Examination of Witnesses (Questions 400
- 419)
WEDNESDAY 1 APRIL 1998
MRS ANNE
DUFFY, MRS
SUE BOTES,
MS LYNN
YOUNG AND
MR MALCOLM
WING
Ann Keen
400. Can I just ask about this directly in relation
to the bath again, because it has been the most important area
of definition in our inquiry to date? We have received evidence
from other witnesses that have actually indicated that the user
likes to have a nurse rather than have somebody who is also performing
other maybe more domestic tasks in the home and also then going
to help them with their own personal hygiene, and users actually
do not like that relationship. Some years ago when I was practising
as a district nurse, you did not always bath the patient yourself,
but at some stage during my working practice I made sure that
I did to make that continuous assessment. Is that really what
you are saying, that the district nurse assesses and then delegates,
but always reassesses?
(Ms Young) Yes, absolutely, and I believe also what
we are saying and would like to say quite strongly is that if
someone is requiring help with personal care and care of a very
intimate nature, that comes under the umbrella of nursing and
it may not be a nurse carrying out that activity, but the activity
is under the supervision of a nurse, and we have also picked up
this evidence that members of the public feel very comfortable
with a nurse carrying out certain aspects of care and rather uncomfortable
about other carers.
Chairman
401. Can I pursue that point? Just how practical
is that kind of response? Having been involved in social work
for a period of time and taking account of what you have just
said, are you saying, for example, that a social worker visiting
somebody who may have soiled themselves does nothing about that,
but waits until a nurse is around to clean up that person? Is
that a practical response to a person's difficulties?
(Ms Young) No, I am saying what we should be working
towards is having an integrated social nursing team whereby if
that person did not feel comfortable in carrying out such an activity
they would have access to somebody who would very, very quickly.
Where teams work well in the community, that is not an unreasonable
suggestion; it is manageable.
402. Are we not in the current situation actually
defending sectional professional interests and not looking at
the interests of users and patients and carers? In looking at
what other countries have done, they have addressed the professional
roles. Are the narrow professional roles we have had historically
in this country appropriate? Should we not be combining the professional
roles of social care and nursing care under the same person, as
has happened in other countries?
(Ms Young) I would have to defend nursing—would
I not?—and I will! I do not think you can find a wider,
more expanded role than that of nursing. Nursing is the most flexible
job there is. We expand upwards, a long way downwards, and where
the public need us that is where we go. I am saying that we improve
the interface and there are jobs that many of us can do and there
are jobs that only a nurse can do. We, within our teams, have
to sort that out. Are you going to help me out on this, Malcolm!
(Mr Wing) I do not think I will help you out. I think
the first point to make is about the concern of users, and obviously
users are concerned about having to pay for services they expect
to be free. I think that is the problem with the health and social
care divide. We do feel that there is an over-emphasis on nursing
or medical concerns. Most people do not recognise this, but the
bulk of community care is not medical, and the role of nursing
should not lead necessarily to nurses having the care management
role. We do not want to be over-defensive of professional boundaries
and professions, what we are concerned about is that local authorities
and the health service collaborate and work together, and the
most appropriate profession is responsible for care managing that
particular service. The other point that UNISON would want to
make is that there are groups other than nursing staff, there
are occupational therapists, social workers, and maybe there ought
to be more diverse opportunities to test the best way forward
in terms of care management, but we certainly would not argue
for a nurse model where the district nurse is the care manager
in all circumstances.
Dr Stoate
403. I would like to pick up something you said,
Mr Wing. In talking about this problem of when people should pay
and should not pay, witness after witness has thrown up this idea
that paying is a barrier between people getting the care they
need; this comes up time and time again in our evidence. You have
made the point that people feel sometimes that they are paying
for care they should be getting free. I would like to tease out
that interface a bit more, because I think that is at the heart
of what we are trying to get at. Could you give examples of what
you think patients should pay for and what you think people should
not pay for because that is where the divide comes? For example,
would it be reasonable to expect them to pay for meals-on-wheels,
home helps, that sort of thing, whereas it would not be reasonable
to pay for something which is much more nursing? Where does the
divide come?
(Mr Wing) The divide has changed over the years, and
in 1980-1981 local authorities were charging for home help services
for the first time. That has not always been the case. We have
talked about the historical position from 1974 and whether the
reorganisation that took place at that time was a positive or
a negative change, but the reality is that home help services
were generally free up until 1981 or 1982. If there is a pressing
and urgent need, then I would support free home help services.
There has been a long tradition of paying for meals-on-wheels,
and I think most people would accept there are current financial
constraints that make that necessary. So these things do shift
and change over time and it is very difficult. I would not be
able to draw up a list which would lead to consensus inside this
room. The point I was making is that we keep hearing that users
are concerned about whether this service is provided by the local
authority or the NHS, but what most users are concerned about
is when they are expected to pay for a service which they did
not expect to pay for. They are the real problems users face.
Increasingly that line is being redrawn.
404. So what you are saying is not so much who
provides the service, but much more from the user point of view
whether they are expected to pay for it and how much?
