Today, the committee will consider the health strategy in relation to the ageing population, including the development of care options other than nursing homes. This is a very important discussion. We have a rapidly ageing population and shifting demographics. We know that by 2060, one in three of us will be aged 60 or older, so it is very important that we think about the services that are going to be provided to older people and the delivery of those services to ensure services meet the needs of older people. Nursing homes cannot be the default option for everybody. There must be other options and, in particular, homecare must be delivered. A statutory scheme for homecare was promised in 2017 and still has not been delivered, so it is long overdue. It is a core part of Sláintecare and must be prioritised and delivered. Those and many other issues in relation to the delivery of care for older people are crucial, which is why we have prioritised them as a committee.

I am looking forward to this morning's discussion. To assist the committee with this deliberation, I welcome from Age Action Ms Camille Loftus, head of advocacy and public affairs, and Ms Jennifer Brown, policy and public affairs officer; from ALONE Mr. Seán Moynihan, chief executive officer, and Dr. Aileen O'Reilly, head of research, evaluation and policy; as well as Professor Rose Anne Kenny, head of medical gerontology at Trinity College, Dublin; and Dr. Siobhán Kennelly, consultant geriatrician.

I must read a note on privilege. Witnesses are reminded of the long-standing parliamentary practice that they should not criticise or make charges against a person or entity by name or in such a way as to make him, her or it identifiable or otherwise engage in speech that may be regarded as damaging to the good name of a 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 they comply with any such direction.

Members are reminded of the long-standing parliamentary practice to the effect that they should not criticise, comment on or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable.

I invite Age Action to make its opening statement.

Age Action thanks the committee for the opportunity to speak to it today. As the Chair said, I am accompanied by my colleague, Jennifer Brown. The committee has asked us to address a very broad area, so we will try to focus our remarks on a number of key issues.

We all want to be able to age in our own home and community, surrounded by family and friends. While some long-term residential care may be needed towards the end of life, far too many older people are there because they have no other option. Some 80% to 90% of informal home care is provided by family members, and 15% of these carers are themselves aged 65 or older. This is not a sustainable model. Demographic and economic change mean more older people have no family member who can provide care for them.

We welcome the programme for Government commitment to develop a statutory homecare scheme, and we are encouraged that the Minister of State with responsibility for older people has made this his number one priority. Age Action believes that everyone should have the right to receive the care they need at home for as long as possible. Developing an effective homecare scheme is a complex challenge that will need to include not only much-needed financial support, but also integrated and tailored packages of multidisciplinary health and care supports that reflect older people’s needs. Staffing shortages are a key challenge which will need to be addressed, including via pay, training and career pathways to ensure we have the skilled workforce we need to deliver homecare.

The failures in older people’s care exposed in last year’s "RTÉ Investigates" programme represent a shocking indictment of our regulatory oversight and enforcement systems. Addressing these failures is an imperative in the context of a new homecare scheme. Placing adult safeguarding on a statutory footing is another urgent priority. We welcome the Government’s commitment to place policy on a legislative basis, and look forward to seeing the general scheme of an adult safeguarding Bill later this year.

Making home care a reality for older people also requires action on housing. We simply do not have a sufficient supply of smaller, age-friendly homes across a range of tenures in existing communities, with the facility to make support services available on-site. While Delivering Homes, Building Communities recognises the need to build more age-friendly homes, Age Action argues that a dedicated strategy is required to develop the number and range of housing options needed for a growing older population.

Effective prevention can play a critical role in healthy ageing. For example, The Lancet commission on dementia prevention finds that about 45% of dementia cases are potentially preventable by addressing 14 modifiable risk factors at different stages across the life course. Primary care services are key to ensuring access to the health care we need, when we need it, throughout our lives.

It has recently been reported that over 32,000 adults are waiting more than a year for an initial primary care assessment. These adults will likely face a further waits for services once assessed. Delayed care exacerbates poor health. These waiting lists are not routinely published, and are not age-disaggregated. What gets measured gets managed. Age Action calls for waiting times for these services to be published and for all waiting list data to be broken down by age group.

The enhanced community care programme is a welcome development, providing a multidisciplinary and more person-centred model of healthcare delivered in people’s homes, preventing avoidable hospital admissions and supporting ageing in place. This kind of delivery is integral to an effective home are scheme. Age Action calls for expanded provision and coverage.

Health costs are a growing challenge for many older people. For example, in 2025, to get the health insurance cover they need, people aged 65 and older paid 45% more than younger people. Over the period from 2017 to 2025, full medical card overall coverage fell by 5.8 percentage points, but by nearly twice this amount for older people. A full medical card can relieve older people of a range of health costs not covered by the GP service card. A review of income assessments for the medical card is long overdue; core thresholds have not increased since 2005. Under the heading of cost, we also note that transport costs to medical appointments can represent a significant burden for older people.

Age Action also argues that the nursing home subvention scheme does not provide a fair deal for residents and is in need of review. Residents must pay for personal expenses, activities and therapeutic supports, which should be covered by the scheme, often leaving low-income residents with next to no disposable income. These fees are not regulated, nor are they monitored for affordability.

In conclusion, Age Action agrees with the Minister of State for older people that "a new vision is required to make Ireland one of the best countries in the world to support a long and fulfilled life". We call for a new national strategy on ageing and older people to provide a comprehensive cross-government strategy to ensure we can all live full, independent and active lives as we age, with the right to receive the health services and care support we need in line with the Sláintecare vision of "right care, right time, right place", as close as possible to our own homes and communities.

Realising this vision requires a significant increase in the supply of age-friendly homes, expanding health programmes such as enhanced community care and addressing workforce shortages, as well as the regulatory and statutory adult safeguarding systems to ensure quality care, and effective safeguarding, whether receiving care at home or in a healthcare setting.

I thank the Cathaoirleach for inviting ALONE to present to the committee this morning. The number of older people in Ireland over the age of 65 is set to exceed 1 million by 2030. Demand for nursing homes is projected to grow by 80% by 2040. Although people are living longer, they spend an average of six years in poor health and, yet, the health system continues to treat long-term residential care as the default response to ageing, at enormous cost to the State and older people.

Last year, through our national network of staff and volunteers, ALONE supported more than 46,500 older people across our services. The older people we support report higher levels of loneliness, poorer quality of life and greater use of health services compared to national populations. Many of them face challenges across physical and mental health, loneliness, housing, finance, energy poverty and safety, issues that are deeply interconnected. Our goal is to deliver what matters most to them, ensuring that all relevant strategies and programmes reach each older person through their own front door.

Delivering what matters to older people means building the pathways and systems that make remaining at home possible. Ireland's health strategy must rise to meet a rapidly ageing population by recognising that ageing is not a uniform experience and designing a system flexible enough to reflect this reality.

Structural reform must be matched by greater investment in community-based supports that prevent or delay hospital admission and nursing home entry. There is broad consensus on the need to deliver care closer to home, and ALONE is proud to be a key component of the HSE's enhanced community care programme. However, progress across health and social care services is not fast enough to meet existing demand.

ALONE believes there are a range of practical initiatives that could support older people to age at home for longer. When delivered early and equitably, these interventions cost a fraction of long-term residential care and deliver far better outcomes. Tools like InterRAI, when fully rolled out, can provide the clinical foundation to identify early need and connect people to the right supports at the right time. These include falls prevention, assistive technology, a national action plan to tackle loneliness, addressing malnutrition, improving transport and expanding home support.

Falls are one of the biggest reasons older people seek support from our services and a leading risk factor for nursing home admission. Specialised exercise programmes can reduce the rate of falls, and these can be funded at scale. Evidence also highlights that assistive and digital technology can support older people to live well at home, and that when appropriately funded and delivered, may generate cost savings to the State.

Loneliness remains the second highest-level issue for older people we support and has been shown to be an independent risk factor for nursing home admission. Despite clear international recognition of loneliness as a public health issue, the commitment to develop a national action plan on loneliness has not been delivered.

Malnutrition among older patients is also a significantly under-recognised issue, reducing the likelihood of discharge back to home following hospitalisation. It is a problem that can be identified and addressed in the community before it leads to hospitalisation. Better collaboration between primary care, Healthy Ireland and community organisations like ALONE could make a meaningful difference.

Beyond these issues, there is a broader set of measures that would allow significantly more older people to live well in their own homes. Implementing a statutory home care scheme, improving transport, investing in GP services and properly resourcing mental healthcare and community multidisciplinary teams could collectively transform what is possible for people living in the community. We have set out detailed recommendations across these areas in our pre-budget submission, and we are happy to discuss them.

On housing with care, the community-based measures outlined above can keep people at home for longer, but it is vital that older people also have somewhere appropriate to live should their needs change. At present, they do not. Ireland effectively offers two paths: remain at home or enter a nursing home. There is little in between. Long-term residential care costs the State up to €1.2 billion a year and the current system comes with high risks and costs. Many older people who do not require the highest levels of care either remain at home beyond safe limits or enter residential care. Although nursing homes play a vital role in the provision of care for older people, our over-reliance on them has been highlighted in numerous reports, including previous Oireachtas Committees and successive Government policies. The result is poorer outcomes for individuals and significant avoidable costs and risks for the State.

Housing with care is a well-established international model, grounded in universal design principles and a "home-first" approach to ageing. It combines independent "own front door" living with access to 24-hour onsite supports, enabling older people to maintain independence, dignity and community connection for as long as possible. The first national housing with support demonstrator project opened in Inchicore this year. ALONE provides supports to residents within this scheme. However, despite strong policy alignment and more than a decade of sustained effort across both the NGO and State sectors, individual projects have not yet translated into a national model capable of ensuring equitable access and consistent service provision.

The core problem is structural. Housing with care in Ireland is treated primarily as a housing product rather than as a health and care intervention, with access determined by social housing need rather than clinical or support needs.

Without clear leadership from the Department of Health and the HSE, the potential for housing with care to reduce pressure on nursing homes and acute health services will remain unrealised, and it will not be replicated. This is despite strong evidence that investment in supported housing models would deliver significant financial and social benefits for the State and older people.

Ireland's housing demand is approximately 50,000 new units annually to accommodate population growth and demographic shifts. Housing with care represents a tiny proportion of these units. Developments should be driven by clinical need and not housing need so that delivery, if successful, would be led by health services. ALONE is ready to work with the committee, Ministers, the Department of Health and the HSE to make sure that we collectively deliver housing with care and ensure equal access to community care.

