House of Commons - Health - Minutes of Evidence

Select Committee on Health Minutes of Evidence

The Evidence of the Royal College of Nursing to the Health Select Committee Inquiry into the Relationship between Health and Social Services

INTRODUCTION

1. The Royal College of Nursing (RCN) is pleased to offer the following evidence to the Health Select Committee inquiry into the relationship between health and social services. The RCN has a membership of over 300,000 nurses working in hospitals and in the community, within the NHS and in the independent sector in areas such as nursing homes, hospice nursing and private hospitals.

2. At the heart of the relationship between health and social services is the artificial divide between health and social care which, although always apparent in some form, was exacerbated by the development of community care policy in the early 1990's. The RCN supports the principle of caring for people in their own homes or in a homely setting wherever possible. However, the health and social care divide impacts on the delivery of community care. The RCN has voiced consistently its concerns about this divide and the potentially deleterious effect this has on patient well-being and recovery.

3. The Community Care legislation (1990) devolved the funding of nursing home and residential care from the Department of Social Security to local authorities. This raised issues around ownership of budgets; the appropriateness of means testing and care provision; and cost-shunting between local agencies in an attempt to balance budgets. This has served to side-track professionals into debates about who does what and who pays for it rather than focusing on people's needs and how these can be met effectively and speedily.

4. In 1989, the RCN made public a number of its concerns about the proposed legislation in its official response to the White Paper "Caring for People". In summary, the RCN argued that the following were prerequisite to the success of community care policy, particularly in respect of avoiding a worsening of the split between health and social care:

4.1 a commitment to "ring fencing" the budget allocated for community care services;

4.2 the involvement of all team members in the assessment of individuals. The RCN has argued consistently that nurses are often best placed to lead this both in terms of expertise and accessibility. Nurses are often the ideal key workers when patients have predominantly health and nursing needs;

4.3 an increase in the number of community nurses being educated and employed, across the range of expertise. This was paramount in respect of having enough nurses to care for a growing population of older people and an increasing number of individuals with mental health needs and learning disabilities needing care in the community;

4.4 a system of grants/financial reimbursement for full time carers and an increase in respite facilities;

4.5 national standards of care and service provision in all sectors;

4.6 specific attention to discharge and/or transfer of care arrangements;

4.7 an integrated primary health care authority in order to avoid discontinuity and fragmentation of services; and

4.8 access to a General Practitioner (GP) and other medical services whether in residential/nursing home care or at home.

5. Eight years on many of these issues have not been addressed satisfactorily and our initial concerns remain. These particular points are discussed in greater detail as they apply to the terms of this inquiry.

6. This evidence is structured in relation to the specific questions wishing to be addressed by the Committee. This takes the form of a critique of the failures and benefits of the current system. The RCN's proposals for change and different models of care and service provision are outlined at paragraphs 31 to 41.

DIVISION BETWEEN HEALTH AND SOCIAL SERVICES

7. The RCN has long argued that the current division between health and social care is unworkable and potentially damaging to the continuity and efficacy of care provided to very elderly and infirm people and those who are sick and vulnerable in our communities. Historically, health care has been provided free at the point of delivery and social care has been means tested. Whilst not disagreeing with this, the RCN believes that giving the lead purchasing power for all community care services to social services in 1990 has exacerbated the division between health and social care. The process of splitting the two renders the care provided for some people in danger of being broken down into a series of tasks. The battle over finances may lead to an incentive to minimise the needs of clients. Care is then delivered in such a way as to undermine the holistic approach to care that many nurses have achieved (RCN, 1993 and 1996).

8. Much of the current debate focuses on the provision of continuing care for older people and the health component within such provision. Many nurses are now finding that older people who hitherto had been assessed as requiring continuing care with input from nurses, are now defined as requiring social care, sometimes in direct contradiction of assessments conducted by doctors and nurses who determine that a patient has on-going health needs. It is often the case that older people's need for nursing care is not being picked up during initial or subsequent assessments and the delivery of care continues without nursing supervision or intervention. In this way, inappropriate packages of care may go undetected with potentially disastrous results. District nurses have informed the RCN that they are concerned that social services departments are providing care which they are ill-equipped to do and nurses are only being asked to intervene when what should have been preventable crises occur. This lack of involvement of nurses at all levels is exacerbated by the disinvestment in community nursing referred to later in this paper. Nurses can no longer provide the interventions they would like to offer even when approached to do so.

