Delays to Home Care Reform is Impacting the Entire Health Service

Although some progress has been made in the last 12 months, reform of the home care sector is progressing too slowly and is still beset with delays. It is welcome to see the public consultation on home care regulations open, yet the piloting of the Statutory Home Support Scheme which was initially due to report back in Q3 2022 is now unlikely to report back until Q1 2023. The National Home Support office is not open and recruitment of InterRAI assessors has only recently begun, 18 months after funding was secured. The Government’s renewed target to implement the Scheme by 2023 is now unachievable.

We are now facing the real possibility that the Scheme will not be implemented in the lifetime of this Government. This means more people will go without the care they need and deserve, or they will prematurely enter nursing homes. These delays are a disservice to older citizens and people with disabilities in Ireland, and particularly alarming against a context of rising waiting lists in the sector. What is certain is that, if the current trend in delays occurring at just about every stage of policy development continues, then it will be impossible to implement the Statutory Home Support Scheme before the next election. The margin of error is gone and excusing delays because of Covid19 is no longer acceptable. The Government needs to put weight behind its commitments and give the development of the Scheme the highest priority.

The Commission on Care has been floated in the Dáil, with a commitment to begin by Summer 2022 but has not been mentioned since. This is another example of the Government paying lip service to home care and the people who need it.

Waiting lists for HSE Home Support is higher than it was 12 months ago. This reflects the recruitment crisis that HCCI members and the HSE are facing. The Cross Departmental Strategic Workforce Advisory Group (CDSWAG), which is examining this, and recommendations to Minister Mary Butler are due by September 2022. Budget 2023 must make provisions for these recommendations and, just as important, is that the relevant Ministers prioritise and equip their officials with the resources to implement the recommendations as a matter of urgency. HCCI’s primary concern is that the recommendations are subject to review or further study and drift into the policy abyss. While not all recommendations can be implemented immediately there are a number of things that can almost instantly add capacity to the home care workforce. These include reforming social welfare entitlement rules, providing for the living wage, travel time and expenses in HSE 2023 Tender and by allowing home care providers to recruit from outside Europe. CDSWAG cannot imitate the delays we have seen to the development of the Statutory Scheme. All Departments involved must make home care workforce issues a high priority or we will continue to see mounting waiting lists and the denial of care to those who most need it.

Impact of Delays

Delays to home care reforms are impacting every area of the health and social care sector. People’s care is being cancelled or curtailed and people in need are facing long waiting lists. This is entirely regrettable and completely avoidable. These situations are being reported in the media and in the Oireachtas with growing regularity and will continue until people are finally given a legal entitlement to home care and the recruitment challenges are addressed.

Lengthy waiting lists are leaving people languishing in hospital beds, exposing them to the risk of Covid-19 and physical and mental deconditioning. These delayed discharges feed into other areas of the acute system, inflaming Emergency Room overcrowding we are now seeing. Diverting resources to cater for delayed discharges and overcrowded A&E units exacerbate waiting lists for out-patient care, culminating in a crisis on many fronts.

It appears that the impact of Covid-19 on our older and vulnerable people has been quickly forgotten. As this submission is being written, Ireland is in midst of another wave of Covid-19, with experts indicating these waves could be a quarterly occurrence for years to come. A reformed high quality home care sector can act as significant mitigation to Covid-19 waves. Yet the Government seem content to funnel people into institutional and congregated settings. In a climate where there is little appetite for restrictive public health measures, waning viral immunity and rapidly changing variants, the Government must appreciate the mitigation that home care can bring against Covid-19.

What is regrettable about this situation is that it was entirely predictable. HCCI warned that an increase in funding without a home care workforce strategy would lead to a waiting list log jam. It has been clear that insufficient resources have been allocated to the Statutory Scheme and that this would inevitably delay it. Government commitment without action has led us to this point of great concern and uncertainty. If this Government truly wants to see the Statutory Scheme implemented and the recruitment crisis tackled, then it must make home care a high priority and show leadership from the top.