Ireland's overall health strategy must shift towards a broader vision of healthy ageing. This committee has an opportunity to drive that change and ALONE is ready to support it in doing so. I thank the committee.

Most of the data I will be citing comes from The Irish Longitudinal Study on Ageing, TILDA. The data collection is funded by the Department of Health. We support data analysis by additional resource so that for every €1 spent by the Department, we accrue an additional €2.40, mostly from non-Exchequer research funding. The study celebrated its 20th birthday on Monday. Its value is that we have been tracking people aged 50 older in Ireland for the past 20 years. It is representative of the population in Ireland. We can see the entire health and social framework of a man who was 50 years old at the start of the study and how it has evolved over 20 years. We can also see how new policy interventions have influenced those health, social and economic factors. That is the value of the study.

There are 10,500 people in the study at the moment. We do interviews with relatives and friends, who have been agreed by the participants, six months after the person's death to understand if the person's end of life was as they expected and met their wishes, and to discover the issues that the family encountered at the time of death.

Ireland is one of the fastest ageing countries in Europe. That is important. Over the next 15 years, we will see an escalated increase, as the Chair said, in the number of people aged 65 and over. That number will increase by 60%, whereas the proportions in the population, if demographic changes continue at the same pace, will decline by 20%. Currently, 20% of the population was born outside of Ireland, 32% of whom aged 25 to 44. Approximately 10% are aged over 65, but that demographic will also change as our new demographic complexion ages further into older age ranges. This underscores the importance of regularly updating the data so we keep track of this rapidly changing population demographic.

Although lifespan is increasing and we are all living longer, which is a good news story, healthspan, the period of life we spend without illness, is not keeping pace with that and, by and large, we have a sick span for the last decade of our lives in Ireland. Over one third of adults over 50, for example, have three or more disorders. That has a significant impact. In many cases, this is fluctuating. You get an illness and go into hospital, get therapy and whatever other intervention, and come home. However, for many it is chronic and it certainly increases over that decade, requiring more and more intervention. At 50 or 60, what one requires when one becomes unwell is very different to what one requires in the last five or perhaps ten years of life, when the interventions need to be more intense.

Sláintecare and the integrated care programme have made a difference to how disorders are being treated and identified, but we know from TILDA that this is nowhere near meeting the needs of illness. Some 25% of people over 50 are taking inappropriate medications, for example, that lead to falls and strokes. Some 48% have untreated or inappropriately treated high blood pressure, the commonest cause of dementia, strokes and heart failure. Some 30% have an abnormal heart rhythm, atrial fibrillation, either undiagnosed or inadequately treated. It is also a very common cause of stroke and dementia, etc. There is actually a pretty long list of disorders that are inadequately treated. If we captured those early enough, we could decelerate the ageing process and make a difference to this discrepancy between lifespan and healthspan. There are programmes in place, including, of course, the chronic disease programme, but they need to keep pace with the population demographics and perhaps need a broader picture of how best to deliver those screening programmes, given the pressures we are seeing on general practices country-wide.

To give the committee a sense of the value of that economically, it is possible that we could make significant economic savings. A lovely health economic paper by Professor Andrew Scott in Nature Aging showed that if the USA would extend healthspan by just one year, it would make an annual saving of $38 trillion. We do not have a similar health economic analysis in Ireland, but it would be very valuable if we did.

Access to primary care is uneven across the regions, including disparities in GP availability. That issue is terribly important to the success of any programme with ageing and may constrain individuals' ability to prevent or delay entry into institutional care in later life. The need for enhanced care options is great and will continue to increase substantially. It is not like this is going to happen in the next 15 years. It is happening now. That is what I mean when I say that we need to keep pace with this, year on year. Estimates from TILDA, for example, predict that there will be a fivefold increase in those with significant functional impairment over the next 15 years, year on year. By that, I mean the ability to dress, move around on your own, toilet yourself, feed yourself, manage financial affairs, answer the telephone, get out and do your own shopping, etc. These are incredibly important and a threefold to fivefold increase is massive. That is what keeping pace with the need means.

The objective of care should be autonomy, as far as possible, for the individual and dignity and respect at the end. In that spirit, we know that 81% of our participants in TILDA, and this is absolutely generalisable nationally, wished to die at home. Some 9% expressed a preference to die in hospital. However, the reality is that 27% died at home, 45% died in hospital, 11% died in nursing homes and 8% died in hospice care. We can track this data every two years, so if a policy is introduced we will be able to share with the committee the changes in those numbers.

Long-term care is delivered through a combination of formal and informal supports. We have heard a lot of good evidence in that context to date. Among people aged 50 and older, 70% of the care that is received is informal care from family or friends, 10% is formal and only 20% is a combination of formal and informal. We know that informal carers have a threshold of 15 to 20 hours per week, depending on their circumstances, beyond which their health, both physical and mental, breaks.

Ireland is ageing. Many Irish adults have treatable conditions that remain undiagnosed. Priority should be given to early comprehensive screening programmes and access to good rehabilitation programmes, when it is needed, as a metric of the quality of care we are delivering. The development of effective care models to facilitate ageing in place should be a policy priority, given the strong preference among Irish adults to remain in their own homes and communities.

I thank Professor Kenny. We will now have questions from members. Each member will get eight minutes to direct questions. We try to stick closely to that and if I am cutting a witness off, it is only to ensure equal treatment of all the members on their questions. We operate on an agreed rota based on party size. We will take a break approximately halfway through. In an hour's time or thereabouts, we will take a five-minute break, if that is all right. We will start with Fianna Fáil. I call Deputy Daly.

I thank Age Action, ALONE, Professor Rose Anne Kenny and Dr. Siobhán Kennelly for coming here this morning.

It is not often we can say this, because many claims are made about world-class research in Ireland that do not stand up when you examine them, but the TILDA study is a piece of world-class research that is a pre-eminent piece of work in this field anywhere in the world. I want to recognise that. It is an outstanding piece of work, and data matters. That is why what Professor Kenny says here today is based on fact - on real data.

I want to go straight into the ageing piece. In Ireland, we are sorely deficient in policy and planning, and human, physical and infrastructural systems. We need to take this seriously with this impending tsunami of ageing. We heard this morning on the radio that people were taking out mortgages now for the first time at 40 years of age, which means they will carry a financial burden into their later life. Our birth rate has fallen, so we will have fewer people to look after our older people. We need to address that through housing and proper childcare, and that is happening. We were with the Minister, Deputy Norma Foley, last night and she was talking about that particular issue, but I come back to the underdiagnosis and undertreatment of chronic disease that will impact in later life in terms of dementia, heart failure and kidney failure.

This is disappointing. It has improved since the introduction of the chronic disease programme, it must be said, but it is not nearly at scale and is not keeping pace with the problem. Maybe we need to look at alternatives to this. Are we utilising our pharmacies, for example, to their maximum capacity? Are there other ways that we can implement screening that will enable it to be scaled rapidly but be sufficient to inform changes in intervention? General practitioners should always be involved, of course, but maybe at the decision-making end of things rather than the actual process.

Do we need to invert the way we look at this? We have invested huge amounts of money in hospital care and congregated nursing home care, but primary care and community care remain the Cinderella of the system. Now, with this demand, that is exactly where our resources should be placed.

I totally agree. At the last count, 20% of practices were vacant across the country and there are some areas that find it very difficult to fill places. I agree that we need to incentivise people to engage in primary care.

Professor Kenny talked about the adverse effects of medication on older people aged over 50. It is hard to believe that over-50s are older people, but we are getting older. That is the reality of it. We have not placed enough emphasis on medication review, and funding it, because it takes time. In busy surgeries and pharmacies, it does not often happen, not because no one wants to do it but because it needs protected time resourcing. You could save a lot of money by avoiding the falls, the trips and the head injuries and also save a lot of money on the cost of drugs because if you go down through a list, you strip out drugs from those lists.

The age-friendly programme has introduced the four Ms as a quality measure. This needs to be escalated and can be used across the health service. The four Ms are: what is your mobility like; what matters to you; what medications are you taking, apropos of the Deputy's last point; and mental state, which means cognition, mood, depression, anxiety, etc. They are very good metrics.

The other thing that I was taken by - there were a couple of other things but I am on the clock - was the burden of informal care. We have presumed that families will take that burden up. The estimate of €4 billion to replace that care in 2017 would be a multiple of that now. We need to plan better in that regard.

Absolutely. It will be a multiple of that now and will increase year on year. Those are the facts.

On where people want to be looked after, older people want to be in their own homes in their communities, yet many of them end up in nursing homes. I do not mean "end up", as it is a pejorative term, but they finish their lives out in settings that they would prefer not to be in. The data bears that out.

It does.

On the one hand is what they want and on the other hand is what happens to them.

Other cultures have managed to do this better than we are at the moment. We need to look at those models and see how best we can replicate that shift from an emphasis on nursing home care to ageing in place, wherever that place is, within the community.

I would add that intergenerational ageing in place is really important. Warehousing older people is not what the Deputy, anybody else or I would want at a certain age.

Our view on carer's allowance and home help is far too narrow. People need to be literally disabled in their own homes. In her presentation document, Professor Kenny gave a very good example of a lady with a bilateral rotator cuff injury who simply needed someone to make a cup of tea for her, answer the phone and do some basic work to keep her in her own home, keep her out of a nursing home and keep her away from a hospital setting. Our view is far too narrow.

That is where flexibility comes in. We have to broaden the scope. TILDA looks at this. It looks at activities - what makes up the tapestry of your life and how we as a system can engage with that flexibly for the period of time somebody needs it. It may or may not be consistent over a long period of time. That is flexibility and that is choice.

I am reflecting on this because of an emerging sense among older people that there is ageism creeping into their management because the systems are under pressure in the hospital. In the west of Ireland, we have the longest interval between a decision to discharge someone and getting them into the community. We have the least access to primary care therapies. We have the least access to respite care. There are older people who will say to me in my clinic that they do not want to go to hospital and that they are treated differently because they are older. I do not believe it is a philosophy, but it is a creeping philosophy that older people are now seen as a burden to be managed and got out of hospital - "bed blockers" or whatever pejorative term we want to use.

I test-bedded consultant colleagues across the country and this is a consistent theme - ageism in hospitals. It is about numbers. It is about bed days and no metric of quality of care, but the four Ms and access to rehabilitation are a solution to that within the hospital.

