Joint Committee on Health debate -
Wednesday, 19 Jun 2024

Before we get to the main item on today's agenda, the minutes of the committee meeting on 11 June have been circulated to members for consideration. Are they agreed? Agreed.

The purpose of the meeting today is to commence the pre-legislative scrutiny of the general scheme of the health (amendment) (licensing of professional home support providers) Bill 2024, which has been forwarded by the Minister for Health for consideration. To commence the committee's consideration of the matter, I am pleased to welcome from the social care division of the Department of Health, Ms Fiona Larthwell, principal officer, Mr. Tommy Sheridan, assistant principal officer, and Mr. Cody York, assistant principal officer; and from the Institute of Public Health, Professor Roger O'Sullivan, director of ageing research and development.

I will read a short note on privilege. Witnesses are reminded of the long-standing parliamentary practice that they should not comment on, criticise or make charges against any person or entity either by name or in such a way as to make him or her 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 relation to 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 or entity 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 be able to permit any member to participate where he or she is not adhering to this constitutional requirement. Therefore, any member who attempts to participate from outside of the precincts will be asked to leave the meeting. In this regard, I ask any members participating via Microsoft Teams to confirm, prior to making their contribution to the meeting, that they are on the grounds of the Leinster House campus.

I now invite Ms Larthwell to make her opening remarks on behalf on the Department of Health. She is very welcome.

I thank the members of the committee for their invitation to meet today to discuss this general scheme for the health (amendment) (licensing of professional home support providers) Bill 2024. I am joined by two of my assistant principals, Mr. Cody York and Mr. Tommy Sheridan, from the older persons section within the Department of Health. I will now outline the background to and rationale for this draft legislation, before briefly addressing its main provisions.

As a matter of public policy through Sláintecare, Ireland is committed to supporting people who need our health and social care services to stay living at home for as long as possible. When Sláintecare was published, the State was investing approximately €403 million in home care and home help for older people - what is now called "home support".

This was to deliver about 16.2 million hours in 2017. Sláintecare called for an additional €120 million in funding over five years, by the end of 2022, which would have brought this to €523 million. The State had more than met this target by 2021 and this year the Oireachtas has allocated approximately €730 million to deliver 22 million hours of standard home support to older people, with a further 3.5 million hours to be delivered to people with a disability. At any one time, home support is to be delivered to over 54,000 people aged 65 and over, and 7,000 people with a disability. As of the end of April, the targets for older people were being exceeded. Preliminary figures show around 56,000 people were in receipt of home support and approximately 590,000 more hours had been delivered than at the same time last year.

Home support is not just delivered by the HSE and HSE-funded services. People with a range of personal circumstances also purchase it privately. Information is very limited on who is delivering services privately, how many hours they are delivering and what types of services this includes. However, estimates indicate as much as 25% of provision may be delivered privately. This would be a further 8.5 million hours being delivered nationwide.

Alongside the expansion of care, the type of support being provided has become more intensive as the level of needs that can be catered for at home have increased. This means that, on average, more hours are now being delivered per person. As home support has expanded and the needs of those at home have increased, it has become more urgent to ensure there is verifiable consistency and quality in care. There are inherent risks for service users in the provision of health and social care services by an unregulated sector. In vital areas such as infection prevention and control, staff training and clinical governance, there are no standards or regulations that all home support providers must comply with, whether HSE, HSE-funded or private. There is also no independent oversight of the provision of services; therefore there is no independent mechanism to ensure that the standards that do exist, such as HIQA’s national standards for better, safer healthcare 2012, are complied with.

The absence of regulation across the home support sector has contributed to geographical variation in the quality of care. A recurring theme in the responses to the Department’s public consultation on home support services was the need to address variation in provision across the country. Many stakeholders have raised concerns about the lack of regulation and there have been proposals to bring forward relevant legislation for some time. Recognising this consensus, the Government has committed to introducing legislation to regulate the sector.

As members will know, the Health Act of 2007 established the Health Information and Quality Authority, HIQA, and the Office of the Chief Inspector of Social Services. It also provided for a scheme of registration and inspection of residential services for older persons, people with disabilities and children in need of care and protection. HIQA’s functions include the setting of safety and quality standards in respect of these residential services and the Chief Inspector of Social Services monitors compliance with standards and regulations.

The purpose of the Bill is to introduce a framework for providers of home support services to be regulated by HIQA. This will be done through amending the Health Act of 2007, as necessary, to provide for functions in relation to the licensing of providers and to set out the licensing framework. These amendments will act to safeguard service users and raise the quality and consistency of care nationally, and will give partial effect to the programme for Government commitment to “Introduce a statutory scheme to support people to live in their own homes, which will provide equitable access to high-quality, regulated home care”.

The general scheme is modelled after the regulatory framework for residential services for older persons, also known as designated centres, set out under the Health Act 2007. It sets out to introduce a licensing framework for home support providers, who will be required to meet minimum standards set out under ministerial regulations in order to provide a service. The general scheme introduces a statutory framework to provide independent oversight of these minimum standards by conferring on HIQA’s Chief Inspector of Social Services the authority to grant, amend and ultimately revoke a license if a provider fails to meet the minimum standards set out in regulations or contravenes a provision of the Act. The chief inspector will be responsible for monitoring and assessing compliance of registered providers against regulations and HIQA standards. This regulatory framework and inspection process will ensure quality standards are met and will help build public confidence in the expanding provision of home support.

The licensing and regulatory framework will apply to services that deliver home support to adults aged 18 or older who, by reason of illness, frailty or disability, require this service. As such, it applies to provision under the auspices of both the Department of Health and the Department of Children, Equality, Disability, Integration and Youth. This means that there are roles and responsibilities set out for both Ministers in relation to the regulations and the legislation more generally.

Under the general scheme, the Chief Inspector of Social Services will have responsibility for establishing and maintaining a register for licensed home support services operating in Ireland. The chief inspector will also be responsible for monitoring and assessing compliance by registered providers against ministerial regulations and national standards developed by HIQA. It will be an offence to carry on the business of a home support service without a licence. Before getting a licence, providers must satisfy the Chief Inspector of Social Services that they can comply with these regulations and other requirements under the legislation.

Once licensed, if a registered home support provider is not meeting licensing requirements, the ultimate sanction is the withdrawal of the licence, but other options are provided for in the scheme to address failings where lesser sanctions or conditions would be more appropriate. This statutory framework will be supported by national quality standards that are being developed by HIQA. The national standards will focus on a human rights-based approach and aim to promote progressive quality improvements in services. An advisory group made up of 20 members has been convened to support the development of these standards, including people who use home support services, carer representatives, staff, advocacy groups and a range of statutory bodies. The next stage in the development of the standards is public consultation, expected to take place later this year.