9. The divide between health and social care is an artificial one. Consequently the boundaries of responsibilities between health and social services remain unclear at some points. There are services which are clearly the responsibility of the health sector and others which belong to social services. For example "meals on wheels" and house work are clearly the province of social care. Dressing of wounds, managing incontinence and symptom control of patients suffering from profound illness are the remit of health and within this nursing. There are, however, essential services which fall between the health and social care extremes and it is here that the separation of health and social care is both artificial and untenable. It is this lack of clarity on agency responsibilities which causes conflict over the funding and therefore the provision of essential services.

10. Areas of care where there is often conflict over responsibility between agencies include the provision of bathing services; respite care; personal care services such as helping people in and out of bed; night sitting-in services allowing carers to have a night's sleep; and the provision and maintenance of equipment in the community, for example hoists, commodes, stair lifts and doorway ramps.

11. The RCN has much anecdotal information collected over a number of years from its members about these difficulties. In one area inter-agency conflict caused a delay in providing a hoist for a patient with severe Motor Neurone Disease, the symptoms of which include progressive paralysis and the inability to carry out the daily activities of living. A hoist was needed to help his wife, the main carer, to move the patient without compromising her own health and causing further discomfort to her husband. Conflict in respect of agency responsibility and funding caused unnecessary delay and in the event the hoist was finally delivered to the house as the patient was being taken away in his coffin.

12. In another example an older woman with a colostomy needed help with bathing. Social Services refused to provide care on account of the patient's colostomy but in fact her health care needs were minimal. In other words the colostomy provoked a conflict between health and social services and the patient's needs were relegated to second place.

THE VALUE OF NURSING

13. It is nursing supervision, expertise and skill which often prevents deterioration of health and is able to treat health problems quickly and with effect. For example, pressure sores can occur unnecessarily as a result of poor positioning and inadequate care and nutrition. Incontinence can be the result of an infection but with specialist intervention this can be identified early and managed well. This nursing action promotes independence, healthy living and maximises an individual's health potential. In time a patient may need fewer services on account of early nursing intervention.

14. The value of the nursing contribution should not be underestimated nor the effects of its omission ignored. A number of studies over recent years have aimed to demonstrate the value and skill of qualified and expert nursing (Buchan and Ball, 1991; Bagust et al, 1992; University of York, 1992). In 1992 the RCN published "The Value of Nursing", a qualitative record of real life experiences of nurses whose care had made a difference to patients. Similar studies were published in 1993, 1996 and 1997 focusing particularly on older people (RCN, 1993, 1996 and 1997).

15. These studies demonstrate that nurses are viewed as reliable, sensitive and willing to listen—they care. Nurses are perceived as having the knowledge about health, individuals and families and the environment. They are considered to be a constant in an ever-changing world. The old, vulnerable and frail in our society need nurses who have a broad repertoire of skills, knowledge, experience and expertise.

16. Expert nurses can attend to many aspects of a situation at the same time: for example how the patient looks (posture, expressions, behaviour, skin tone), what the patient says, how relatives and other professionals react, other indicators such as sounds or smells and what is happening in other areas of the environment. They can recognise patterns which may go unnoticed by less experienced clinicians or carers. They know when they have a good grasp of the situation and feel uncomfortable when they do not. They are fluidly skilful at managing multiple aspects of a situation at one time (for example patient, relatives, other professionals, equipment) and of keeping track of what is happening to each of these elements. Throughout these processes expert nurses can remain responsive to the needs and concerns of the patient, relatives or others in the team and can adapt and tailor care accordingly.