It is extremely concerning that there would be such a sense. We do not tolerate racism. We do not tolerate genderism. We are beginning to tolerate ageism, which is absolutely unacceptable.

We are overdependent on the provision of primary care infrastructure by private providers. This is a statement, because Professor Kenny will not have time to answer a question. GP practices up and down the country are dependent on private investment. It used to be an issue in deprived urban areas and rural areas, but it is now an issue for the east coast where there are growing populations and a lack of GPs.

I now move to Sinn Féin. Deputy Newsome Drennan is substituting for Deputy Clarke this morning.

I thank the witnesses for their opening statements. I want to touch on the delayed transfer of care. In St. Luke's in Kilkenny, there is on average of ten beds for delayed transfers of care and I have had a number of families contact me in relation to that. One woman has been in hospital for four months. She needed to be there for five days. There is a lack of home care. I have sent questions to the HSE in relation to a recruitment drive for home carers, which I am not seeing. I am not getting any answers back either. However, we need to see that recruitment.

I spoke of this lady whose family had contacted me.

She is 99 and a half years of age. She has dementia. It cannot be that you are just treated as a number; it has to be individual cases. In this case, the family member is also looking after her father, and this lady is her aunt. The home care packages need to be looked at with regard to the people in the household, not necessarily as a package for each individual, so that we can get better use of time.

Both of these people with dementia want to be in their own homes where they know their surroundings. They are country people. If the HSE were to pay for nursing home care for them, it would be about €1,600 per week each. Instead of doing that in every situation, including where people do not want to be in nursing homes and their families cannot continue affording it, how could we spend that money better?

The Mount Carmel Supported Care Home in Callan, County Kilkenny, has 20 beds in its centre, but it also has individual front doors so that people have support but can also come in and out and use the centre, such as for nutrition where they can come in and have their dinners. We need to see more of this. The people there have supports from doctors, day care services and everything else. In one case, a lady with her own front door there had a fall, so she moved into the centre for two or three weeks because she needed extra support and then went back out to her own home. We need to see more of these situations.

This place is being funded by the HSE - partly grant funded - and there is fundraising as well as residents' fees. These homes cannot just rely on fundraising. There has to be more involvement from the HSE. If we can take the delayed transfers of care and have proper home care support or supported home care, we could save the HSE much more money and free up hospital beds. To be in a hospital bed for four months when they do not need to be there is a total waste of everybody's money; this lady does not want to be there. This needs to be looked at and become a larger element.

I want to see a proper recruitment drive from the HSE for home carers, but that is not being done. We need the likes of the Mount Carmel Supported Care Home in every community. I know we have smaller villages, but in the village where I am from, it is three villages in one, where there is one sports team and we have a few houses there that are connected to a doctor. We need to see more of home care centres with individual beds so that when people need that extra support, they can go in for a time. I want to see that. How do the witnesses think we can get there?

I thank the Deputy. I will throw in a few comments regarding the development of statutory home care. There is a Bill going through the Oireachtas to provide a registration system for home carers, which is very important for ensuring that the quality of care provided is of a high standard and accountable.

When we consider statutory home care schemes, it is very important to recognise that what we are trying to do is put together a package of supports depending on the individual needs of the person who needs to be cared for. When a person moves into long-term residential care, the need is generally very high. Members have described a couple of different situations where it may just be a question of a small amount of help with daily living - dressing, washing and feeding - or it may require pretty specialised and high-level medical support.

When we think about home care, we need to be able to conceive of a scheme that will allow a co-ordinated package of supports to be delivered into the home. Deputy Newsome Drennan referenced dementia. It is very difficult to support people effectively with dementia when they are in circumstances unfamiliar to them. One of the things people often say when they get a diagnosis of dementia is that they are told to go home and prepare themselves for the end. However, and as I am sure Professor Kenny can speak to, there are lots of different interventions you can make with people who have dementia. The brain is plastic, so we can keep working with that to ensure that there is a better quality of life. Instead of warehousing people away from the rest of the community, we can ensure they are a part of it.

Deputy Daly said that we were beginning to tolerate ageism. The reason we have such an underdeveloped system of care and health for older people is because we have tolerated ageism for a long period now. We need a dedicated strategy to focus our minds and co-ordinate the supports and services we need across a range of Government domains to ensure that we prepare both for the people who are older now and in exactly the kind of situation the Deputy is outlining, and for all of us, namely, the younger people who will be in among that much larger cohort in the future.

Our next slot is for Fine Gael, with Deputy Burke.

I apologise for being late. Unfortunately, I was dealing with an issue in the Dáil relating to cancer care, which is an area that also affects older people. As the witnesses have outlined, there is a growing population, but there is also a growing number of people being identified with cancer. Are we doing enough for older people, not just in terms of cancer, but in a whole range of medical areas? What are the three priorities the Department and HSE should now be doing in order to identify medical issues before they become serious for people as they get older? We have a certain plan relating to, for example, women's health and other areas, but not to people getting older. What are the three areas that the witnesses would now prioritise for implementation in a very short timeframe in order to deal with these issues? We will have more than 1 million people aged over 65 within the next three years; we currently have 860,000. What would the witnesses prioritise now?

The strategy of the four Ms that we discussed earlier is a useful one. The earlier, the better. We should be starting screening programmes at 50 years and upwards in order to really decelerate the ageing programme. This would identify cancer at an early stage when it will not progress, early stages of mental health issues, inappropriate medications and cardiovascular risk factors. That last is a big area we are missing out on. How you implement that screening should be more comprehensive than it is at present. We need to involve more agencies than are currently involved.

We should not underestimate the role of a geriatrician in all of this. There are very few holistic physicians left who look at the whole person and not just a single area of disease. One is the general practitioner and the other is the geriatrician. We need to invest further in both of these areas to ensure that there is a comprehensive look and that somebody's lifespan is matched by good healthspan.

I would mention a couple of things. We do not have the workforce we need to do this job. The care workforce and medical workforce that we need-----

If we took into account the workforce we currently have, is there a screening process we could set up immediately, starting with over-70s? Could we start a screening process at this stage to make sure that we are identifying the problems at an earlier stage?

One of the things you will see in the data is that health conditions are being caught quite early in a person's life cycle but they cannot get access to the services they need for treatment. That is why I drew attention to the waiting list of 32,000 just for an assessment for primary care services. The only way we know about that is because parliamentary questions are being tabled, because that data is not published on a routine basis. As the Deputy knows very well himself, if this data is not published, it does not get managed, so we need a much more forensic focus on the provision of primary care services like audiology, ophthalmology and physiotherapy - all of those things which can play a critical role in the prevention of ill health and the promotion of good health in older age.

I am talking about a dramatic change that we need to get. Can we do that? We did it long ago. If we take, let us say, nursing home care going back to pre-2004, there was no structure at all there. It was a hit and miss. It was the result of a legal challenge that I myself was involved in that brought about the change. There is now a need to bring a fundamental change to how we deal with older people at this stage, rather than the focus being on waiting for them to go into hospital or into a nursing home. Now we need to focus on how we get to them earlier and making sure we have proper assessments.

Programmes like the enhanced community care programme and the integrated care programme for older people are the kind of packages of care that can provide healthcare services to people in their own homes and communities. They can prevent them from having to be admitted to hospital and certainly avoid admissions to long-term residential care, which as we now know, and as Professor Kenny said, is overwhelmingly provided by the private sector, is not geographically distributed and, as we also saw last year, is not appropriately regulated because there are fundamental failures of care happening in those institutions.

Is there a response from ALONE?

Our calculations are based on the older people who come to us and who use our services - data is important – who have twice the use of the GP and seven times the use of the emergency department as the average older person. One of the huge things that will create a shift is falls prevention. Some 38% of the people coming to us have falls issues. One in 16 admissions to accident and emergency services for older people is for falls. There have been lots of programmes nationally but we need to update and roll out the national falls prevention strategy because the evidence produced is that the chance of a person going to a nursing home after a fall increases exponentially and also, in fact, unfortunately the chance of passing away.

I remember seeing a figure previously that indicated quite a large percentage of people were back in hospital within six weeks of being discharged. On Monday we opened a new centre in Cork. It is a rehab facility for people discharged from hospital. On average, patients would stay there between 30 and 35 days. They are helped to get more physically active. That is a new centre that just opened in Cork on Monday. Do we need to have more of those centres where a person can go when they come out of hospital and where rehabilitation is provided?

The reality – taking into account the previous Deputy's input - is that these things are connected. Approximately 600 of the around 2,000 people who had those type of delayed transfers or discharge needed rehabilitation in the community, so as well as having alternatives like housing with care and housing with support, we need to have a strategy for falls and more rehabilitation within the community. It is a multilayered solution but ultimately if we have the right to home care following falls and rehabilitation-----

Does Mr. Moynihan not accept that we do not have enough step-down facilities?

Absolutely. Without drifting into it, our pre-budget submission has costed out how we need to scale that across the country. We need rehabilitation and the national falls strategy must be updated. The programmes that have been tested and researched like the one in UCC must be rolled out nationally.

We need to do more of what we were talking about – like the centre we opened on Monday. Rather than a person going straight home from hospital and then waiting to get access to physiotherapy and everything else, we would have it there online, where it is structured and in place and then people can go home after that, but are in a far better position to deal with being at home.

The other final issue relates to people living on their own. Do we need to do a lot more about providing support for them, because it is a huge challenge at the moment where a person is living alone, especially in a rural area?

I thank Deputy Burke. Unfortunately we are over time on this. We can come back to it. The next slot is mine.

What I find really interesting about this whole discussion and conversation is that it is different to some of the other discussions we have at the committee because ageing is something we will all experience or are experiencing, and it is ahead of all of us. It is a really interesting one in that it is something we all have an investment in. Sometimes we talk about particular illnesses or particular things that we may or may not experience but, all going well, we are all going to age and experience this. We all want to remain independent. We all want to age in place and have the best quality of life in older age. It is something we are all invested in and we need to ensure that we have the services, supports and strategies in place to ensure we can do that. That is why it is a really welcome discussion that we are having. It is an important one and we need to continue to have it, particularly given the demographic changes.

To date, the State has been ill-equipped to deal with it and has not focused on it. Politics and the political system in Ireland is too short-term focused on election cycles that are four or five years. We need to think long term. We need to think about the next generation and not just the next election. That has been core to my politics and that is why I really welcome today's discussion.