Finally and importantly, the general scheme echoes new provisions in the Health (Miscellaneous Provisions) (No. 2) Bill 2024, which is proceeding through the Houses of the Oireachtas. This includes extending provisions in relation to the collection and reporting of data by HIQA that will be shared on an aggregated basis with the Department and other relevant public bodies as determined by ministerial regulations. As we progress through our programme of reform and legislative enhancement of home support, it is essential that this is based in evidence and data. Improving the amount and type of information we know about service providers and people who use services, particularly privately commissioned services, is fundamental to ensuring that new developments will be efficient, effective and meet people’s needs.

The ultimate objective of the proposed licensing system is to improve the safety and quality of home support services by ensuring that registered providers do not operate below the standard set by ministerial regulations and that those regulations are applied in a consistent and systematic way.

I thank HIQA, the HSE and officials from the Department of Children, Equality, Disability, Integration and Youth for their engagement and assistance on the general scheme and the ongoing development of this legislation and the wider regulatory framework. I thank the committee for giving its time and look forward to discussing the proposals

I thank the committee for the opportunity to present. I am director of ageing research and development at the Institute of Public Health, IPH. I understand a copy of the IPH submission has been shared with the joint committee. IPH is jointly funded by the Departments of Health in Ireland and Northern Ireland and provides research and analysis support to both Departments. Our work focuses on promoting health and well-being, improving health equity and reducing health inequalities.

IPH was commissioned by the Department of Health to assist with the development of the public consultation process on the new draft regulations for providers of home support services, undertake an analysis of the public consultation responses and produce a report on the submissions received. The draft regulations set out proposals for regulating public, private and not-for-profit providers of home support services to obtain a licence. Home support in this context covers assistance with a wide range of activities to help a person live at home if they are ill, frail or have a disability. This can include help with washing, dressing, getting around, social activities and essential household tasks.

The aim of this public consultation was to seek the views of organisations and individuals on the scope, content and potential impact of the draft regulations, to help inform their development and to contribute to a regulatory impact assessment. This public consultation used a survey as the primary method for seeking views on the draft regulations. The survey included a combination of open and closed questions. Submissions were received online, with an option to email or post the survey, and some submissions were made outside the survey format. The public consultation took place over a six-week period from 16 June 2022 and this was extended for a further week on request until August 2022.

The public consultation was promoted by a Department of Health press release on its website and on the Government public consultation hub, as well as on social media and via email. The Department of Health held several online meetings with stakeholder groups, including the disability, participation and consultation network. Plain English and easy-read summaries of the draft regulations were developed by IPH and made available along with the consultation documents. In total 210 submissions were received, 198 through the survey questionnaire and 12 via a free-form submission format. The majority of responses were made by individuals - 118 - of which 43 were a combination of service users, their family members and others with support needs. There were 92 responses from organisations, including home support providers, healthcare organisations, advocacy, public sector, and worker representative bodies. IPH’s role was to summarise the public consultation responses. We did not comment on or evaluate the views expressed by respondents.

I will now provide an overview of the public consultation responses. Please note that this is a summary and further details are available in the report submitted with this opening statement. Some 74% of survey respondents believed the impact of the proposed regulations would be positive, 4% negative, and 22% were unsure. Home support regulations were considered as key to providing better quality of service and guidance for all involved in home support services. Some 85% of respondents indicated this view, which was consistent across all sectors, including service users, providers, and State bodies.

It was felt that by specifying minimum standards, the regulations would create a level playing field for providers that would ensure higher and more consistent standards of delivery. Some 82% of respondents felt the regulations would provide greater protection to service users, which was considered particularly important if they were vulnerable due to ill health or reduced cognition. Clarity was sought by all sectors on how the home support regulations relate to the overall architecture of publicly-funded home support provision.

There was a concern by some that the regulations reflected a form of home support provision based on a model of services for older people rather than the diversity of users. There was widespread support across all sectors for having minimum qualifications for home support workers to improve service standards - at 78%. On the other hand, there was also concern that this could worsen existing staff shortages. Improved conditions for home support workers were seen as vital to creating a more sustainable workforce and high quality service for home support service users. Respondents indicated that implementing the regulations could be onerous for providers and home support workers in terms of increased record-keeping and documentation, and that this could impact negatively on the service user. There were concerns that some types of home support service are excluded from the draft regulations, particularly services for children - 28% disagreed - services by healthcare professionals - 27% disagreed - and services provided by individuals directly employed by service users - 30% disagreed.

To summarise, across the public consultation submissions there was a high level of support for the proposed regulations, with benefits viewed as better quality and consistency of service, guidance for all involved in home support services, greater protection for service users, and a more qualified workforce with clearer career pathways. However, 46% of respondents also expressed concerns on the new draft regulations, such as home support becoming inflexible, may be costly to comply with, and may increase ongoing challenges around staffing. Respondents also highlighted the importance of recognising the diversity of need among those requiring home support.

I will finish with a quote from a home support service user who responded to the consultation:

I live alone without family ... I couldn’t remain at home without home support services. Sometimes I feel rushed but understand that home support workers are very busy and do not have much time to get to the next house. I value this service and those who provide it. [I] think that the regulations will improve services for me and home support workers.

I thank the committee for the opportunity to present today and I welcome any questions members may have.

I thank the Cathaoirleach and Professor O'Sullivan and the team from the Department. I will play devil's advocate on this issue and touch base with the professor on the 46% of respondents who expressed concerns about the new draft legislation. For a long time the biggest concern with regard to home help was the lack of funding and then it became the lack of staffing. What evidence is there regarding concerns about quality of care or regulations at the moment? Is there an informal complaints mechanism? Have complaints been made to the HSE community support? Is there a body of evidence to suggest this is an area in need of regulation or oversight?

If it is a HSE-funded or a HSE service there will be a complaints mechanism. However, there is no independent complaints process at the moment and that is one of the reasons we see regulation as being so important. When we discussed the new regulations with HIQA it commented on the fact that when home support gets a lot coverage on the news, it is approached by people with concerns and it has to say to them that it has no role here and cannot do anything for them. We want to avoid that. It is really important people feel they have somewhere to go when they have concerns.

In terms of specific concerns raised with the Department, they are more about provision. It is more about the number of hours and the accessibility of hours. We do not tend to get a lot of submissions about quality of care issues but they are out there. People are uniquely vulnerable when they are at home. It is potentially just them and another person. We have heard about cases of financial abuse and there is always a possibility of things such as physical abuse. They are the sort of things we do not want to think about but they can happen and it is really important we have regulations in place.

