NHI Letter to Minister Simon Harris 26 June 2017

Minister Simon Harris TD
Minister for Health
Department of Health,
Hawkins House,
Dublin 2
D02 VW90
26th June 2017

Re; Nursing Home Charges

Dear Minister Harris,

I am taking this opportunity of communicating with you on the matter of nursing home charges under the Nursing Home Support Scheme (Fair Deal).
As you will be aware under the Nursing Home Support Scheme – commonly referred to as Fair Deal – the State offers financial support to people whose care needs confirm, following a care needs assessment, that they need long-term residential care. All nursing homes are required under Regulations to provide services expressly excluded under the Fair Deal and the regulations are explicit re charges for such services to residents supported by the Fair Deal.

Prior to and since inception of the Fair Deal scheme, NHI has consistently highlighted the narrow definition of goods and services under the scheme and that State financial support to residents approved under the Fair Deal do not encompass the reality of the health and social care costs incurred to meet the day-to-day care and living requirements of persons requiring nursing home care.
NHI submitted amendments to the legislation during the passage of the NHSS Bill through the Houses of the Oireachtas however our amendments were defeated.
Such concerns have also been advanced by the Office of the Ombudsman and Health Information and Quality Authority (HIQA).

The definition of long term residential care services under the Fair Deal specifically excludes services that are provided to persons in nursing homes to enhance their health and wellbeing. Excluded in this regard are services that include, for example, social programmes, physiotherapy, occupational therapy and other health and social care services. These services are essential to support living and healthcare requirements of older persons in nursing home care, as recognised within the national standards and Regulations, and are provided in all nursing homes. Because such services are expressly excluded under the Fair Deal, their costs are not included within any such negotiations with the NTPF and therefore nursing homes are required to charge for such services.

EXTRACT FROM THE Deed of Agreement under the Nursing Home Support Scheme
“Long-term Residential Care Services” shall have the meaning assigned to it by the Act and shall, without prejudice to the generality of the foregoing, include:
• Bed and board;
• Nursing and personal care appropriate to the level of care needs of the person;
• Bedding;
• Laundry service; and
• Basic aids and appliances necessary to assist a person with the activities of daily living.

For the avoidance of doubt, Long-term Residential Care Services shall not include: inter alia
• Daily delivery of newspapers;
• Social programmes;
• All therapies;
• Incontinence wear
• Chiropody;
• Dry cleaning;
• Ophthalmic and dental services;
• Transport (including care assistant costs);
• Specialised wheelchairs; and
• Hairdressing and other similar services”

I refer to the statement issued by the NTPF 18th March 2014 in respect of nursing homes charging fees for services provided which stated: “Under the Nursing Home Support Scheme Act 2009, price negotiation for cost of care in approved nursing homes is administered by the NTPF. The NTPF consider the pricing of long term residential care for each private and voluntary nursing home on an individual basis. Rates, for the cost of care to be paid for by the State, are arrived at by negotiation with the proprietor(s) on a one to one basis with each of the providers. The ‘cost of care’ in private nursing homes covers services as outlined in the Nursing Homes Support Scheme Act 2009, and subsequent regulations. Such costs include bed and board, and nursing and care services as defined. Private Nursing Homes may impose additional charges for incidentals/extras such as social programmes, transport, newspapers, hairdressing etc. as these costs are not included in the cost of care. Under the Nursing Home Support Scheme, it is the client who chooses the nursing home in which they wish to avail of residential care services.”
The Office of the Ombudsman and HIQA have previously raised concerns regarding the exclusion of care and activity-related services within the fee that is set between nursing homes and the NTPF for provision of care.

In its report ‘Who Cares? An Investigation into the Right to Nursing Home Care in Ireland’, the Office of the Ombudsman states: “The exclusion from the care package of therapies and social programmes appeared to be at odds with what (in the words of the Department) “is commonly understood as long-term nursing home care”.

