parts to this. It is the nature of the complexity of the process. However, we urge that all these elements be taken into consideration when looking at the pre-legislative scrutiny and throughout the processes and, as time goes on, on the next Stages as well.

Seán Crowe (Dublin South West, Sinn Fein)
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Another area we probably have not touched on, on which Ms Loughran made a point, is the tendering process, the pricing model and the challenge that will face. It does not fund travel expenses and only partially funds travel time. When talking to those in the carer sector, that is a big anomaly that is not covered.

Mr. Seán Moynihan:

The main thing is to make sure there is equitable access to services, both in urban and rural areas and in hard-to-reach places. All the tenders might be for high-density areas.

Seán Crowe (Dublin South West, Sinn Fein)
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Yes. It is not going to work unless that is resolved.

I thank the representatives of ALONE for their engagement with the committee on the important matter of healthcare related needs of older persons and the general scheme of the health (amendment)(licensing of professional home support providers) Bill 2024. As a committee we will have to decide how to proceed with the next piece of the pre-legislative scrutiny. I propose we look at this at our next private meeting and discuss whether to bring in other groups or make recommendations to the Department. I thank the witnesses for coming in and really appreciate their input to this meeting.