As the provision is expanding so much nationally people are more and more at risk because there is more provision happening. Even by the law of averages things will go wrong more often. That is the basis for this legislation.

It is important to reflect there is a stepped series of sanctions that could be put in place under this legislation so I do not think that, typically, we would see a licence being revoked without prior warning or early warning signs. There will be the ability to put sanctions or conditions on a licence, so that people have to comply with things in order to remain licensed. I share the Senator's concern and we would not want to have this done in an unmanaged way. That is why measures such as revoking a licence have to be notified, I believe, to the Ministers and the HSE to ensure continuity of provision.

We are in a slightly different position than we are with the designated centres because they are people's homes. Therefore, people's homes going away is a bit more of a concern whereas being able to move one's provision from one service provider to another is a bit more straightforward.

For example, if the issue was with one employee who was not providing the level of care that would be required or sufficient, presumably the onus would be on the company to deal with that situation rather than removing the 100 employees which would have a huge, immediate impact on the people they are looking after.

We would never want to see a sudden withdrawal of services. The regulations will describe all of these things and have yet to be determined by the Minister in consultation with the Minister of State for disabilities but we expect complaints processes and all of those sorts of things to be in place so that these kinds of actions can be taken appropriately.

A guess is all we have. Some research by the ESRI suggested that up to 25% of provision could be being delivered outside the scope of the HSE and its funded services, but that research was done prior to 2020 or thereabouts and, because of the additional investment, we expect that we have probably pulled some of those people into the HSE-funded net at this point. However, it is hard to tell. At some point, The Irish Longitudinal Study on Ageing, TILDA, estimated unmet need to be approximately 26% and we are not sure whether the unmet need is actually being met through private provision or just going unmet. These are the kinds of things we really want to find out and that is why we are looking to register all home support providers and not only those working for the HSE and HSE-funded services.

I presume it is the same as for any other company. There are no regulations or standards people have to comply with and that is where we feel people are potentially at risk. However, that is not to say anything about the quality of those services, which may be excellent. They may be very small and going under our radar a little.

We assume so. Without an evidence base we do not know, but we have put exemptions in the Bill for certain circumstances, such as family relationships, unpaid care or where there are fewer than three users. Especially in the disability sector, carers tend to have more personal relationships with people to whom they are giving a lot of one-to-one care and they would not be able to work for a number of people. We are not trying to capture those ones, but rather the ones that are slightly larger. However, we think small mom-and-pop providers, if you will, are out there.

To go back to the company that has 100 employees across a region, let us say it is providing what would be deemed to be quality care. If HIQA comes in, will there be an educational standard, such as certain Further Education and Training Awards Council, FETAC, qualifications? Will a certain cohort of people suddenly be deemed not to be acceptable to work as carers?

We will look at that very carefully because the Senator is right that there is a crisis in the workforce across social care internationally and it is affecting home support. It is difficult to get people into the area, although there has been some success in recruitment. We do not want to put people off but, at the same time, it is important that people understand that regulations and standards mean something. We will be looking to introduce something that is clear and consistent, but not too onerous. One of the issues that came up in the public consultation was such feedback. Our original draft regulations had quite high or specific standards and we are pushing that back a little in the draft regulations. However, that is yet to be determined by the Minister.

People who are living alone with no immediate family get comfortable with their carers. A lot of intimate care is needed, so I assume people get used to their carers. Where the quality of care is excellent, as I am sure it is in most cases, there is no problem. However, if the quality of care is less than that, it creates an issue. Should carers be rotated so that there is not a single carer for an individual, in order to pick up issues?

That is an interesting point. I am not sure we had picked up on it previously. We might take it away and look at it. We had not envisaged a regulation around that, but the HSE certainly does a little more rustling and it allows it to be a little more flexible with the provision. However, it is difficult. There is always a tension because some people absolutely prefer to stick with one person they know, some people prefer to have the intimate care done by someone who is not the person who does their other types of care and some people do not mind either way as long they are getting the care. We have to consider all those circumstances.

The witnesses are welcome. I will start with Ms Larthwell.

The programme for Government committed to a statutory home care scheme, the essence of which was a legal right to access home care. Does this Bill deliver a statutory right to home care?

We are not even at a stage of a Bill being developed to deliver a statutory home care scheme or a statutory entitlement. The essence and core of the commitment given in the programme for Government was a statutory right to access care. Many of us supported Sláintecare and the right care in the right place at the right time. One of the core tenets of that was to deliver a statutory home care scheme. It was in the programme for Government. We are four years in. Ms Larthwell cannot account for the Government. That is its role, but she is before us as a Department official to discuss what she described as a stepping stone to it. In reality, it is not, because it licenses and regulates the sector but it does not deal with the core of what the programme for Government was to deliver for citizens, namely, a statutory right to access home care. I would like a bit more detail about the preparatory work. What does that mean?

The enablers need to be in place to have a statutory right. The Government commitment relates to having regulated care. The first step is that we need to have regulated care before we can have a right to anything. That is one of the reasons this was chosen as the first step in the process. We see it as a staged process that has several different elements, which-----

If it is a staged process, it is painfully slow. That is not what was envisaged as the first step. We were promised that the regulations would be developed in tandem with the other elements. A number of modules were promised that relate to the delivery of the statutory home care scheme. They are a statutory entitlement and there does not seem to be any development of that, apart from vague references to preparatory work, regulation, which we are dealing with, funding, which the Minister said last week had not been agreed and we are a long way away from it, and a reformed model of service delivery. It is a safe bet at this point that before the end of the Government's term, we will not have a statutory home care scheme in place. The best we will have is licensing and regulations, if this Bill even gets passed. That is the best we will get. Is that a fair assessment?

This is a matter for the Government as opposed to the witnesses but, at the same time, the programme for Government commitment is clear and here we are four years on.

I want to deal with some elements and touch on a number of other issues. Why are personal assistance services not part of this? What is the difference between personal assistance services and home care services? I thought personal assistance services were also a core element of delivering home care.

This happens in the disability sector more so than in the older persons sector. We do not see personal assistants in the older persons sector.

We have been discussing it with the Department of Children, Equality, Disability, Integration and Youth extensively. As we understand it, and bear in mind this is our interpretation because it is not something we deliver, personal assistance is much more about helping people access the community. It is much more about helping people outside of their homes. It is helping people go out and about in the community, whereas home support is what is happening in their homes. That is the distinction as we understand it. It is a matter for the Department of Children, Equality-----

I think people who provide personal assistance services would disagree that they do not have a role to play in the home. There are a number of organisations that have written to us and lobbied us as members of this committee asking us to ask that very question. Why has the regulation of personal assistance hours or services been excluded? We are being asked to ask that question of the witnesses, who developed the Bill.