Something that is very important is the overall reform of our health services and our care system generally. Over the last two weeks we spent a lot of time talking about Sláintecare, which is about more than just separating public and private medicine. It is a holistic reform for health services and at the core of Sláintecare is the right to home care. It was promised in 2017, almost a decade ago, and it has still not been delivered. We cannot pick and choose which parts of Sláintecare we want to do. It all has to happen. It is like a jigsaw puzzle. You have to do each piece and it is only going to work when we do all of it. That is my message to the Minister and to the Department. It is welcome that we are talking more about Sláintecare but we have to do all of it not just some of it.

I will deal with Age Action first. What are Ms Loftus's thoughts on why there has been such a delay in the statutory right to home care?

I think there are two factors to it. One, is that it is not an uncomplicated endeavour. Let us admit that and recognise it in terms of trying to work it through. We are only trying to register home care staff now. That is really a baby step in terms of the development of the scheme.

Second, it is very difficult for older people to have their voices heard. They are frequently made to feel like they are a burden and that their healthcare needs are an unfair imposition on other people. This is the ageism that we referred to. Home care and statutory adult safeguarding have long been promised. We saw that while Ireland held up reasonably well during Covid the one group that suffered really badly during that period of time was older people in long-term residential care. When we take older people and put them in a different location in long-term residential care, in centres, and we hide them away from the rest of the community, it is harder for the rest of the community to understand what their experience actually is. Of course, we simply do not have any plan in place around ageing broadly. We have no plan in place to meet pension needs. We have no plan in place to meet housing needs. We have no plan in place to meet healthcare needs. The Chair is absolutely right: Sláintecare is a holistic vision of the development of a healthcare system and those kinds of community-delivered services are absolutely integral to that. Let us remember: if you are an older person and you are going into any sort of institutional setting, you are at risk of infection. You are better off at home. When you are discharged, you are better off to be delivered home and to get the physio you need and any other discharge services in your own home around your own friends and family and support network than anywhere else.

The thing that I am hearing is that the delay is around the funding model and the level of legal entitlement. Does Ms Loftus have thoughts on what either of those should look like?

It is absolutely fundamental that everybody has the right to receive the care they need in their own home. When we are thinking about statutory home care, that should be central to it.

It is not what this system feels it can provide but that the system designs itself to provide and to meet the need. That is really important. The Cathaoirleach said we will all get to be older. We will all get to be older if we are lucky. It is a privilege to get older. If we are lucky, we will reach older age in relatively good health and it will be in the latter years of our lives when our health will decline. We should not be impoverished to receive the care that we need in that consequence. We speak to a lot of older people who are afraid to spend savings because they may get ill at some point and need to pay for care. They cannot improve their own quality of life or the quality of the housing that they live in because they need to retain this sum in case some catastrophic health incident befalls them. People should not be approaching the latter years of their lives around that. The idea of our right to care at home has to be core to the development of that scheme.

On that point of extending healthy life, I was interested in the reference Professor Kenny made to the study in the US about the economic and social benefits of extending healthy life. What would Professor Kenny or another academic need to do a study like that in Ireland? Is that possible?

We have the data. We just need a good economic analysis of that data now. We did it in 2017 using the TILDA data. That needs to be refreshed now because I guess it will be four to five times that estimate of €4 billion. We need to look at that.

Professor Kenny also referenced that priority should be given comprehensive screening programmes. I ask her to tell us a bit more about that. What should be prioritised? What are the benefits of dealing with undiagnosed and inadequately managed conditions to date?

It is fairly easy to do a comprehensive screening programme. At the bottom line, we just look for the common chronic diseases that I have cited and implement the four Ms. It depends on what stage of one's lifespan that we are introducing the screening programme. Medications are really important. Medications change all of the time and not infrequently. Those who are involved in general practice will see somebody start a medication and they assume they are on this drug for the rest of their life for blood pressure or whatever. They need to be varied. It is frequent screening, not just a once-off. I believe in starting screening early but continuing it through the lifespan. Start at 50 years old, for example, and make it available to everybody. It does not have to be doctor delivered, but it should be doctor led. The interventions should be doctor led.

In the statement from ALONE, it was said that loneliness is the second highest issue for older people. I ask the witnesses to tell us a little bit more about that. What is driving that? How do we need to address it?

Just under half of the people who come to our services report feeling lonely. We have been campaigning for the past number of years to have recognition of it as a very serious health issue. There is empirical evidence, both from Ireland and other countries, that it is linked to a range of different diseases, health conditions and mortality. We do not seem to recognise loneliness as an issue that is equivalent to things like obesity or smoking. ALONE and a number of other organisations through the loneliness task force have been campaigning to have loneliness recognised as a health issue. Over the past number of years, we have an action plan. There are a number of different things that the Government can do to address loneliness, particularly among older people where we see it as a very entrenched issue often. They range across campaigning to interventions that are targeted at the people who need it the most and more data.

I thank Dr. O'Reilly very much. Our next slot is the Independent slot. I call Senator Clonan.

The witnesses are all very welcome. I thank them all very much for the invaluable work that they do. On the question of ageism, ageism and ableism are two sides of the same coin. I am reminded of Tiergartenstraße 4 in Berlin where the T4 programme was rolled by the Nationalist Socialist regime. While we are aware that disabled citizens in Germany were targeted for murder, it is probably less well known that older people were also murdered. Approximately one third of a million older German citizens were killed because they were deemed unworthy of life; that they were basically a cost to the state. Interestingly, the medical profession in Germany collaborated with this and felt it more efficient to kill elderly people in their local institutions by giving them lethal overdoses of morphine or whatever or starving them rather than having to centralise the operation. This is part of political ideology.

In Ireland, as a parent of a disabled young man, we have all sorts of issues here related to the Catholic Church and probably Famine memory about how we see older people. I had a terrible model of ageing with my own parents and that suffering and illness are supposed to be consistent with age. Even going back to popular culture, there is An Béal Bocht and the seanathair or seanmháthair in the corner of the house next to the fire. Recently politically, disabled citizens and older people are not seen as productive economic units. Care is devalued. It is not seen as a useful or productive thing whereas if someone designs a widget that can increase the number of phone calls one can make, that is reified.

In relation to ageism - this is open to all the witnesses - I was very disturbed by the Government's wording of the care referendum. I was delighted to see that 75% of those who voted rejected it. That revealed an ideological imperative that is very much alive in the Government. It was also evident in the Green Paper on disability reform. It is also evident in what the Government plans to do with the Disability Act 2005. It is not only that we should proactively be supporting the policies that the witnesses identified but that there is huge resistance here to it. What are the witnesses’ thoughts on that generally? It is kind of a philosophical question.

I do not know what the terms of reference are with TILDA. At the moment, there are 55,000 young adults with disabilities over the age of 25 living at home and being cared for by parents over the age of 60. On 26 August, I will join that cohort. I will be caring for a 24-year-old man and I will be 60. I am lifting him in and out of his wheelchair, toileting him and dressing him. There are 2,000 people over the age 70. That cohort of 55,000 is not going to diminish much. Is that something that is measured? What is the likely impact going to be on older people if they are not only going into crisis themselves for lack of timely interaction, but then are also having to care for that cohort of people?

I am being inundated at the moment with older people who are homeless. I had one lady in my office a few weeks ago. Tragically, about two weeks after meeting with her, she died by suicide. Twenty years ago, we did not have 17,000 homeless people. Is that something the witnesses have incorporated into their work? Is it something that they have predictions for? I thank them for their patience.

I will be very brief. Life gets better after 50 years old. That is the evidence. It continues to get better between 50 and the early 70s. The one thing that impacts on quality of life in the early 70s is physical ill health. If we can work to increasing health span, that good news story will continue. It is important to say that. That is for the majority.

If one is caring for an adult child-----

Carers are different. We collect data on carers aged 45 and over. We know the physical and mental impact that caring has. As I said in my presentation, there is a threshold. Caring for grandchildren does not seem to have the same negative impacts. Caring for the disabled, irrespective of age, does in total have a negative impact, ultimately-----

Why?

-----depending on the-----

We are not worried about what will happen to our grandchildren after we die.

Correct.

However, I am not afraid of dying, but I am terrified to know what will happen to my son when I die.

Absolutely. That is a huge burden of worry.

There is a huge moral injury with that. It is very traumatising.

Absolutely. I agree.

That is why the work that the witnesses are doing is so valuable and important.

I will come to the topic of the homeless. We have done a test bed of TILDA in the homeless. We found that even in their 20s and 30s, the homeless have accelerated ageing. They are 20 years older biologically than they should be according to the number on their birth certificates. In the intellectual disability supplement, IDS-TILDA, we have looked at those aged 40 and above.

That is one cohort we are studying but we have not actually looked at general disability, which would be a separate subsample. However, in the context of homelessness, in the first tranche of data that started 20 years ago, only 7% of those aged 50 and older were living in rented accommodation. That has more than doubled in that period and it will continue to get worse. In my clinical practice, there is nothing worse than somebody sitting in front of me who is ill - I can manage that - but who, once they retire cannot afford their rent and will have to leave their community. That is a problem.

In the most recent census, 43% of people who lived in the private rental sector were aged 40 or older. Most of these people will not get access to a mortgage so they will reach older age without having secure or affordable homes. We get contacted increasingly by health professional who ask, "I am treating a gentleman who is older, who is not in secure housing and I am really worried about the impact of the housing on his health. What is available out there?". Again, I stress the point of the need for a housing strategy to manage ageing and older people.

I have two quick points. One third of people who have disabilities in Ireland are aged over 65. The ageism-ableism interface is really important. We changed the system of pension entitlements for carers in the past couple of years, but somebody in the Senator's situation could provide full-time care and attention for his disabled, now adult, son and then go on to provide full-time care and attention perhaps for a partner or parent. In fact, people could spend an entire working life providing full-time care and attention and we will cap the credited contributions they can get in respect of that at 20 years, denying them a full rate pension. That is not right, given the burden of care that is there; and it is full-time care and attention. They cannot leave, they cannot work and they have to provide alternatives if they leave.

Do the witnesses have any view on why the Government sought advice from the Attorney General to indemnify the State against any obligation to care and to put into the Constitution a constitutional expression that the family is the primary carer and that should bear that responsibility? Does that make them despair?

Can we have a quick answer because the meeting is over time? Does somebody want to come in, quickly?

I thank the Chair.

Care is undervalued because it is primarily being done by women, for no money. That is not sustainable any longer and is one of the reasons we need to transform and revolutionise our care system.