Priority Status for Statutory Home Support Scheme

We are facing the very real possibility that the Statutory Home Support Scheme will not be implemented in the lifetime of this Government. HCCI believe that the lack of progress in developing the Scheme means that the Government’s 2023 implementation target is now unachievable. For the Scheme to be implemented by 2024, the Government must give high priority status to developing the Scheme.

Proposals:

1. Fast track the evaluation of the Statutory Scheme pilot sites and ringfence funding to implement the recommendations.
2. Commit to opening the National Home Support Office by Q4 2022.
3. Begin the public consultation on funding for the Statutory Scheme by the end of 2022.

Rationale:

• Any further delays to the Statutory Scheme risk the possibility that the Scheme will not be fully implemented in this Government’s term.
• While the Scheme has cross party support, meaning any future Government would likely pledge to implement it, further delays would be inevitable, as seen with delays caused by the last change in Government.
• Opening a National Home Support Office would assist with co-ordination of the various aspects of the Scheme including regulations, licensing of providers and service-user funding.
• Publishing the heads of bill would allow scrutiny of the Scheme in advance of the legislation coming before the Dáil.
• How the Scheme will be funded is an important area to address. HCCI is concerned that cost of living issues will mean the Department of Health may delay addressing this for fear of beginning a politically charged debate. We think this is a mistake. Debate is necessary and should not be avoided because of fears of political controversy.

HSE Tender 2023: Attracting Home Care Workers

When Tender 2018 was introduced, it was expected that the Statutory Home Support Scheme would have been legislated for and commenced by the expiration date of 31st December 2022. With the Scheme now delayed until 2023 at the earliest, a new Tender is needed to provide the framework in which the Government funds home support and the HSE contracts approved home support providers to deliver care.

With the Statutory Home Support Scheme being the key driver for structural reform, the 2023 HSE Tender should focus on improving the recruitment and retention of home care workers (HCWs) and not attempt to pre-empt the Scheme. What that, and the CDSWAG recommendations due to be published in September, there are a number of measures that the HSE can use to attract more HCWs into the sector.

Proposals:

1. Guarantee the living wage for all home care workers (HCWs) operating on HSE contracts.
2. Set national criteria for paying travel time and mileage to HCWs.
3. Provide continuity of income for up to four weeks when a service user suspends care.
4. Guarantee payment for a set number of hours to support hospital discharge.
5. Introduce an Overnight Home Support programme.
6. Support innovation through developing a framework for assistive technology.

Rationale:

• Ensuring all HCWs are paid the living wage, travel time and mileage is an important step in encouraging recruitment and retention of HCWs, developing a sustainable career pathway and recognising the crucial work that HCWs preform daily.
• It is important that changes to pay and benefits follow transparent criteria that are applied equally across each CHO to avoid exacerbating existing variations in recruitment and to move on from the opaque situation that currently exists in relation to paying mileage to HCWs.
• Currently, if a service user is admitted to hospital or goes on holiday, providers are not paid, meaning HCWs are not paid. This means that HCWs income can change weekly. HCCI members indicate that fluctuation in income is a leading factor in staff turnover. Through the Fair Deal scheme, nursing homes are guaranteed payment for up to four weeks when a client ceases using their bed. This should also be applied to home care providers.
• Setting aside a block of hours within each CHO would assist timely discharge of hospital patients. Guaranteeing a set number of hours would aid providers in planning and help guarantee that a HCW would be available.
• In tandem with the above point, introducing Overnight Home Support would assist with hospital discharge and alleviate hospital overcrowding which is affecting all areas of the health service.
• The absence of funding support for emerging assistive technologies has led to a reliance on physical HCWs whose time could be better spent with high dependency clients and has contributed to miserly weekly allocation of home support hours which is between 6.5 to 7 hours.

Proactive Covid-19 & Winter Planning

Home care should be used as a mitigation tool against what the World Health Organisation forecasts as a “challenging autumn and winter” as Covid-19 cases increase against the backdrop of reduced virus surveillance and minimal appetite for further public health restrictions. Winter has always been a challenging time for the Irish health system and the threat of Covid-19 and a bad flu season, like Australia is experiencing, causing severe disruption to Ireland’s hospitals remains.