I ask the Deputy to bear with me for a second as we have a briefing from the relevant Department, but as I understand it, there is a personal assistance review group that is looking at the definition of personal assistance. At this point, it is difficult to include something in legislation when there is not a clear definition of it. We are waiting upon the results of the personal assistance review group to come forward with an agreed definition we will be able to examine in consultation with our colleagues in disabilities. We expect them to bring forward the request to legislate for it at the appropriate time.

As this Bill progresses, I imagine we will get more correspondence from people who are listening in to this session. I would say that many groups that have lobbied us on this issue will not be satisfied by those responses. However, we will take that up with the Minister whenever we get to the point of having a Bill to discuss with him.

Is the fixed price authorisation scheme under the Department’s remit?

We got correspondence from the National Community Care Network, which is an umbrella group of the non-profit home care and support companies. I have a concern about developing the model around the private sector as opposed to seeing a model that develops public capacity and public health and social care services, which would be my preference. However, be that as it may, what I have been told in the correspondence received by all members of this committee is that the rate being offered is €31 an hour, but that covers – I ask the witnesses to clarify this – the cost of travel time, a living wage and other expenses the providers would have to cover. Is that correct?

They say it has to cover care staff wages, administration staff wages, training costs, which includes mandatory training, which we all would support, uniform and PPE costs, recruitment costs, insurance costs, rent and utilities. They have put it to us in writing, which I am putting to the witnesses, that many of their providers, which are non-profit providers, have actually been offered a lower rate than what had been achieved in the 2018 tender and it can be a loss-making price now for some provides. Have they communicated that to the witnesses?

I will ask a final question about safeguarding. Safeguards were mentioned in the context of the Bill but the whole concept of adult safeguarding is to protect an individual from potential neglect or abuse. We have seen some of that happen in nursing homes. The vast majority of nursing homes provide a very good service but there have been examples of neglect and abuse. It is the same in disability centres. There is a whole debate about safeguarding legislation, an independent safeguarding authority and so on. What is in this Bill in respect of safeguarding people with regard to home care? What can Ms Larthwell point to in this Bill?

It is not in this Bill because this Bill is about providers. It is about regulating providers and the regulations will contain aspects that speak to safeguarding. However, the adult safeguarding policy that has been developed relates to all health and social care settings, so equally it will relate to home support. We will-----

Did the witnesses consider it in the context of this Bill? Because it is not in it does not mean that should not be in it. Safeguarding is obviously very important. It has been the subject of a lot of public debate on how care is provided in this State. The vast majority of care, I would argue, is delivered to a very high standard, but where standards fall and where we have examples of neglect, we have a duty to make sure we have the highest level of safeguarding protections in place. Waiting for something else to be done when a Bill was going to be presented to us was not satisfactory. Again, perhaps that is a matter for the Minister as opposed to the officials who are here.

I will leave it at that. I have a lot of frustrations with this Bill but my overall frustration is that we are a long way from a statutory home care scheme, that is for sure. While I welcome the licensing and regulations, what we were promised and what we got in this area are, unfortunately, two different things. I will leave it at that.

I wish to pick up on that point. The most disappointing aspect of this legislation is that it does not provide for the long-promised statutory right to home care. I was just reading the history of that promise yesterday and I saw that in 2017, the current Taoiseach, as Minister for Health, committed to the introduction of a statutory right to home care. That was 2017. In 2020, when questioned about it, he said the scheme was almost ready. It was almost ready in 2020. We were certainly given to believe that this legislation would provide for that. Last week at this meeting, we were told by the Minister of State, Deputy Butler, that she and the Department had not managed to crack the nut of the charging regime for home care. I cannot understand why that is the case. The Department of Health has had seven years now, and there were clear commitments and promises given at political level. From a health as well as an older person’s well-being perspective, it makes no sense whatsoever on any level to direct older people into nursing homes instead of supporting them in doing what is in their best interest and what they want to do, which is stay in their own home with home care. There are umpteen examples of where a person is entitled to the fair deal scheme, and it will cost the State more to provide the fair deal and support somebody in a nursing home than it does to support them in their own home, and they do not want to be in a nursing home in the main. It makes no sense on any level for the Department and the various Ministers involved to have welched on the commitment they gave. I cannot understand it. Why are we doing something that is not in the interest of older people and is not in the interest of value for money either?

Having said that, I also express disappointment at the actions taken last year. It was good to have the expert group’s report on putting home care staff on a proper footing in relation to pay, conditions and so on. However, when those changes to the pay and conditions were introduced, no additional money was provided for that. What then happened is that, in a sleight of hand by the Government, the number of hours provided to older people were reduced to pay improved rates and conditions to staff. It was older people who paid the price for that rather than the Government following through on its commitment to make it a decent role.

All of these issues, in the main, are arising because of decisions taken over recent years to outsource a key area of social care whereas social care should be provided within the public sector. However, a decision was taken by consecutive Ministers to outsource that, and we find ourselves now in this situation.

Will the witnesses give an overview of the rough kind of percentages of care provided, in the context of all HSE-funded services, between HSE directly provided, privately provided and voluntary sector provided? What is the breakdown?

From speaking with the HSE, our experience, is that it has significant problems with recruitment in terms of trying to find numbers. An interesting thing about HSE provision is that it tends to be delivered by older people - people over the age of 60 - so a lot of retirements are happening and in terms of even back filling that need, the HSE is finding quite difficult to meet those commitments.

Regarding the exclusion of personal assistants from this scheme, I am trying to understand the thinking behind this. Ms Larthwell made a point about in the home or not in the home or in the community. When we talk about home care, it is in an institution or for a person in his or her home but that does not mean it is within his or her own home. It is for people who are living at home as opposed to living in institutions. Many home care workers take older people out for walks around the local area, which is very much in their interest, and, equally, many personal assistants provide care within the home so it is very hard to understand why personal assistants have been excluded. Has the Department considered the fact that some providers may re-categorise the staff they have in order to avoid regulation? Does Ms Larthwell accept that there is the potential for that.

That is a really important point. That is something we have considered and we have discussed it with HIQA in terms of even how to differentiate between the two. One of the things that the Department of Children, Equality, Disability, Integration and Youth has said to us is that there is a different attitude and emphasis in personal assistance compared to home care. Personal assistance is user-directed support whereas home care is more directed by the HSE generally, which will say that this person needs this amount of services and this type of service and you have to deliver this kind of service in this kind of way. Personal assistance is much more around enabling what the person wants to happen happen. I hope that is a bit of clarification but it is not-----

I think the Deputy is right and it is something we have considered. We have spoken to HIQA about the fact that when it start engaging with providers, it will need to look at this very closely and look at that differentiation and distinction because we would not want things to fall out of regulation by accident or design because people are trying to avoid regulation - not that I think people would necessarily. It is something we will be looking very carefully.