We will take a quick break and resume in five minutes.

We will now continue the committee's consideration of the health strategy in relation to the ageing population, including the development of care options other than nursing homes. We will return to Fianna Fáil and Deputy Cahill.

Gabhaim buíochas leis an gCathaoirleach. I, too, welcome our guests today. The importance of home care cannot be emphasised enough. Our senior citizens, our loved ones, wish to remain at home for as long as possible, especially if they are of sound mind. We need to invest more in providing extra carers and home helps, and extra hours and days. There is no need to justify it. It is good value for money.

In my own county of Kerry, last year, respite for families was cut from four weeks to two weeks. Two weeks in the run of the year is very minimal and that needs to be looked at and revisited. I have raised that issue here before. We should go back to the beginning of what I would call the journey for a lot of our senior citizens. They are admitted to accident and emergency and, in many cases, are left on a chair for up to 24 hours. That is inhumane. I raised this with senior officials of the HSE last Friday week. They meet every three or four months with Oireachtas Members. I am aware of cases where people have fallen off chairs while in accident and emergency and that is not good enough. It needs to be addressed sooner rather than later. Some of them - I hate saying this - are nearly worse off after, be it when they go back to the home or into long-term care. I know different people have different health conditions and all of that, but I attended two funerals last week where they were only a couple of days out of accident and emergency. We need to start getting things right, getting our priorities right and getting our people seen as soon as possible when they go to accident and emergency. I know there are emergency cases, which could very well involve younger people who would need and deserve greater priority, but we need to focus on that area as well.

In a response I received to a parliamentary question recently, it was stated that we have 162 unfilled positions in University Hospital Kerry. That obviously has a knock-on effect. We have a great hospital and we should be proud of our county hospital. We have a great manager and staff there but they are run off their feet. Staffing is a huge problem as it is in the area of home care, carers and all of that. We really need to get our house in order and invest more because, as I mentioned, it is good value for money in the long term.

Housing is a huge issue and priority should be given to our older people. I know that ALONE has been a strong advocate for housing with care as a model that promotes independence and well-being for older people. What practical financing, development and operational approaches would be needed to scale this model nationally? What lessons has ALONE learned about successfully building, funding and managing housing with care schemes on a day-to-day basis? We are trying to prioritise housing and housing for the disabled. We should also obviously prioritise housing for our older people. That has not been happening, to be fair about it. I would like a response to that.

I thank the Deputy. For us, housing is always the third highest need that people come to us for. Older people are sometimes left out of the housing conversation. If you take social housing, over the next decade to 15 years, we are going to need 80,000 units of housing for older people alone to provide safety and security for those who will retire in private rented, which is not a suitable model for an awful lot of older people. How do you pay the rent when you retire or if you are bereaved? I think rightsizing will be another element of housing that older people with choice may avail of but, within the continuum of housing and health, you either age at home with home support or you go into a nursing home. Most European countries have different language around it - either housing with support or housing with extra care. In the UK, around 1% of older people live in these types of models. If you imagine somebody going into accident and emergency who cannot go home due to healthcare issues, and has got six years or a decade ahead of them with poor health, residential care will not be the option they will want. We do not want, for the 4% of older people who currently live in nursing homes, that nobody wants to build the extra demand we need, nobody wants to live in them and it is not a desirable state. They will always be needed for a small percentage.

Ultimately, for us, it is three pillars. You build universally designed buildings where people have around 52 sq. m because that will allow for people, no matter what their healthcare, frailty or disability is. Then you provide on-site support and 24-hour personal care embedded in the local healthcare system. For the person who decides who goes into this housing, it is built on healthcare needs and from the side of the geriatricians, etc. From that, you keep people living in the community because they have their own front doors, they can stay connected to the community, we can maximise their independence and autonomy, and ultimately we can also make sure they stay connected.

We believe, like the UK, around 1% of older people could live in these types of units if we develop them. We described in our input Richmond Place, which was a development along the way but, ultimately, it needs to be driven from the healthcare side. While the local authorities and the Department of housing will have enough problems trying to deliver 250,000 houses for older people, this is around 4,000 to 8,000 units, probably driven from the health and care side.

I will add quickly to that and endorse all those comments. There is no integrated funding model for the delivery of supported care. If you are an approved housing body, for example, and you are trying to do this, you have to get funding from the Department of housing. Then you have to go separately and negotiate funding from the health service in order to do that.

We need an integrated funding model that would allow the kinds of developments that Mr. Moynihan is talking about. Second, just to flag that lots of these supported housing tenures do not provide tenancies. Occupants are licensees and they do not have recourse to things like the Residential Tenancies Board, RTB, and the protection of tenancy legislation. That is an area that we need to look at with a degree of urgency. We have a housing crisis unfolding right in front of us.

Sincere apologies for being late. I managed to listen to most, but not all of the session. I thank Alone, Age Action, Professor Kenny and Dr. Kennelly for being here today. I will start by saying that TILDA is wonderful. The decision to fund the establishment of TILDA all those years ago was really inspired and I want to pay tribute to all those who have been involved in it. I know that Professor Kenny has been pioneering that for many years. Between it and the Growing Up in Ireland study, we have really a really rich dataset now and we need to see that developed in other areas. I just want to pay tribute to all of the work that our guests have done but I know there is so much more that could be done with that dataset as well.

I want to touch on a comment made earlier about life expectancy and particularly healthy life expectancy. Sometimes that gets lost in the conversation but it has stagnated, if not retreated, over the last number of years. In terms of preventative health, I am interested in the views of the witnesses on access to vaccination, particularly vaccination for older people. Apologies if these questions have already been asked this morning but I would like to hear their views on that because we have had a considerable conversation about access to the shingles vaccine but we know there are other vaccines out there as well. There does seem to be a slightly inconsistent, incoherent or uncomprehensive approach to vaccination for older people.

That is a great question. This whole domain of vaccination is growing very quickly. The output from many of the studies is really positive and RSV is one example of that. The implementation of the RSV vaccine in childhood made a huge difference. We saw a 90% reduction in the number of children being admitted to intensive care units, for example, once it was introduced. The impact of the RSV vaccine in adults is very similar in older adults in preventing pneumonia and viral chest infections which are very toxic and lead to hospital admission. There was a review done of this. It was a very long review, at 600 pages, which I read over the summer. The decision was that it was not cost efficient. However, other countries have introduced it, including the UK and have found it to be cost efficient. I think we need to readdress that.

Some of us have been questioning the economic basis for that assessment as well and the variables that are included in it.

I do not disagree.

I ask the witnesses to clarify something or confirm it for me. There has been enormous progress made with the chronic disease management, CDM, programme. It is hugely welcome and a groundbreaking change for many people. However, the issue is access to it. It is not available to patients do not have the free GP card or a medical card. I would like to hear the views of the witnesses on the age at which it should be available.

I cannot stress enough that the earlier a patient gets involved, the better, but it is never too late. I would like to see a screening programme available from 50 up. That is a fairly reasonable threshold for preventing chronic diseases from escalating. We want patients to get in there early. That is the first thing. The second issue is that the system is not equitable. The GP card is one thing but there is a whole lot of other things that patients do not have access to if they do not have a medical card. They cannot access incontinence wear, for example, or physiotherapy if they need it for a period of time at home. There is a menu of interventions which people need to keep them ageing in place which are often transient. I keep stressing that they can be flexible inputs but they are not available. Many older persons who do not qualify for a medical card cannot afford the intensity of intervention that they need at a time of need.

Thanks. I want to ask about housing now. The point has been really well made in terms of the housing crisis that is coming down the line. Indeed, it is happening currently judging by the number of constituents coming to me who are renting at an older age. While it is critically important that we have that statutory right to home care packages, I am looking at many people who will never be able to access care in the home because they have three generations living in their home or they are in rented accommodation on their own. Yet, when we talk to the HSE, it says that it does not build housing. That is the mantra. I would like to hear the views of the witnesses on this. Ms Loftus articulated quite eloquently the issues involved in setting up supported housing. What other countries do it well? Do we have good examples of places where supported housing has been developed? Is it the HSE or some other entity that needs to be developing this? Who needs to take the lead?

This, with respect, is not a complicated thing to resolve. The HSE should not be building housing. That is not its job. The HSE is there to provide health services. People who are building housing should be providing housing that is appropriate to the needs of the population. What we need are housing funding schemes that integrate this as part of the package. The entities that are primarily developing this kind of housing are approved housing bodies, AHBs. If one speaks to any of the AHBs, they will tell one of the extraordinary administrative burden involved in trying to put a funding package together to build homes and to do the kinds of things that Mr. Moynihan was describing, namely provide the ancillary services that allow support to be provided to those homes on site. Putting a funding package together to deliver those kinds of homes requires an enormous investment of time, energy and negotiation on behalf of the AHB. There is absolutely no reason that the funding programmes for AHB housing cannot include a funding stream which incorporates the support services as part of that. The health service has enough to be doing in that regard.

To pick up on the issue of the medical card, we can see falling medical card coverage over the last number of years but it is much greater, at over 12%, among older people. I suspect there are some older people who think that because they have a GP card, they actually have a medical card. The point Professor Kenny makes is really well made because there is a large swath of services involved. We heard the controversy recently in relation to blister packs, for example. The way that will work is that patients who have a medical card will be able to get their medications delivered in blister packs but patients who do not have a card will not. When we think about home care, blister packs are a really important aspect of delivering safe care at home. To me, this is penny-wise but pound-foolish. We need to look at medical card access and that really needs a substantial review. The medical card thresholds are so far below the State pension level now as to be absurd. The ESRI produced a publication last year examining the amount of discretionary cards but that is a really cumbersome process. Again, older people are not going to go through that process unless they have some assistance. We could do an awful lot to allow people to get the services they need at home if we would just provide them with medical card coverage.

The last thing I want to raise in the remaining few seconds relates to an earlier conversation about delayed transfers of care out of hospital and the sheer lack of resources with regard to dementia-specific and other beds. For 79 out of the last 93 days there have been over 500 people languishing in our acute hospitals. They are ready to leave but cannot do so because of the lack of step-down facilities. It is absolutely outrageous that this is going on. It has not got much coverage but it is worth saying here in the committee.

The witnesses are most welcome. My apologies for missing the reading of the statements but I have a good grasp of what has brought our guests here today and I commend them on that. To those people listening in from the comfort of their own home or from a nursing home, I want to say that those providing care, whether paid or voluntary, are doing a commendable and brilliant job. They will never get enough recognition or thanks for that and that is important to say.