The HSE should be proactive in preparing for this possibility with a timely Winter Plan that acknowledges the role that home care can play in reducing hospital admissions and supporting hospital discharges. This should be accompanied by ensuring there is an ample supply of personal protective equipment.

Proposals:

• Develop a Winter Preparedness Plan that acknowledges the significant mitigation that home care can bring in combatting Covid-19 and other infectious diseases. The Plan should be published by the end of October at the latest.
• Guarantee funding to support timely hospital discharges.
• Ensure ample supply of personal protective equipmen

Rationale:

• Hospitals, nursing homes and other congregated care settings carry significant risk of patients acquiring Covid-19, flu and other infectious diseases. Therefore, care in the home should be prioritised, particularly during the Winter.
• Delayed discharge adds to this risk of acquiring infectious diseases and by taking up hospital capacity, it contributes to Emergency Room overcrowding and increased waiting lists.
• Guaranteeing funding for hospital discharges will allow home care providers to properly plan and organise their workforce, ensuring there is sufficient supply of home care workers throughout the entirety of Winter

Fund Cross-Departmental Strategic Workforce Advisory Group

The Cross Departmental Strategic Workforce Advisory Group (CDSWAG), set up to address recruitment and retention challenges within the social care sector, was announced by Minister Mary Butler at HCCI’s Annual Conference in September 2021 and is due to return recommendations by September 2022.

Summary of HCCI Recommendations to CDSWAG

• Expand the recruitment pool to target new groups of potential home care workers (HCWs).
• Guarantee the living wage, travel time and mileage for HCWs.
• Create a graded career structure within the sector to encourage retention.
• Expand training options, including an apprenticeship/‘earn as you learn’ scheme.
• Make home care a protected profession similar to nurses and social workers.
• Reform social welfare supports eligibility rules.
• Incentivise non-EEA workers to relocate to Ireland to become HCWs.

Proposals:

1. Bring forward the deadline for CDSWAG to publish recommendations to influence Budget 2023.
2. Ringfence funding for CDSWAG recommendations.
3. Prioritise implementation of CDSWAG recommendations.
4. Ensure Departments and Agencies have sufficient staffing and related resources to implement CDSWAG recommendations.

Rationale:

• Now that Budget 2023 has been moved forward, the publication of CDSWAG recommendations must do so accordingly.
• Budget 2023 must make provisions for CDSWAG recommendations or home care waiting lists will continue to grow which will affect people needing and already receiving care as well as hospital waiting lists and emergency room overcrowding.
• CDSWAG input from various Departments and Agencies must be prioritised at a political level, particularly for Departments that have little previous history dealing with home care.
• We know from delays to the Statutory Scheme that the Government committing to a policy measure is meaningless unless Departments and Agencies have well-resourced staff who are focused on implementing policy.

HCCI has participated in each stage of CDSWAG so far and see potential in the Group. However, HCCI has identified areas where the Group could flounder. CDSWAG must return recommendations in time to influence Budget 2023, which has been moved forward by two weeks. It is important that funds are ringfenced and the budget explicitly makes provisions for CDSWAG recommendations. Doing so would reflect the urgent need to implement a home care workforce strategy to avoid a continuation of the lengthy waiting lists that are currently plaguing the sector. If funds are not ringfenced, it is likely that CDSWAG recommendations will drift for an indeterminable amount of time and the issues causing the recruitment crisis will not be addressed.

Other than the Department of Health, most Departments and Agencies involved have had little experience with home care and HCCI is concerned that they may not give it sufficient priority. HCCI is also concerned that if the Group returns with recommendations for further review it would unnecessarily delay vital workforce reforms.

Departments and Agencies involved require political backing from their Ministers to drive the necessary reforms. By their nature, Departments will have other priorities, and most will be unfamiliar with home care. To implement CDSWAG, officials will need the backing of their Minister, who should provide sufficient staffing and resources.