Yes. It is not very significant in the context of its overall budget. It is estimated at about €1.1 million per annum. That is currently to deliver 14 whole-time equivalents for the three-year development period. We anticipate that after that development period, there may be a few more people provided. In terms of the number of providers, it is much smaller than the designated centres and the disability centres so it will be-----

In terms of the survey responses, in response to the question "do you agree that home support regulations should cover the following types of activities for those who need assistance due to illness, frailty or disability?", with regard to personal assistance as a package of assistance provided to support independent health, 94% of respondents indicated their support for the inclusion.

We are taking a punt that it is 2020. I am just trying to get a sense whether this is a stepping stone towards the statutory right. This piece took four years to get to here, which, obviously, is not quite halfway through the process. It is not the full process. I am trying to get a sense of how long it might take for that incredibly complex piece of work subsequent to this to be done. If we took four years to get to here, that is not looking good.

I read the consultation submissions in great detail. It has been very instructive to hear that conversation between Deputies Shortall and Cullinane around personal assistants. I am looking at the consultation responses. There is a question around clarity in terms of where the disability sector sits in this legislation. When Ms Larthwell was talking to Deputy Cullinane, she defaulted to the position that this is an older persons' sector. We now have the UNCRPD and the rights of persons with disabilities, which are very separate and distinct and put a very specific focus on the State to vindicate the rights of people with disabilities. Yet there seems to be a grey area regarding where that sits within this Bill. Could Ms Larthwell speak to that and provide clarity to people who are concerned about that issue? Could Professor O'Sullivan speak about the opinions he came across were on that issue?

I take the Deputy's point. Our focus will always be on the older persons side because that is under the remit of the Department of Health while disability is under the remit of the other Department but we have been working with it extensively in the development of this Bill. The provisions that involve the Minister directly involve the Minister for Children, Equality, Disability, Integration and Youth as well. In the health sector, we are also conscious of our own responsibilities under the UNCRPD. We do not differentiate particularly in the Bill in terms of the two sectors so I am not-----

Ms Larthwell can see that there is differentiation in reality both recognised by the State and in terms of the requirements of that cohort.

The Department of Health has a requirement to provide services to that older persons sector and that responsibility is borne by a different Department for people with disabilities. Is that creating a structural issue with the completion of this Bill? In addition, the Bill does not make a differentiation between older persons and people with disabilities.

The reason we are not making a particular differentiation within the Bill is that this is about home support providers and not about home support provision. It is not about the care being provided at this stage although the regulations that it provides for will be more about the care being provided.

What I mean is that in a way differentiating between those providers would not be possible because it may be the same providers. Lots of providers within the State are providing services both to older people and to people with a disability. We did not see any particular rationale for differentiating.

The important point is that the regulations will cover the differences between the two cohorts. This legislation allows for the Minister for Children, Equality, Disability, Integration and Youth to make regulations for the disability sector specifically. It is not one set of regulations that allows for it.

As I concluded my comments, I outlined that respondents highlighted the importance of recognising the diversity of needs for those requiring home support. A large number of the submissions called for the inclusion of a rights-based approach or a specific human rights framework within the regulations. This was particularly important for stakeholders from the disability sector, who were concerned that the regulations reflected a care model for the frail or sick older person rather than supporting independent living in the community. Some noted that this could result in a risk-averse, medicalised model of home support rather than one that could support and empower those using it to live their full lives.

That is a very worthwhile and relevant concern if we are not making the differentiation between people who require support towards the later stage of lives and those, often young people, who simply need support to live their lives.

In my last three minutes I will move to an issue relating to the complaints process. Am I correct in assuming that once this Bill has passed, effectively the complaints process follows the HIQA model?

The wording in the draft regulations is that the service provider shall have a system in place to analyse complaints to ensure that lessons are learned from patterns of complaints made and that the quality of service is improved. That is all very welcome for future users of the service. However, what I was looking for in those draft regulations is an outline of remedy. Is Ms Larthwell's understanding that HIQA would outline a remedy for the person who has not received the service or who has received an insufficient service, an incorrect service or a damaging service and that this relates to this service provider only?

This relates to the service provider only. This is different from the regulations which will follow from this. We are providing for regulations here. The public consultation was on a draft version of those regulations and not on a draft version of this Bill. Those are two distinct processes and two distinct stages.

One of the issues that came up in the consultation was the issue of direct employment. I ask Ms Larthwell to expand on the concerns in respect of direct employment. As has already been outlined by other contributors, in some cases people have a close relationship with their care giver that does not necessarily fit into the natural State-led regulatory environment. There might be a situation where the existence of direct employment might create a two-tier system where that is not regulated and there is no discretion or space within the regulations to bring that in. Is that a concern?

I do. However, much of the focus in the Department is on the HSE-funded provision which is the vast majority of the provision. To the users, it is free at the point of use. That is a draw for people. If they are making a decision to pay for their own care, they have a right to determine the terms and conditions of that care for themselves. We would not want to interfere in that very close relationship too much.

It is something we would need to take up with HIQA. I made a point earlier that HIQA now having no standing regarding home support means it cannot respond to complaints. That may be a possible avenue for people to make a complaint in the future. Despite its not being part of the regulations, there would, at least, be some security there.

I thank our guests for their presence this morning and for the information they have given. This is a very important issue and one that has received adverse publicity in the past, institutionally and in general.

The provision of assistance with mobility, personal hygiene, nutrition, hydration and toileting or prompting or supervising such activities where a person is otherwise unable to perform them effectively is very important even in an institutional environment and requires a great deal of co-ordination, supervision and expertise. Does Ms Larthwell envisage a set template to apply across the board for the number of people who can receive a service in a particular area at a particular time? In other words, the challenge is obviously to look after 20 patients, 100 patients or whatever the case may be. How effectively can we provide services to those people at various stages, the ten people, 20 people, 30 people, 40 people or whatever, dispersed throughout the community and compare that with providing for the same number of people in an institution? That is the measurement that needs to take place. Has the Department agreed or identified the level required there? If it is already agreed, is it proposed in the Bill?