17. The RCN's document "The Value and Skills of Nurses Working with Older People" (1996), a copy of which is enclosed with this evidence, emphasises particularly the value of expert nurses in:

17.1 understanding the influences on care, for example, the impact of ageism, the effects of class, race, gender and so on;

17.2 building and maintaining relationships, for example, through skills in communication;

17.3 assessment. Expert nurses recognise subtle changes in older people's health and can take action to prevent deterioration; and

17.4 intervention, especially in relation to rehabilitation and in maximising the potential of older people.

THE NURSING RESOURCE

18. Nursing is a national resource and in the community setting nurses are vital to the success of the NHS and community care policy. Yet as the shift to care in the community has been effected numbers of nurses have not only failed to rise in response to demand but have in fact been allowed to drop. The most recently published figures by the Institute of Employment Studies (1997) and the UKCC (1997) show that whole time equivalent (wte) numbers of nurses employed as District Nurses have dropped every year over the last three years. Health Visiting reflects an equally depressing picture. These lamentable figures demonstrate graphically one of the most worrying aspects of the shortfall in resources—that is, the gap between the need for expert nursing care and the adequate provision of suitably qualified nurses. The outcome of this lack of investment in nursing is falling standards of care, delays in discharge from hospital and at worst, greaterre-admission rates to hospital and/or placement within care.

19. Nurses find themselves struggling with increasing workloads and plummeting morale. In September 1994 the RCN published findings of a three year study into the morale of nurses working in the community (RCN, 1994). For convenience this document is attached to this evidence. The study showed that district nurses were becoming increasingly dissatisfied with their workload and their prospects and found the discrepancy between the desire to deliver a high standard of care and the constraints upon care delivery difficult to reconcile. One district nurse, cited in the report, commented,

19.1 "District nursing is a constant battle against the clock. My patients only receive the care they need because I stay late and miss lunch hours to get my paperwork done."

20. Frustrations at resource constraints were also expressed.

20.1 "Money has replaced the patient in our focus of care. We need to resist this insidious erosion of our commitment to people."

21. Continuity of care depends on the existence of robust health and social care planning and delivery systems, adequate funding and the recruitment and retention of high quality staff. Caring for people with long term chronic disease and disability is often very demanding, both mentally and physically for the carers. Burn out is common, while at the same time turnover of staff can be disruptive and confusing for the person needing care. Additionally, adequate training, preparation and supervision of home carers is essential if community care is to achieve its policy objectives—a responsibility which is often placed on the shoulders of community nurses.

22. Many community trusts are experiencing difficulty in recruiting community nurses and because of demographic trends a disproportionate number of community nurses are due to retire within 10 years (IES 1997). There has been a major disinvestment in pre and post registration nurse education since 1984 so the UK is unable to replace the number of nurses leaving the profession with similarly qualified staff.

23. Depressingly, the latest round of health planning within ever tighter resource authorities in community nursing staff—especially those engaged in public health activities such as health visiting and school nursing. These cuts are against the actual workforce that tread the most difficult interface between health and social services and whose numbers are active in the development of health alliances between health and social care agencies. Questions must be raised as to whether these cuts are in fact a sign that the health service intends to focus increasingly in the future on acute secondary care and to relinquish its responsibility for proactive primary health care and the promotion of health.

THE NEED FOR COLLABORATION AND JOINT WORKING

24. There is no doubt that the split between agency responsibilities and the separate organisational structures of health and social services militate against joint working and inter-agency collaboration. Where there is effective joint working this occurs as the result of local commitment and shared objectives of health and social care workers. In other words teamwork exists despite the current structures not because of them.

25. In particular, the organisational structures are problematic because of the following:

25.1 lack of co-terminosity between health and social services areas. A single health authority or large general practice may have to negotiate with a number of different local authorities, with differing eligibility criteria, in order to ensure the adequate provision of services. This can result in the bizarre situation of people accessing or being denied access to local services, including whether or not they pay for them, purely in relation to the street within which they live. Nurses find this anomaly problematic in that they may be caring for some patients whose social care needs are means-tested whilst others are receiving the same services free of charge;

25.2 cultural differences between health and social services exacerbated by lack of opportunities for shared training and education, both pre and post basic; poor or non-existent joint planning leading to different organisational objectives, priorities and ways of working; and separate budgets and funding streams. Moreover health authorities focus in the main on clinical services and may therefore be unaware of how inappropriate and insufficient social care impacts on health and vice versa; and

25.3 differing lines of public accountability.