End the Welfare Trap: Introduce Flexibility in Social Welfare

The current social welfare eligibility rules have led to a “social welfare trap”, particularly when social welfare eligibility is calculated on the binary basis of days worked rather than a cumulative hour worked basis. This leads to the situation where a person who works for one hour is treated as if they worked the entire day. Other social welfare support including carers allowance, working family payment and the medical card either limit income or hours worked. This acts as a disincentive to work and a barrier to entry into the sector and the rules should be re-examined given the recruitment crisis in home care, the impact of lengthy waiting lists and the strong public interest in delivering home care.

78% of Home Care Workers employed by HCCI members and a majority of HSE HCWs work part time. This is partly because of the nature of home care, where demand peaks between 7am – 10am and 6pm – 10pm and the current market conditions as set by the HSE, where on average a client receives 6.5 hours of home support per week. Until the Irish healthcare system develops to the point where more health and social care (e.g. physiotherapy) is provided in the home, and at various times of day, HCCI expects part-time work to remain the norm.

HCCI members cannot fully monitor the social welfare supports their staff receive but we know anecdotally that many HCWs receive some form of means tested support. We also know from HCCI surveys that nearly all HCCI members have encountered the situation where a HCW was offered and willing to work more hours but had to decline because they feared losing their social welfare entitlements. While this is happening, the home care sector is in the midst of the most acute recruitment crisis in its history.

Introducing flexibility in social welfare rules can immediately release capacity within the existing workforce. HCCI appreciates the need to balance social welfare supports with incentives to work but, at present, the social welfare entitlement rules are providing a disincentive to work. Given the market conditions which favour part time work and the overwhelming public interest in delivering home support, HCCI believe it would be prudent to allow HCWs to work additional hours on a pilot basis until such a time when recommendations from CDSWAG, the Commission on Taxation and Welfare and the Statutory Home Support Scheme are implemented.

Proposals:

1. End the ‘Three day rule’ in part time jobseeker’s payment.
2. Create a pilot scheme where home care workers can receive a temporary public interest exception to social welfare eligibility rules in order to care for an existing client whose regular home care workers is absent.

Rationale:

• A majority of Home Care Workers (HCWs) work part time because of market conditions and the hours when demand peaks.
• Many HCWs receive social welfare supports which inhibit them taking on additional hours. A person can work three full days, which is 22.5 hours, and still get jobseeker’s benefit for the other two days. A home care worker can work one hour per day for five days or even two hours per day, which would be ten hours per week, but they cannot get jobseeker’s benefit because the payment is based on the three-day rule rather than hours. Rules should be changed to reflect the nature of home care, where demand peaks at certain times of the day.
• Social welfare rules also act as a barrier to entry, discouraging new HCWs from entering the sector. Reforming social welfare entitlement rules to allow HCWs to work additional hours would immediately add capacity to the sector to reduce waiting lists and ensure that existing clients always receive care.
• HCCI members are at capacity and are encountering issues delivering care to clients when a HCW is absent. HCCI propose creating a pilot scheme where HCWs who are receiving social welfare supports (e.g carers allowance, medical cards, working family payment) are given a temporary public interest exemption to social welfare rules, allowing them to work above their permitted hours/income to care for an existing client whose regular HCW is unavailable. This change reflects the part time nature of home care and the overwhelmingly public interest in delivering care. This scheme should be benchmarked against waiting lists so when waiting lists exceed an agreed level, then this exception would come into effect.

Commit to the European Care Strategy

On September 7th 2022, the European Commission will announce its proposal for the European Care Strategy which will seek to strengthen the care of older people in member states. While the exact details are unknown, the Government should recognise the benefits of a European Care Strategy which includes access to EU funding, improved training for and access to workers and the sharing of best practise in care and commit to supporting the Strategy. This would involve taking an active role in shaping the Strategy and a commitment to be proactive in implementing it. The Government can do this through direct engagement with the European Commission and through our MEPs, including Frances Fitzgerald who has been a leader in developing the Strategy.