We have not agreed that. We have not set out any particular template. However, the Deputy's point is well made. What we are finding is that because we do not have that insight into the data in the sector, we would not necessarily be able to know right now how many providers are being serviced by-----

The HSE would be able to pull some of it together manually. Obviously, we would not have any information on the privately commissioned services. One service provider might be providing services through the HSE to older people and to people with a disability, and it might be providing privately commissioned services as well. We do not have a global view on that.

The Bill's provisions on information gathering will allow us to consider such issues and make policy based on what we are seeing.

The services are overseen within the services themselves and they will have the appropriate clinical support to allow them to do that. We do not envisage a clinical oversight group or anything like that for the service as a whole, but standards and regulations are about setting standards against which the chief inspector can inspect.

A broad level of services are anticipated. We get complaints from time to time, generally from the services’ users. Some users are very pleased, some are not pleased, but all of them have different requirements. This is where the difficulty arises. It is difficult to deliver a daily service across a dispersed area with a high degree of quality to people with different needs. For instance, some people who are isolated in rural or urban areas might put it on the long finger, but having a tea and a chat is a very important service to them. A ten-minute chat would be fine in such cases, but there are also people who require a great deal of care and more than five or six minutes. How does the Department differentiate between the two levels of service required? How does it tell the service provider where to go and what levels are required for patients A, B, C and D? We have to determine the optimum number of persons who can be provided with a service in a particular area and by how many people. What has the Department in mind in this regard?

This speaks to what we call the single assessment tool for standardised assessments of care. The tool that has been introduced – a little slowly at first but now picking up pace – is the interRAI tool within the HSE. It is a standardised care needs assessment tool. How do we know what people actually need and how do we ensure that is fairly and consistently defined across the country? Currently, decisions are being made every day by a group of professionals involved in the care of people about how much care the latter need. They look at that on a granular basis. Does the person have a walker available to him or her? Is the person just out of hospital? What family support is needed? That is great and I am pleased that they take into consideration all of those personal circumstances, but it presents difficulties where someone in one part of the country gets ten minutes because that is all the provision that is available but would get 20 minutes were he or she in another part of the country. We need this to be standardised across the country. That is fundamental to the question the Deputy is asking and is why we are introducing the standard assessment of care.

In various contexts, a great deal of emphasis is placed on vetting these days. What level of vetting takes place? We need to know what level of checking is done of those who have direct access to vulnerable people in order to ensure that they are appropriate for the job and have adequate knowledge of the situation and that their patients do not suffer in any way at their hands or anyone else’s.

Our understanding is that, in most services, vetting is already taking place because that is what service providers do. They know the cohort they are dealing with. They know those people are vulnerable and they want to ensure they are safe. However, the regulations will specify requirements in respect of vetting, and those will apply to all services.

We do not have a particular position on the number of service providers that are necessary. The authorisation scheme for HSE-funded services works by publishing the conditions for what is effectively a tender. If a provider satisfies those conditions, it can be placed in a framework to deliver services on behalf of the HSE. We do not get involved in how many organisations that might entail.

Some interesting consequences may arise from this legislation. For example, we may see some consolidation of the sector. People might look at the regulatory burden, which is not high but is there, and decide it would be better for some small providers to band together and make one larger provider to manage the services.

How does the Department propose to handle emergencies that may arise from time to time, for example, service providers’ staff being out ill or otherwise unable to attend on the day? How well organised is the system to deal with such issues? The person availing of the service cannot postpone it for a day or a week. How will gaps be filled during emergencies?

It depends to some extent on the service providers themselves and what arrangements they have in place. We do not have a system whereby, if someone’s hours cannot be delivered, they go back out nationally to any provider. It has to be dealt with within the service provider in question. We anticipate all service providers having policies to cover illnesses where they can.

What I am trying to get at with these questions is a standardised quality of service. If there is no service in an area for a day, two days or whatever the case may be, it causes problems for the person availing of it. Is there any way an emergency service can be provided in those circumstances in order to ensure the patient is not left on his or her own?

It is important.

There are many independent service providers throughout our communities. Some provide a good service, and some provide a service that is not so good. Depending on the availability of staff, gaps can be created in the system. It is the same everywhere. We cannot afford to have such gaps. We need consistency in the level of care provided and reliability and satisfaction for the person to whom the service is provided. All of these are part and parcel of what is needed.

I welcome the proposals in as far as they go, but I will need more information about the matters I raised.

I thank the Chair for facilitating my participation online and I thank the witnesses for their presentations.

We have gone back and forth on the PA versus home care issue, but will the witnesses clarify something, please? They stated that there was not a clear definition of what PA services were, which is why they were not being included in the legislation. The witnesses also stated that those services were not being included because they were different. Obviously, both statements can be true at the same time, but which is the reason? If a clear definition were miraculously found in the next few weeks, could PA services then be included or are they being left out because, based on age brackets, they are seemingly different?

That is an interesting question. If there were a legal definition we could hang the legislation on and if it had been available during the development of this legislation, it is something we would want to go back to look at. However, it would not be us making that decision, it would be the relevant Department bringing that forward to us. I think they are keen to ensure this sector is not overlooked. It is a matter for them in terms of how it is managed.

The UNCRPD has been mentioned in this committee before. It lays out various things that need to be done and should be done. It is an aspirational document, but it also contains some clear things. Would Ms Larthwell say that without the statutory right to home care included in this, and the plan is that will come at some point, the legislation as it stands would be UNCRPD compliant? Is the statutory right to home care not within the realms of what the UNCRPD says? I am not sure if that is open to interpretation, or if there is a clear line on that.

On the matter of the UNCRPD, I have to defer to our colleagues from the Department for disabilities. We would certainly aim for our legislation to be UNCRPD compliant. The disability sector is really important and one of the things we have talked about is that there is a slightly different emphasis and a smaller number of people affected and getting home support. However, they could be getting it their whole lives. Sometimes older people get home support for six weeks after they have been in hospital. It is a different animal, and it is essential we comply with whatever regulations and legislation is out there.

That was rattling in my mind as we were talking as to whether excluding the statutory right is making something UNCRPD complaint, or if the commitment to make it a statutory right at some point is enough to get us over the line to make something UNCRPD compliant. Those are the questions I have been chewing on.

Good morning, everybody. I have one question, as the others have been answered. If the legislation were passed tomorrow, what would that look like for the service providers and the individual's carers? The majority of the time they would be in individual's houses. How would that be regulated by HIQA? Our interpretation of a HIQA inspection is that it goes to the premises. It can sometimes go unannounced and do an inspection. How would that be conducted if a carer were in somebody's house? How would it be carried out if this legislation were passed?