I am always taken when I hear of older people who want to be at home but who, because of the commitments of their sons or daughters in terms of work and so forth, are lonely, isolated and full of fear.

I am saying that in the context that for a lot of older people, the only comfort they have is listening to the radio or the visit of the carer or home help. Night-time can be a massive challenge for them. No matter where we live in Ireland, particularly rural Ireland, we hear about the spate of rural attacks and rural break-ins. That puts the fear of God into anyone who is living alone. I can mention a number of people I have spoken to over the years who chose to go to a nursing home for those very reasons. We have a sad situation where there is a lovely little home and a person who, if he or she had enough support, could continue to live there. We need to invest more in adaptations to homes to facilitate those people, particularly those who are aged and have to manoeuvre upstairs to get to and from their beds. The investment needs to go into adapting the housing to ensure they continue to live at home because that is where they want to be.

I hope I am wrong but I am reminded of something, based on all this stuff I hear. In east Galway which I represent, for example, there are quite a lot of people who may be hospitalised today. They will be waiting to get a nursing home space and it is nigh on impossible. It is very difficult. Therein lies the problem. This is not to cast aspersions on the State but I believe that we do not have enough State-owned care facilities. We need to start looking very carefully at this because Mr. Moynihan's report suggests that in 2030, there will be 1 million people over the age of 65. It may be more than that - I doubt it will be less - but we need to be prepared for that. I do not care who answers the first question I have to ask. Have we done an analysis on what sort of nursing home space and nursing home bed capacity will be required? That is only a short number of years away in 2030.

Can I grab first shout?

By the way, if we mind the pennies, the pounds will take care of themselves.

I thank the Deputy. That is exactly the expression I was looking for. First, Government did make a commitment to roll out the care and repair programme nationally. Age Action has been talking with the Minister and the HSE around funding programmes for that. We aim to deliver that throughout the country in conjunction with a lot of other community organisations, for example, ALONE, to make sure that when people are being discharged from hospital, the adaptations are available because the way we run care and repair is to say that if people are being discharged, they will be prioritised in that context for the kinds of home adaptations we need. It is really important that when we think about planning for the healthcare needs of an older population, we do not assume that long-term residential care is the default. Most people should be able to be cared for in their own homes without having to go into nursing home care. Nursing home care should only be for situations where there is an extraordinarily high need, possibly towards the latter stage of life. We need a mindset shift in that regard. Nursing home care should not be the default option.

I spoke to the niece of a gentleman who, at 68 years of age, is being admitted to nursing home care simply because nobody can put together a home care package for him. There is no family to provide care for him. He does not have kids. He does not have younger siblings. It is not reasonable to say to a man of 68 years of age that he should live the next 20 or 25 years of his life in institutional care. The point Professor Kenny made around intergenerational ageing is really critical in that regard. If we are housing older people in different places and if they are not part of our communities, there may not be other members of the community saying, "I have not seen Camille today. I wonder how she is doing. Maybe I will knock on the door and just check that everything is okay." That is one of the critical ways we will provide for decent quality of life for people in older age. That mindset shift is something that really needs to happen. Long-term residential care is not where anybody wants to be.

Mr. Moynihan made reference to rightsizing. We are not good enough at that. I can honestly say that if anyone in this room was to walk into their local housing estate, there would be many people who would be mad anxious to rightsize and allow their home to be considered as a home for some of our homeless or some of the people on the long waiting lists. Those people could then fit into one of those residential purpose-built rightsizing units in their own community. It might only be 1 mile from where they live. We are not good enough at advancing rightsizing. It would do two things. It would free up a home that is not suitable for the older person and would match young families' needs and it would give a unit to an older person in the local community. It would not just give them a home. It would give them the security and the confidence to know that all their needs will be met.

It is not reasonable to say to somebody who has been living in a place for the past 50 years of their life to uproot and go to some other place entirely where they know nobody. That is not a reasonable solution. I note there has been some change in relation to lending provisions for older people. That was a key barrier in relation to the rightsizing challenge. It is easier for older people who want to rightsize to get finance now but the key issue is there is nowhere for them to move to.

That is the key point.

Does Mr. Moyhihan want to come in?

What the Deputy was saying about State homes was really interesting. If we keep going on this trajectory, the demand will be around 800 extra nursing home units per year, going back to the shortage in Galway. Nobody wants to build them, nobody necessarily wants to pay for them and very few people want to live in them. If we take the delayed transfers, and members heard most of the results this morning, we need more rehabilitation and more housing choices in the community that come with support and, at the same time, we need the statutory home care scheme. It is, therefore, a multifaceted input.

I thank Mr. Moynihan. The next slot is for Fianna Fáil. I call Senator Costello.

I thank all the witnesses for coming in today. I absolutely love data so their stuff is just fascinating to me. I could listen to them all day. I have one question. ALONE has been a strong advocate for housing with care as a model that promotes independence and well-being for older people. What practical finance and development and operational approaches will be needed to scale this model nationally? What lessons has ALONE learned about successfully building, funding and managing housing with care schemes on a day-to-day basis?

I appreciate the question. People have mentioned approved housing bodies. We are actually an approved housing body as well. After spending 17 years running an approved housing body, I can tell the Senator all the challenges around funding, development, planning and so forth, which most members know. The reality is that the housing needs of older people are so big. People mentioned rightsizing. We have housing adaptations and people at home who have home help. There is rightsizing for people who cannot cope with their current home. There are choices there. Then, there are situations where people need social housing. We move along then and there is a gap and it is straight to nursing homes. The reality is that we have been on the road for around a decade with housing with care. Ultimately, we need to find a funding model that integrates both housing development and the care needs. The challenge here is always going to be that for it to be fair and equitable across the country. The allocations have to come from the Department of Health and HSE because, ultimately, it is an alternative. If we imagine that people go to hospital and cannot return home, the only choice now is a nursing home rather than what we want, which is that they would have a choice of housing with care, which is still in the community. That means the funding model predominantly has to tilt from the healthcare side. The reality is that Department of housing is going to struggle. We all know it has €8 billion per year for a €20 billion problem. To actually then get involved in the delivery of care modality is-----

I am on the clock; I thank Mr. Moynihan. Another thing he mentioned was AFib and incorrect medication.

If we immediately address that it would address so many issues.

That is right. Programmes were introduced when we brought out the data initially and it has got better but it is still not complete by a long shot.

My dad had AFib. He ended up getting blood clots, strokes and dementia - the whole lot. That leads me into the whole home care thing. With my parents, nursing homes are a no-no. Even with the caring provision, my mother literally did not sleep for the two years minding him. Care assistants came to the house three times a day. It is not enough but they were earth angels. Something was mentioned that struck with me. It is about encouraging people into a career, making it a career and showing how valid it is with the 4Ms framework. I look at society and I have a huge issue. We are taking away people's independence and dignity even before their health fails. Revenue has gone online.

Correct.

If you are in your right mind and your body is working but you are not computer literate, then you have to rely on your child to know your financial business. I raised this as a councillor. We really need to sit down and rethink this. We are talking about the PACE programme. The PACE model needs to catch up with the AFib. The PACE model also needs to catch up with the incorrect medication issue, which I do not think would be a huge one to sort out. On incorrect medication, we need to get it right. We need to be people focused. We are talking about a generation and we will be that generation ourselves. Time is ticking.

I thank the Senator so much for raising that because it is a huge issue. The data on this is that almost 70% of people over the age of 80 are not computer literate. That is the data. You can do nothing.

I get people coming into my clinic. I say to anybody coming into my clinic in Tallaght that if they need help filling out forms, I will do it for them. If they need help navigating the Internet, I will do it for them but it should not be like that. Not everybody knows that I am around, not everybody has family members, or perhaps not everybody wants their family to know their business and that is their right.

That a really important point because what it does is open up people to a financial safeguarding risk. This is all the information we are told not to share with anybody else and if people are in that situation they have very little option but to divulge that information.

Do we think enough is being done with regard to elder abuse?

No.

I had to step out for a while so maybe this has been raised.

It has not been with. It is an issue. It is a very delicate issue but incredibly important.

With adult safeguarding, what needs to be done?

The IT issue is very important because that is one of the main structures on which elder abuse is very often framed. If we are going to get to the stage with this discussion where there is a strategy, it should involve the business community. Their approach is ageist with respect to IT and that would go some way-----

Does Professor Kenny think there should be statutory adult safeguarding?

Absolutely.

We are due to a general scheme of an adult safeguarding Bill later this year.

I think is working really well from my experience. The age-friendly co-ordinators in South Dublin County Council, Ms Mary Roche and Ms Paula Swayne, go out to houses and identify what people need. They identify the safety issues and they enable people to live in their homes independently. The waiting times for occupational therapists are a cause for concern when it comes time for processing all of these forms. The age-friendly co-ordinators are that human contact I am talking about, so I suggest pouring more money into that.

The Rose Cottage in Tallaght is a day centre. My dad got one day a week there and my God he waited at the front door to go to Rose Cottage. It was human connection, activities and being cared for by people who knew what they were doing and the roles they were doing. It is only open for three days a week. We need more funding for that kind of thing. This leads back to the carers who are to the pin of their collar. As much as we say that we really appreciate carers, there are the unofficial carers who bear the unofficial out of working hours care. They do need more.

We are reduced to two weeks of respite. In terms of digitalisation, elder abuse and the other things that were brought up, assisted decision-making and the decision support service has been fully digitalised. I am sure the Senator has people coming into her clinic who really cannot manage. One of the main ways we protect ourselves is knowing who it is that we want to help us when we are not able to help ourselves. That is the fundamental principle of what is there in terms of enduring power of attorney. They are extremely difficult to navigate for people who are not computer literate. We spend a lot of time in clinics trying to help people and to find help to be able to navigate-----

I could talk all day about my difficulties with this. We really cannot be moving to a place that we are not at yet. I thank all the witnesses very much.