Furthermore, it appeared that the care packages provided for in the NTPF agreements are not consistent with the obligations placed on private nursing homes under the Health (Nursing Homes) Act 1990 (as amended) and the Health Act 2007 (including regulations made under the latter Act) (14). The Ombudsman was concerned that, in many individual cases, the NTPF agreed care packages were not adequate to meet the actual care needs of that individual and that, in this event, the agreements made by the NTPF were falling short of the level of care apparently envisaged under the NHSS Act. However, a careful reading of the NHSS Act suggests that the narrow care packages agreed by the NTPF may not necessarily be at odds with the provisions of the Act.”

The HIQA report ‘Designated Centres for Older People: An analysis of inspection findings during the first 15 months of inspections’, published February 2012, highlighted the most common breaches of the regulations underpinning nursing home care. In this respect it stated: “Inadequate access to all care services, i.e. physiotherapy, chiropody, occupational therapy, or any other services as required by the resident. This reflects a wider funding and access issue in the sector and is an issue in particular for some private centres who are not able to access HSE services such as those listed above as they fall outside of the Fair Deal Scheme. Therefore, the options in these circumstances are either that the resident pays privately or the provider pays. Otherwise the resident does not receive the service.”

In 2013 the HSE Quality and Safety Audit ‘Review of Provision of Primary Care Team Services for Older Persons resident in Long Term Residential Units’ report confirmed significant deficits in the provision of Primary Care Services for residents in nursing homes (public, private and voluntary). This together with the HIQA findings outline discrimination of older people on the basis of where they reside.

It is important to note under the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations, all nursing homes – public, private and voluntary – must agree a contract of care with each resident that includes the services to be provided, whether under the Nursing Homes Support Scheme or otherwise, and the fees to be charged for such services.

The Care and Welfare Regulations 2013 (as amended) extract:
Contract for provision of services
24. (1) The registered provider shall agree in writing with each resident, on the admission of that resident to the designated centre concerned, the terms, including terms relating to the bedroom to be provided to the resident and the number of other occupants (if any) of that bedroom, on which that resident shall reside in that centre.
(2) The agreement referred to in paragraph (1) shall relate to the care and welfare of the resident in the designated centre concerned and include details of—
(a) the services to be provided, whether under the Nursing Homes Support Scheme or otherwise, to the resident concerned,
(b) the fees, if any, to be charged for such services,

I have also attached correspondence from your Department in 2010 which states. “As stated above, the regulations require that residents are provided with a contract included in which are details of the services to be provided for that resident and the fees to be charged. These services should include optional services and activities and any charges applied for availing of them.
It is appreciated that there may be small items for which administratively it would be disproportionate to collect individual fees and in such cases nursing homes could look at bundling them together as a small package of items. However, this could only be done with the consent of residents.”

Nursing Homes Ireland has provided all NHI Members with a Template Contract for Care. The NHI template Contract for Care details all charges for such services and the Contract for Care must be agreed on admission.

The requirements in the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013 (as amended) are abundantly clear both in terms of the contracts of care and complaints. All nursing homes are required to have a robust complaints policy and procedures in place that is prominently displayed in the nursing home and included within the ‘Residents Guide’ provided to residents on admission. There are explicit requirements outlined in the regulations in respect of complaints and HIQA are the regulatory authority tasked with monitoring compliance against the Care and Welfare Regulations and their inspections monitor and report on both the contract of care and the complaints procedures as can be evidenced in numerous inspection reports published on their website.

In addition, following the Ombudsman (Amendment) Act 2012 all private and voluntary nursing homes now come under the remit of the Office of the Ombudsman. NHI have engaged regularly with staff in the Ombudsman’s office to assist member nursing homes to update their complaints policy in line with the Ombudsman’s ‘Model Complaints System’.
This provides a standard template of complaints handling and investigation and which specifically highlights that residents now have the option to complain to the Office of the Ombudsman if they remain dissatisfied.

I look forward to meeting with you at the earliest opportunity.

Yours sincerely,
Tadhg Daly
Chief Executive Officer