There are two parts to the Deputy's question. One is a technical point about the legislation itself. Even if the legislation were enacted tomorrow, there is a 12-month transitional period before it is commenced. Once commenced, providers have to register, and a 24-month period is envisaged for that. Certain provisions would come into place almost immediately on commencement. Those are to do with the role of HIQA and the chief inspector and things like that. However, the chief inspector would not be able to inspect until there were an inspection regime based on the regulations. The Deputy also raises a practical point about what that would look like to the person at home. The reality is that they will probably not see an inspector. The nature of a home support business is that people are out there delivering care to other people. The business itself is from a central location, and that is the location of the inspection. There would be a lot around the processes they have in place and the data they keep, the management of complaints and things like that. We do not envisage a situation where there would be a standard that involves going out to people in their homes. There is provision in the legislation that allows for it should it be necessary in particular circumstances. What we almost want to see is no effect on the service user except for a better quality of care. That is all we want to see.

I will follow up on a couple of questions from Deputy Durkan about potential gaps in the system and how those challenges and gaps are dealt with. I want to know more details on that. It is a very concerning issue. If somebody does not have home care for a couple of days, it creates enormous challenges and difficulties. I was not 100% happy with the response given to Deputy Durkan so I will give Ms Larthwell the opportunity to elaborate a little more.

Our experience is mainly with the HSE and HSE-funded services, which are the majority. In the case of the HSE, I expect it would be able to cover those gaps as it has the capacity to do that. Outside the HSE, once a person is provided with hours and the number of hours to be delivered is assigned to them and sent over to the private provider, we expect that provision to be delivered. We expect providers to have policies in place around these kinds of gaps to make sure they are covered.

I agree with Deputy Cullinane's earlier point. I would have expected that a statutory home care Bill would be before us, as per the commitment in the programme for Government, but it is not. It is one of the elements of the programme for Government that has not been delivered. That is concerning. Why has it taken four years to get to this point?

All of the older persons unit was occupied during Covid with Covid-related matters. There were a lot of important home care matters we had to look at during Covid. There was a point where people were not getting a service at all, but the service providers still needed to be paid. We needed to work on the service providers' PPE. There were the care workers' vaccinations and an awful lot going on for approximately two years. While some work was ongoing it is true to say resources were diverted during that time.

Deputy Durkan, who is seated beside me, has been talking about this issue for years as well. He deserves acknowledgment and credit too. I would consider the glass half full. We have a long way to go with this but people like Deputy Durkan and the Minister of State, Deputy Colm Burke, deserve to be acknowledged for the contribution they have made.

On that note, there was reference in the opening statements to the number of people who are actually getting home care help and I think that needs to be acknowledged. As elected representatives, we tend to hear about those who are not getting the services, additional hours and so on. Those are probably some of the challenges. In her opening statement, Ms Larthwell stated that 54,000 people access the home care supports. All of us collectively, regardless of party or non-party, would agree that the need for legislation on this whole area should be addressed.

On the fact that there are 54,000 people getting access to it, 210 submissions were received to the survey that was carried out, of which 43 responses were from service users, their family members and others with support needs. Is it a small sample? Professor O'Sullivan is basing the response to the need for it on the survey, but it seems like a tiny number of people. Would that be a typical level of response to a survey for such a key element of legislation that is clearly needed right across society, and the number of people who are using the services at the moment?

I thank the Cathaoirleach for the question. To clarify, this is a public consultation. It is not a piece of research and it does not claim to be a representative sample. It is a process of engagement whereby the Government facilitates everyone to make a submission and present their view.

On the number of submissions, in the last few such consultations I have been involved with, approximately 200 submissions were received. In the past, say back in 2017 or 2018 when the piece of work around home care was previously consulted on, I think there were 2,500 responses. In terms of sample size, that is quite modest as well. To be clear, this is a public engagement process rather than an independent piece of research that includes literature and representative samples.

It just struck me that it is a small sample. That is not a criticism of anyone. It was put out there and people may not have felt a need to respond or maybe they believed that it should have gone ahead.

Question No. 4 in the survey referred to areas not covered by the regulation, of which under-18s were one. I would have thought there would be a larger response. Can Professor O'Sullivan talk about that section and what is not covered?

On the under-18s, 28% disagreed and then there were those who were unsure and those who agreed. It stood out that there were particular views in respect of what should be included or not included. Regarding the exact percentages, 49% of survey respondents agreed that services for people under 18 should not be covered, 28% did not agree and 20% were unsure. If you combine the numbers who did not agree or were unsure, it is very close to the number who agreed.

One of the questions related to registered healthcare professionals, such as physiotherapists and so on. One of the concerns some members of the committee would have is that many of those who are engaged in healthcare professions might not necessarily be registered. We had people who were dealing with feet, for instance. There is no regulation there. There is no regulation in respect of many of those key elements. I think chiropractors are among those not registered. Anyone can establish themselves as chiropractor. There are others, such as hypnotherapists. There are all these professions out there but there is no actual regulation on them. I would have thought that would be a concern, but it did not come up in the survey.

Okay. The geographical gaps in the system come up quite a bit. Could the witnesses outline some of the gaps? In their experience, what is the big challenge? It was said that regulation is needed. Why is that so? Where are the notable gaps? I presume it is in rural Ireland. We know that from the work of the committee on this. The witnesses might outline their views on that.

I think it was Deputy Shortall who asked about the percentage of provision nationally. That is the 63%-37% split between the HSE and non-HSE providers, with the HSE being the smaller part of that. However, that is not even throughout the country. We see in some CHOs - we are still on CHOs as we have not quite got used to the new areas yet - that it is almost entirely private provision, while in other CHOs it is maybe not entirely public provision, but very heavy reliant on public provision.

The ways in which the public and private provision are delivered are a bit different. That is something that is not really addressed through the regulation. What we are talking about with regard to the geographical variation of care is how that follows through in terms of the standards of care that are being provided. The Chair is absolutely right to point out that there may be issues in more rural communities because there may be more of a need to travel further for visits, and perhaps you do not get as much time with the people as you want. Those are the kinds of issues we would be looking to address.

With some of the providers, particular in the private sector, there was more of a reliance on the likes of technology to keep in touch with those people, particularly in isolated areas and so on. That has been the pattern in other jurisdictions as well. I looked at one provider that was talking about using a smart television, phone or whatever to keep in touch with the individual who is getting the care. It has machines that give the individuals medication and remind them about it. They can talk to you through the television about whether you have taken your medication today. I do not know how that would go down with some people but I imagine it would be fairly frightening at the beginning. There are others that would be able to tell you that Mary or John has not been in the kitchen or has not been in the bathroom. That is the extent of the technology. It would tell you whether Mary has gone outside the house. That could be particularly relevant if Mary has slight dementia. There is a huge role for technology in that regard.