I thank the witnesses very much for coming in. This is a really important issue and one I feel close to myself having had grandparents that were elderly and passed away. I will start with a wee story. On 12 December last year, I was asked to go to St. Shanaghan House down in Ardara in County Donegal. It is the Ardara Sheltered Housing Association. To be honest I did not know what to expect when I landed there. I went in and I met Teague McFadden and Eamon Byrne who look after St. Shanaghan House. It was one of the most memorable visits I have had in any place since I started here. It was really lovely. I did not know what to expect but I met people I would have looked up to when I was young in the community in Ardara and Bruckless and around that area. To see them in there now so happy with independent living, it is the future and the way we should be going with care of the elderly. They have their own wee place with a kitchen, their flat and so on. They know everything that is going on in the parishes around them. They are getting all the information. There is staff there day and night if they need help with medicines or anything like that. I came away asking: how can we make this better and have it throughout Ireland? They said to me "Manus, we are involved in everything, we know what is going on, we are getting Pilates classes, the priest is coming in, and the reverend is coming in". They all feel so much part of the community. This is what we need to replicate throughout the whole of Ireland.

In Ardara, we are looking to extend and hopefully we will get the application through to extend to cater for another 12 because a lot of people are waiting get in to St. Shanaghan House. It is a house that I was really so proud to have visited. It is only 20 minutes up the road from me. I had always heard of St. Shanaghan House but I never knew exactly what they did. It was one of the most memorable visits I have had since I came in here.

I will start with the witnesses from ALONE. As demands for services grow, how can Ireland build more integrated systems of support for older people? What role should organisations such as ALONE play alongside statutory services and local community partners?

We heard earlier about the pressure on acute services. We will only ever be able to do so much in the acute system. What we are hearing today is that we have to look outside those hospital walls and we have to look at the community. We have to look at things like screening and we certainly we have to look at services and interventions. At the moment in ALONE, we are probably reaching about 2% of older people who would need a service like ALONE but the estimated level of need would be about 8%. We are driven by national data when we infer that number. There are a lot more people. A lot of the poverty and challenges people are experiencing are quite hidden, and ageing is not the same for everybody.

Alongside that we have just finished a very big scoping review with the London School of Economics, looking at all of the interventions across the world that might make a difference. We looked at non-medical interventions that might make a difference to older people. The strongest evidence we see internationally is for things like exercise and physical health prevention. That is both effective and cost effective. It can be delivered in communities. These are inexpensive and they can really help with things like social cohesion and reducing isolation, alongside the intervention and the acute system.

On the housing association in Ardara, it approached us five years ago and we did a knowledge and information exchange because it was trying to duplicate it at the time.

That is the journey for many agencies across the country that have produced an element of housing with care. They want a national model. They have far more older people than they can deliver for. That is the type of thing we were talking about earlier, creating a model that can be replicated across the country to give people choices.

The integration the Senator is talking about is happening, particularly at the interface between the enhanced community care programme and the integrated care programme for older people with a lot of voluntary agencies. Nationally, there has been the development of ageing well groups in tandem with this. In my multidisciplinary team meeting, there will often be local representatives from Alone and from the age friendly co-ordinators group the other Deputy referred to. A lot of that engagement is beginning to happen. It is not formally supported in the system so we need to look at how the statutory interface around that works but it is starting to happen. We have great scope for elevating programmes like ExWell and others in the community, which are favourably received by older people who are often not the people who would classically be interested in gyms or other types of mobility issues. However, their health and social outcomes and data from an ExWell point of view are compelling. An overall expansion of programmes that help people to age well, in place in the way we are talking about, is what is needed. However, we have a lot of the answers already. It is really about expanding and operationalising them across the regions.

We are now, through Sláintecare, in the place of having our regional forums and the structures around them set up and being able to measure the metrics Professor Kenny talked about earlier, such as mobility and what matters to the person and going around the four Ms. The structures are needed to implement those at scale.

The truth of the matter is that oodles of things are happening at local level, but we do not have a strategy to knit it together in a coherent fashion and make sure it gets the funding it needs. That is what is absent. We do not have a system of overall governance for this. We do not have a strategy on ageing. When the HSE goes to argue for funding in the budget process every year, it is trying to ask all the time for more staffing allocation for this because it will save us bed days in the acute system. We need much more support. We need a coherent, organised strategy that brings all those services together and allows the health system to leverage the funding it needs to deliver it nationally to everyone who needs it.

I totally agree. St. Shanaghan House is ten minutes down the road from my house. It is in a different parish and I always heard about it. If the powers that be were to go there to visit those people 20 years ago and see them now, they would see how happy the people are. They are living independently. It means a lot to them to have their own space if someone comes to visit. They can invite visitors in and chat to them. They feel independent in their wee places. When it comes to my time, that is where I would like to end up. People's friends can come to visit and they feel a part of society.

Respite for older people is a real problem in Donegal.

I apologise. I was late, but I was listening.

Senator Costello provoked me to ask my first question. We all have personal circumstances and they probably colour a lot of what we believe to be right or wrong with the healthcare system. For example, my father was ill for a long time. Fundamentally, I come from a view that we would like to keep people at home for as long as possible. Something the Senator raised resonated with me about filling forms. I could open my clinic on a Monday or Friday and I could book in ten, 20 or 30 people. There is no shortage of people to come in to fill forms. There is a reluctance or reticence. People can be unsure whether they are filling the forms correctly. Then the form is left there for a month and everything goes out of date so they start again. We go through those processes and help people as best they can but surely there is a better way than handing people in their 70s a housing adaptation grant or grant for older people application form. It could be 20 pages long. They meet two or three tradesmen and eventually after six or 12 months, they might get some bright hope, long after the adaptation was required. Is there a better way of doing this, such as through public health nurses or local authorities coming out directly? What would be the ideal?

We provide that service to people we help with grants. We will go along the journey with them. What is interesting about it is that in one period last year, for 25% of those who needed support, it was for bathrooms. Many of these grants are misinterpreted. They are about healthcare needs. The reality is that the system is overly complex. Many local authorities are already running out of money and closing systems and we are only halfway through the year. What will people do? Much of this is to do with healthcare and helping people to age at home. We have to simplify the system. Local authorities would not like this, but we are operating 31 local authorities and 31 local systems, which all have different emphases on what is funded and how it is funded. Ultimately, people need someone to go along the journey with them because they might need quotes, an occupational therapist, an architect at times and so on. The reality is that the system needs to be completely simplified and it needs to be consistent across the country.

Again, I will make the point about the need for a strategy because the point Mr. Moynihan made is that often it depends on what the emphasis is in a particular local area. The age friendly homes initiative is useful in being able to walk through the process with people but it does not need to be as complicated as it is. Much of the scheme is about a fairly ludicrous degree of penny-pinching, when, if people can be kept at home, enormous amounts would be saved in comparison with having them admitted to the acute system. That is the kind of thing that can be resolved with an overall strategy. We do not have an overall strategy for the care of older people and we need to start to put that in place sooner rather than later, because as this demographic change is happening in front of our noses, the needs are becoming greater and greater.

Northern Ireland and Wales have commissioners for ageing and older people. That is something most organisations in the age sector have been calling for for a long period. One aspect of that provision is an information service, which can help people in that regard.

I echo the comments around the Decision Support Service. One of the things we are often contacted about is that people have not had the conversations before the care needs arise. People do not know what the preferences are. They do not know who they want to have power of attorney. That system is difficult to manage even for people who are proficient with computers, never mind for those who are not. That is the kind of thing that would be part of a proactive strategy around ageing. All of us, no more than screening, should be thinking in our 50s about what would happen, who we would want to look after our financial affairs, who we would want to make medical decisions for us should that arise, what our preferences would be in an advance healthcare directive. Too often, what happens is that the crisis occurs and people are trying to respond to it in the middle of the crisis. We do not want to be doing that. We certainly do not want to be trying, as the Deputy probably knows from his experience, to string together a homecare package when someone we love is already ill or looking for discharge from hospital because the pressure will be to go to the first nursing home that comes up given it is the quickest way to move that person out of the acute system. We need a system that is much more proactive in that regard and that could deliver the packages in people's homes rather than force those kinds of decisions.

I echo that the issue we have discussed this morning is a cross-departmental one and any strategy must include Departments. We have talked about housing and transport. Of course, we are talking about health but health is predicated on many other elements of the tapestry of our lives and we must ensure it is represented cross-departmentally.

We are talking about ourselves. It is very easy to think of the solution here; it is what do I want and what do I want to look like. That is what we should be going for.

The point on this being cross-departmental is why we need a national strategy on ageing and older people. It is not just a healthcare strategy because all of these things have to be knitted together as a piece.

I know we have spoken a lot about how people do not want to be in residential care but we must understand that it does cater for 5% of the population of our older people. It is estimated that by 2040 there will be 50,000 people living in long-term care from a baseline at present of 25,000. There is a large population who have very high healthcare utilisation needs and they are largely being managed in the private sector at the moment. They are treated as a separate population. Even in the discussion we are having here this morning, we are treating them as people who do not live in our communities. Residential care is integral to our community. It has to be fundamental to an ageing-in-place strategy. Many of our people are inappropriately moved out of residential care and into an acute hospital at the end of their lives because they do not have access to the services they need in residential care. We have to start asking ourselves why there is the terrible fear of residential care and why is it not much more mainstreamed in our options of care where it is needed.

And why we are leaving the development of that sector to private property investors, which is largely what drives it now.

I have one more brief question, which will move the topic a bit. Recently a number of us have become involved in the Before We Die campaign. I would like to gauge the experience of the witnesses with this campaign and how prevalent an issue it is. This is with regard to people caring for adult dependents long into their 70s, 80s and 90s. How do the witnesses interact with them?

From a clinician's point of view we certainly meet a lot of people. We referred earlier in the discussion with Senator Clonan to people living with children with disabilities who are ageing with them. I referred to a case that I recently dealt with, where a man in his 50s who was working remotely at home was looking after his father who had a severe disability and was very functionally dependent, his mother who had advanced dementia, and his brother who had significant autism and other needs. As a clinician with the integrated care programme and as a geriatrician I was allowed to look after the needs. My remit was on the needs of his parents. This man was looking after all of the people in his house by himself with no carers. He was not known to a public health nurse and there were no services in place. He was referred because his father had been admitted to the acute hospital. This is a scenario where we could have identified so many things so much earlier and been able to put in place a suite of services to help that man. All he really wanted to know was where we could get respite care for his brother. He could manage the care needs of his parents and he was trying to work full-time at home. These are the scenarios people are dealing with.

I apologise for leaving as I had to go to speak in the Chamber. I had made some notes and I was here for the opening statements. Something many of the witnesses touched on was age-friendly homes and retirement homes. They have all referred to these in their opening statements. I am based in Limerick and we have The Park retirement village and another dementia -related retirement village in Bruff. There are not enough supported retirement villages. Do the witnesses have any comments on this? At The Park in Castletroy everybody has their own front door. Some of the units are two-bedroomed bungalows and many of them are apartments. There is a nurse and a medical team on site. Would this work?