(Mr Wing) Yes.
405. One of our previous witnesses in a previous
session pointed out that only something like 8 per cent of the
total home care budget is paid for by clients and the rest is
picked up through other budgets.
(Mr Wing) Yes.
406. It seems a relatively small sum of money,
yet it does seem to cause an enormous amount of strong feeling.
If we can tease this out, I think we can get much more to the
nub of the inquiry. Have the other witnesses got any comments
on this?
(Ms Young) One of the big changes has been the provision
of personal care and within very, very recent years personal care
was provided by the NHS free, and that is one chunk of care which
in many areas has gone over to social services and therefore is
now means tested. I do not think anyone is disputing home helps,
meals-on-wheels, the getting of the pension, but it is the personal
care which was supervised by nursing has shifted and therefore
the means testing has caused some angst. We would obviously want
to see nursing free, wherever you are.
407. I go along with you entirely. The difficulty
we have is where does nursing end and social care begin? That
does seem to be one of the big issues we are trying to sort out.
(Ms Young) Of course. It is the same as where does
medicine end.
Dr Stoate: Exactly.
Ann Keen
408. Could I ask the Royal College of Nursing
a question? You state in your evidence that community nurses report
that home carers employed by independent agencies or social services
are poorly trained and supervised. Could you give me some evidence
of this and what would be the consequences for the individuals
receiving care because of this?
(Ms Young) We have received far too much information
on this, far more than we would have liked to have heard, with
the introduction of the market, the plethora, the sudden eruption
of small private agencies, which obviously social services contract
with to provide home care. There was some genuine and real anxiety
about the capability of people employed by these agencies to provide
quite high levels of personal care to really very vulnerable people,
very often living on their own. I think this is where we would
like to see again the integrated team. Because these people were
employed by a different organisation and then the nurses, there
was very little they were able to do to challenge the standards
of care being provided. Once people are in the same team, the
person supervising it, be it a nurse, can actually do something
about the standard of care being provided by another person. This
has been very serious indeed and I think some people have been
at quite preventable risk because of untrained, unsupervised,
incompetent people.
409. In the College's opinion, why would you
say this is allowed to happen?
(Ms Young) I think it has been allowed to happen because
the agencies were encouraged to develop and they were unregulated.
I think it is deregulation.
Chairman
410. Your concern is more with the agencies
than the local authorities?
(Ms Young) I am concerned about the people we send
out to care for very vulnerable people, who have very often a
high level of disability, dependency, very fluctuating states
of health, and I think people actually have the right to expect
safe, high standards of care.
Ann Keen
411. You recommend that home care assistants
should be registered, very similar to the registration of nurses.
Could you explain why you would recommend that?
(Ms Young) We would like to see health care assistants,
those people providing health care be it in a hospital, community,
wherever, are actually regulated and on a register in the same
way nurses are.
412. And why?
(Ms Young) Because we believe that the public has
the right to be protected and this is one way of ensuring the
public safety, or it contributes towards the safety of the public
which we would like to see happen.
Chairman
413. You used the term "health care assistant".
(Ms Young) Yes, I did.
414. Not a social care assistant? You distinguished
quite carefully there.
(Ms Young) Okay, care assistant.
Mr Gunnell
415. But not just somebody sent out by social
services who formerly might have been described as a "home
help"?
(Ms Young) No, we are talking about a large number
of people that are now providing personal care services, touching
people.
416. Whether they are from the agency or the
local authority?
(Ms Young) Yes.
(Mrs Botes) As it stands at the moment, you could
have somebody who has actually been struck off the register at
the UKCC who goes to give care to somebody. There is nothing to
stop them doing that and that is the danger.
(Mr Wing) Can I say that that has happened and certainly
non-registered nurses have reappeared as health care assistants
and we certainly strongly support not only a register for non-registered
nursing staff, but we also welcome the Government's commitment
to a general social services care council to regulate standards
and training and we very much support the idea of care assistants,
including home helps, being part of a national register.
Mr Walter
417. I was a little bit concerned about Ms Young's
use of the language on this because she was criticising agencies
and talking about anxiety and risk and dangers, but without any
evidence because evidence is what we are asking about and Mr Wing
has come in with some evidence of people who have been struck
off and I appreciate that, but is your criticism of agencies or
is it a criticism of the lack of registration?
(Ms Young) I am criticising the lack of supervision
that many people have whilst performing quite intimate tasks on
a group of people that need our protection.
418. Do you have any evidence of people suffering
as a result of that?
(Ms Young) We have plenty of evidence from nurses
who actually are in contact with people who have received less
than perfect care and it is by a group of people that have been
inadequately trained, they are not supervised and it is a very
serious issue that I think needs serious attention.
419. Are you suggesting, therefore, that there
is no monitoring by the employing authority of those agencies
and people working for them?
(Ms Young) I think there has been a lack of monitoring
and I think it is a lack of supervision that these people have,
so the answer to that is actually to put them under the umbrella
of the district nursing team where they would have the very best
and the highest level of supervision.
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