Would HIQA have a role in respect of some of that technology? For instance, if a person was being charged for a particular type of technology that did not work, would HIQA have a role in that and would it have the ability to monitor something like that?

HIQA's role will be about the wider quality of care and all aspects of the care. If the care was being delivered in a technologically advanced way, HIQA would be interested in that and would want to make sure it was delivering the care the person was allocated. We would not want to see a substitution whereby someone has been assessed as needing five hours of care but it is actually all put online. HIQA would have a role in that. There is currently an interesting ongoing pilot in CHO 5 on the roll-out of assistive technology and this is something we see a growth in. One of the things we have talked about today is the workforce and the difficulties in recruiting. To make that workforce stretch further, we will probably have to adopt a lot more of these assistive technologies.

I will give an example. There is one product that does an assessment of a person and determines if they need an incontinence pad. The current regulations, as far as I am aware, are that a person must be checked on every couple of hours. This technology can pick up the scent or whatever else, so there would not be the necessity, for instance, to wake someone up in the middle of the night to see if they needed a new pad. That is groundbreaking. If this were to be introduced right across the board, who would monitor whether it was working? The last thing you would want is for someone to be lying in the pad for hours without being checked.

People would have a responsibility, as part of the regulations that include the statement of purpose, to ensure with any service a provider that purports to be able to deliver a service that it is actually able to deliver it. A home support provider may say it provides these services, which could include assistive technologies. HIQA would then assess whether it is delivering those services. If the provider was not, there would either be a condition on its licence to stop purporting that it delivers that or to build its service to be able to deliver what it states it can deliver.

Again, I am not talking about having to check the smart TV, but as that technology develops, would the expertise be available within HIQA? If that is the way we are going to develop as a society, something like that would be needed. We mentioned the fact that where someone is going into a person's home, there has to be a level of trust and so on. On the standards of care and the survey on the quality of those standards and what level they should be at, do the witnesses have any view on standards relating to the over-reliance on individuals for whom English or Irish is not their first language? If the recipient of care is deaf and uses ISL, is this one of the standards that would be put on these providers? If the individual going into a deaf person's home cannot communicate with that person, sign language would be useful here. What if the person going in had very little English or Irish, particularly in a Gaeltacht area? Are these standards that would be expected as part of this regulation?

The HIQA national standards are currently being developed by HIQA and we expect them to be going out for public consultation later in the year. These will likely echo a lot of what is in the national standards for designated centres. I do not think there is anything particular in there, but it is certainly something we would expect. If a provider is delivering a service to a person, it has to be able to communicate with that person. As we have spoken about, in many cases this is intimate personal care where people might feel uncomfortable or might have particular needs they need to have understood. In the case you describe, I would expect providers to have appropriate arrangements in place to be able to communicate with the person.

As elected representatives, it is common for us to hear stories of someone coming in and it is not the same care assistant every day. It is practically someone new every week. That may be a result of a strain on the service, but it is a big challenge. An individual may not have someone who can communicate with them, and it may be someone with a list of things regarding going for a walk or to the shop, but in a lot of cases, it is in the door and out. The provider might wash the person, but that person might not have access to a dinner. Not all of the services are being delivered, though we like to think they are, and as public representatives we often hear about many of these issues in home care settings.

For me to establish a company right now, there are no rules. Anyone can do it. Can the Kinahans do it, for instance, if they want to invest all their millions-----

No, but I am just saying that is how ridiculous the situation is at the moment. Anyone from a criminal background can come in and you are letting this person into your home and allowing them access to a lot of things. There is a clear need for regulation in this regard. Is there Garda vetting for many of these providers?

We would hear of nursing homes and sharp practice. There is an entertainment allowance that is charged and there are products that are used, for example, soap and toilet roll. These are the things that go on in nursing homes. If the bed used is a particular type of bed, that is part of the charge. These are some of the sharp practices and they surprise a lot of people. The response often is, if you do not like it, you can go somewhere else. There is a lot working within the system and there is a lot that clearly is not. The more regulation that can come in, the better. I am putting some crazy left-field scenarios, but if we do not ask or do not start thinking about what could go wrong with the regulation or proposed legislation, we will not get it right this time and it will impact on people again. Does anyone else want to come in on this?

The Chair has raised an important issue from the point of view of the people being provided with the service. They need to be sure they can rely on the service from a security and reliability perspective as well as everything else. This relates to turning up on the day and that may be difficult in certain circumstances. The delivery of home care should be reviewed as if it were a large institution spread over a wide area, because that is the level of service that is required.

We have spent many years in this committee and other committees talking about the need for home care as a means of relieving the overcrowding in hospitals and so on. Everybody agreed with that. However, the difficulty is that it is a very expensive service. Distributing a service across a wide catchment area is not as easy as distributing a service in a single building. There is a huge difference in terms of expenditure, commitment and how it is supervised. The issue is much bigger. I notice it is said the chief inspector of social services will have the responsibility for establishing and maintaining the register for licensed home support services operating in Ireland. The chief inspector will also be responsible for monitoring and assessing compliance by registered home support providers against the ministerial regulation standards developed by HIQA. This did not always work too well in the past with institutions. In fact, it did not work at all in some of them and some of the cases that received public attention are still ongoing without resolution. That should not be the case.

One of the things we have to do, is provide the recipients of the service with an assurance they are in safe hands. As I said earlier, there is a vast difference in the quality and intensity of services required between one type of recipient and another throughout a community. In one case, it may just be a call with a walk around.

Close observation is required. Whoever comes into the home has to be able to observe any trends as well as any drifts from the regulation that might take place and be able to make a decision and alert the higher authorities.

There should be a hub from whence the services operate, whether it be a nursing home, hospital or a combination of both. I am not certain which, but it requires that in order to ensure that the same quality, level and standards apply in both cases. If they do not, we are slipping backward. If they do, we are improving and evolving.

The demand is also evolving. There are far more people now in the household at work, which means they cannot attend to even their parents in the way they would have liked. That places responsibility on services such as home support and home care services. In those circumstances, we need to be able to tell people two things, namely, that they are in safe, professional or, as the case may be, quasi-professional hands, and also in the hands of people who know what to do in a particular type of situation that may, can and will arise.

Do the witnesses wish to add anything else? No. I thank the Department of Health and the Institute of Public Health for assisting the committee in its pre-legislative scrutiny of the health (amendment) (licensing of professional home support providers) Bill 2024. The committee will be giving further consideration to this matter and will conclude its work on it as soon as possible. The meeting will now adjourn until Wednesday, 26 June, when the committee will meet in public session. I thank everyone for coming in.