Proposals:

1. Support the development of the European Care Strategy.
2. Commit to taking the lead among member states in implementing the Care Strategy.
3. Be proactive in participating in programmes related to the Strategy and availing of EU funding.

Rationale:

• The EU Care Strategy is an important development for people receiving care, family carers, home care workers and care providers.
• Access to EU funding and shared knowledge from member states will benefit the development of Ireland’s home care strategy and help meet commitments set out in Sláintecare and the Programme for Government.
• Ireland is in a particularly favourable position to benefit from the Strategy given that we are in the midst of home care reforms. Implementing the EU Care Strategy can potentially strengthen domestic reforms contained within the Statutory Home Support Scheme, the Commission on Care and the Cross Departmental Strategic Workforce Advisory Group.
• For more information on what HCCI want the Strategy to cover, see this position paper from the European
• Federation for Services to Individuals. http://www.efsieurope.eu/fileadmin/MEDIA/publications/2022/EFSI_position_paper_Care_strategy.pdf

Open Recruitment Pathways for Non-EEA Workers

HCCI has repeatedly called for Ireland to allow non-European Economic Area (EEA) workers to become eligible for employment permits while working for home care providers. The rationale for allowing this is simple; as with all EU countries, there are simply not enough domestic workers to meet the ever increasing demand for home care workers (HCWs). 2,159 people graduated with a QQI Level 5 in Healthcare Support in 2021 and only some of these will work in home care. HCCI members require at least 3,000 HCWs, the HSE likely need 2,000 to 3,000 and non-profits need a smaller number but are facing similar pressures. Indeed, recruitment pressures are not limited to the home care sector. Every area of the health and social care sector requires significant recruitment, as do other sectors.

The EU has recognised the obvious need for member states to recruitment from outside the EU and in April 2022, the European Commission announced a set of ‘Skills and Talent’ proposals that focus on the care sector, highlighting the strong public interest in addressing the sector’s recruitment challenges. The Skills and Talent package is a legal migration policy which aims to attract and create recruitment pathways with partner countries. HCCI proposes that the Government go further than allowing non-EEA HCWs to become eligible for employment permits and work with HCCI to open recruitment pathways to attract workers into home care.

Proposals:

• Allow non-EEA workers in the home care sector become eligible for employment permits.
• Support the development and implementation of the EU Skills and Talent Package including:
  o The revision of the single permit directive so applications can be lodged from inside
  and outside the EU.
  o Impose a four month time limit on issuing employment permit decisions.
  o Allow employees the right to transfer employers without permits being withdrawn.
• Develop, with the support of HCCI, Talent Partnerships which act as recruitment pathways with non-EEA countries to allow streamlined recruitment of HCWs.

Rationale:

• It is clear that recruitment from outside the EEA is necessary to meet current and future demand for home care.
• Moreover, Ireland is effectively in competition with EU member states for non-EEA HCWs.
• Therefore, Ireland should take advantage of the EU Skills and Talent package and become an EU leader in implementing migration reforms and developing recruitment pathways with partner countries.
• HCCI and its members stand ready to both financially and operationally support the Government in opening recruitment pathways

Reform the Insurance Sector

The cost of insurance continues to have a negative effect on our sector, acting as a significant barrier to recovery post-Covid, and will continue to hamper our sector unless it is materially resolved as a matter of urgency. We need insurance reforms that will quickly reduce liability premiums to affordable levels and keep them that way. These reforms have been identified but they are not happening fast enough. We urge the Department and Minister to ensure that sufficient funding is in place to allow for the following to happen:

• Enactment and commencement this year of ‘duty of care’ amendments to the Occupiers Liability Act 1995.
• Enactment and commencement this year of the Personal Injuries Resolution Board Bill 2022.
• Rapid consolidation of the Judicial Guidelines in the courts and transparency as to awards in cases where the Guidelines apply.
• An acceleration of the work of the Insurance Competition Office at the Department of Finance to ensure the urgent entry of more underwriters into the Irish liability insurance market.