26. In 1995 the RCN and the British Association of Social Workers issued a joint statement (RCN/BASW, 1995) in relation to the essential service of "bathing". It is a measure of how serious the division between health and social care has become that such a statement needed to be prepared for so basic a service. This statement, a copy of which is attached signifies a powerful commitment by the RCN and BASW to promote cross professional collaboration in community care and emphasises the need for expert assessment and intervention by qualified nurses and social workers. The RCN has also worked with the British Geriatrics Society and the Association of Directors of Social Services to produce joint policy statements on assessment and discharge procedures (ADSS/BGS/RCN, 1995a and 1995b).

27. In its response to the Green Paper "Developing Partnerships in Mental Health" in May 1997, the RCN stated that both structural change to solve the problems associated with planning and commissioning of mental health services and improvements in nursing practices at provider level are necessary to achieve a workable solution and significant improvements in mental health provision. However the RCN also warned at that point that joint commissioning at "purchaser level" will not in itself solve all the problems surrounding mental health provision. In addition emphasis was needed on how to improve the way that at "provider level" local health authority mental health staff work together.

TRAINING AND PROFESSIONAL BOUNDARIES

28. Community nurses are repeatedly reporting to the RCN that they have concerns over the lack of training and supervision given to home carers who may be employed by independent agencies or Social Service Departments. Vulnerable and frail people living in their own homes need a level of protection which means that adequate training and supervision of home carers is essential.

29. When community nurses are involved in a patient's care they are well placed to monitor standards of home care and should be able to take action when services fall below appropriate quality. This becomes problematic when the carers are employed by agencies other than her own.

30. All registered nurses are professionally and personally accountable for their practice including the appropriate delegation of work to other personnel. In order to ensure safe practice this requires the registered nurse to assure herself of the competence and capability of other workers carrying out these delegated activities. Models of good practice around the country have developed local programmes of training and education for care workers with considerable input from community nurses. This obviously requires adequate resourcing, both in staff and time.

ACTION NEEDED TO IMPROVE RELATIONSHIPS BETWEEN HEALTH AND SOCIAL SERVICES

31. The RCN believes that in order to overcome the problems outlined in this evidence and to improve services the following action should be considered.

INTEGRATED COMMUNITY CARE TEAMS

32. The development of the total integration of health and social care practitioners into locally based teams serving a defined population. The RCN would like to see teams of community nurses and social care workers who have the skills and expertise to design and manage packages of care to a defined population and/or a particular client group. These teams would be focused on developing the appropriate mix of skills required to meet client/patient needs rather than on individual roles, professional boundaries or different employment structures. Health Action Zones provide an exciting test site for such innovation.

MERGED AND DEVOLVED BUDGETS

33. The development of effective integrated teams depends absolutely on the merging of health and social care budgets for certain services. The RCN believes that the new structures proposed in the recent White Paper `"The New NHS"' may provide a suitable vehicle for community care. The remit of the proposed "primary care groups"' could be extended to become `"primary and community care groups"'. Two separate funding streams—from social services and from health services—would allow these groups to commission community care. The groups would then ensure that the budgets for community care services are devolved to practice level. This would enable the integrated community care teams to respond creatively and flexibly to patient/client needs without the problems of cost shunting, bureaucratic delays and organisational tribalism. Such action should curtail the endless futile debates on what constitutes health and social care.

NATIONAL CRITERIA FOR MEANS TESTING

34. The RCN believes that there should be national standards of care. Current guidelines for continuing care which allow local negotiation about eligibility criteria lead to inequitable provision of services, and the RCN has long argued for their replacement with national standards for entitlement to long term nursing care. In order to achieve more equitable access to community care services, national criteria should be set for those services which are available for means testing. Individuals and their families would thus know what to expect.