This is something that should be part of a range of options. We cannot and should not as adults expect to be told. At any other stage of our lives we do not tell people this is where they should go. For some people it is exactly what they will want. With horror would my mother ever live somewhere like this because she wants to be part of the community.

I want to flag, though, that people who are renters in these types of developments are licensees mostly. They do not have the protection of private rental sector legislation. They do not have recourse to the Residential Tenancies Board. We do not know the scale of this provision across the country. We have no data whatsoever on it. We have no data on what is being developed, where it is or who is providing it. Some of these residents get into difficulty. Senator Byrne has given examples of some good places but we have had contact from people living in supported housing provided by an AHB where people have been left without electricity in their homes because the necessary upgrades have not been done, where older people use a candle to get from their bed to the bathroom during the course of the evening, and where older people were left confined to their homes because the lift broke down and was left unrepaired for a period of time. It is very important when we think about these types of developments that we have a regulatory system in place that ensures things are provided to the standards that they should be, and that the people who live there have recourse to things such as the Residential Tenancies Board should they need them. Technically if somebody else can enter your home, which is the case in many of these places, you are a licensee and not a tenant.

I will make a quick point. At a higher level, and not too granular, choice is really important. Flexibility of the system is important. We have heard wonderful examples this morning of pockets of choice and flexibility which are working but it is not consistent across the country. Consistency is necessary and equality, therefore, is an issue.

I thank the witnesses and I appreciate where they are coming from on this. ALONE has experience of supporting older people throughout the country and it is in many local authority areas. What trends is it seeing in the profile of those seeking its services? What is the scale and nature of loneliness and social isolation?

Mr. Moynihan mentioned in our opening statement that we supported over 46,000 people last year. What we have seen over the past couple of years is an increase in the number of older old people coming to us. These are people aged between 76 and 85. We have heard a lot this morning about physical health needs. We have seen quite a significant increase in the number of people coming to us with physical health needs. It is at almost 60% now. We still see about one third of people with housing issues and this has been fairly consistent. We still see very high levels of loneliness. Towards the end of last year we saw a significant increase in the number of people reporting financial difficulties as we headed into the winter and colder weather. To echo some of the points made earlier, we know 96% of the older people we support are on daily medication and three quarters have three or more health conditions. About one third of the people who come with physical health issues report issues regarding falls.

I want to mention our volunteers. We have spoken about formal and informal carers and the workforce but let us not forget there are so many volunteers throughout the country. We had 11,000 last year who provided an equivalent of more than €8 million in support if we were to pay these people. They did an awful lot of the kind of work we speak about with regard to supporting people's physical health, filling in forms and access to technology. Our staff do great work, and staff in other services do amazing work, but we have a great volunteer workforce also.

I was at an event last Friday in Dún Laoghaire to do with St. Joseph's supported care. It is a daycare centre for people with dementia and older people. Volunteerism is something that came very much to the forefront. There is the cost of training volunteers. I am sure these are hidden costs for all of the organisations. Something this organisation definitely highlighted was that there are a lot of hidden costs when it comes to supporting volunteers. The volunteers who go out and do all of these jobs are absolutely fantastic. It is something I am very aware of. In terms of training I am sure many of the witnesses find people have to be highly trained to do the work. Professor Kenny spoke about collaboration between pharmacies, doctors and volunteer groups. How do the witnesses see this collaboration working with supporting older people?

It could be part of the integrated strategy and should be part of an integrated strategy.

We have to look outside the box for this. Frankly, the problem is too big to focus on a single professional grouping. We have to look outside the box and think of additional models outside of that.

That is also very important with respect to training and education, and the recognition of home care workers. They are incredibly important, but they are undervalued. It is about how we can upskill them further and make their training more flexible for all of the different components we have discussed today, but also that they are remunerated properly, with proper CPD at regular intervals.

It is also about career paths. They are burning out at a rate of knots. If people are working in that sector in an understaffed area, just like the carers at home, they start to burn out. There is too much to deal with. One of the things we absolutely have to do if we are serious about this is start investing in that workforce. We need to build and develop this. It is not dissimilar to what we had to do with childcare, which was also mostly done on an informal, unpaid basis by women. It is not a dissimilar process that we need to undertake now in relation to home care. We talk a lot about what AI will do for the jobs market, but this is one of the jobs that cannot be replaced with AI. We can supplement it and assist it, but that care has to be provided by a human being who is skilled, supported and trained, and has a career path.

That is the end of the list of speakers from the committee members. We have ten minutes left. I call Deputy Aird. Deputy Burke has an additional question and I will then conclude.

I thank the Chair for allowing me the time. I thank everybody for the work they do in minding their parents and loved ones. I was a member of the Midland Health Board for many years in my other role. I have seen huge changes. For people who are looking after loved ones at home or friends, respite is very important so they do not burn out. To encourage people to mind their loved ones in their homes is the most important thing. The second most important thing, in my opinion, is to ensure that no beds are lost, for example, at Mountmellick and Shane in my area, or the facility at Abbeyleix, which has now been turned into a respite centre. I visited all of those sites when I was on the committees. When people were in wards, there might be five or six people, or even seven or eight, in one ward. My mother was a nurse in Mountmellick for years. Nobody ever criticised that to me. The biggest problem I had was trying to plead with the matron, or whoever was in charge, to try to get people into places like Mountmellick, Abbeyleix and Shane. My argument is that there needs to be joined-up thinking. Just because somebody decides this might be the best, would they please ask the person who would like to go into the hospital if they are happy to go in where there are three, four, five or six beds, or if they want a room on their own? As a result of what is happening, these people end up with nowhere to go, and they are then asked to go into private nursing homes.

I have seen all of this. I have lived through it. Coming out at the other end of it are all of these non-ideas. It is not good for the person who wants to go in. I am a huge believer in that. We should look back at history and at what took place then. They were greatly cared for. I knew people who went in there who had no one belonging to them. People who were coming to visit their own loved ones would treat that person the very same as if he or she was their own parent. That made life more comfortable for those people. Where are such people now? They still exist, although I am not on the health boards because they were disbanded. I can tell the witnesses this. The best time that I ever spent as a public representative was on the Midland Health Board. I enjoyed my time on it. I enjoyed visiting people and going around the nursing homes. People were cared for 100% in those environments. I ask those like the witnesses to please stop, look at what used to work and allow the people themselves, when they are going into a setting, to make their own decision on it.

I think the Deputy is referring to the public nursing home sector.

Yes.

The public beds that we have currently work very well. The Deputy made a great point about institutional memory. Do not reinvent the wheel if you do not have to. Most people, when asked, would like a room to themselves. Having said that, the public nursing home sector often takes the most complex and difficult to manage patients and affords them a multidisciplinary opportunity for care, with physiotherapy, occupational therapy and so on. That is seen in some places but not across the board in the private sector.

I want to go back to the issue of stepdown facilities. Do we have figures for hospital discharges where people were readmitted within, say, two months? It is interesting. The stepdown facilities provide that crucial three or four weeks that people need when they come out of hospital, and then they might be put into nursing homes, where the HSE has agreed to take ten beds for 12 months. However, when they go into the nursing home, they do not get the same level of rehab, whereas if there were stepdown facilities, they would. Do we have figures for readmission where people are discharged but have not gone to a stepdown facility?

To be fair, they have looked at that data in respect of specific centres from the HSE point of view. Probably of more pertinence is the excellent rehabilitation document published by my colleague, Dr. Emer Ahern, through the national clinical advisory office for older people in the HSE. It looked at the level of rehabilitation provision nationally across the country. We are talking about rehabilitation for older people that is geriatrician-led, with structured multidisciplinary teams providing exactly the kind of post-acute episode of care and structured rehab that the Deputy is talking about. That facilitates actual discharge home as opposed to what we have seen recently with the emergence of other models, which is a looser, more unstructured, bed-based care to maintain flow. That is the main metric that is measured in our acute hospitals at the moment. I do not blame acute hospital managers or our system, but that is what they are measured on. They are measured on trolleys, length of stay, flow and the ability to discharge. We talked about delayed transfers of care today. Until we really start thinking about what issues are arising for people in our acute hospital beds, and why they are not able to transition in care, we are not going to make progress. I appreciate what the Deputy said about rehabilitation earlier. It is a massive issue.

We are coming to the end of our session. We could have many more hours of discussion, and there are many other questions we could ask and talk about. In particular, it would be good to have a deeper discussion on the analysis of gender and ageing, the impact on women, disability, poverty and ageing, which is another key topic, and how ageing impacts the LGBT community. I did work previously with older gay men, many of whom are single, or lived under criminalisation for many years and lived very small lives. There are impacts on many parts of the population that we could talk to in the future. Unfortunately, we are coming to the end of our session.

I would draw the attention of the Chair to the fact that last year, the group with the highest rate of income poverty in the country was older people living alone.

Absolutely. There are many issues we could discuss. Similarly, another issue that we could go deeper on is the financialisation of care, the privatisation of home care and nursing homes, and the impact that has on older people. I do not think it is in their best interest. It is one that deserves deeper consideration and maybe a full session in the future.

Given what we have heard this morning, there are a number of key issues that we need to action out of today's session. What I will put to members is that we write to the Minister about a number of things. One is to get an update on the right to home care, which has been raised by many witnesses as a key issue. Similarly, we need an update on the safeguarding legislation and where that is at. There is also the idea of having a strategy that ties together all the various Departments, which will be key to ensuring there is adequate funding for the research that needs to happen and the continuation of that. I am happy to engage with the Minister on that as a follow-up, with the agreement of the members.

We need to put support for volunteers into that. I think all sectors would agree that they are key to supporting the work that is being done by all of the different organisations.

We are happy to engage in the discussion. As I said at the start, all of the issues around ageing are of interest to members across parties. I have no doubt it is one that we will come back to and engage on over the term of this Oireachtas.

I thank the witnesses for the evidence today and for all of the research and work they do, which informs the decisions made here, in the Department and elsewhere. I thank each of them for their contributions.

I know that a lot of time and effort goes into sessions like today. We really appreciate the work that was put in and the frank and interesting engagement this morning.

That concludes today's meeting. The committee is now adjourned until Tuesday, 16 June at 3.30 p.m., when we will meet in private session.