Examination of Witnesses (Questions 420
- 439)
WEDNESDAY 1 APRIL 1998
MRS ANNE
DUFFY, MRS
SUE BOTES,
MS LYNN
YOUNG AND
MR MALCOLM
WING
Dr Stoate
420. That is a very interesting answer, but
we still have to take it one step forward, so are you also going
to include in that case the social care people because there is
still this blurred boundary between the two and we have already
agreed in this room that we probably could not define where this
boundary is and if we cannot define where the boundary is and
yet we are calling for health care people to be registered, where
do social care people come in because they will be surely doing
tasks which may cut across the same thing? For example, you may
have a social care assistant giving drugs to somebody and that
could potentially be quite a risky procedure if it is not carried
out by someone who is trained and it could be even more risky
if it is carried out by somebody who may have malicious intent,
for example, somebody who has been removed from a register somewhere,
so where are we going to draw the line? That is really the nub
of what I want to get at. How are we going to go any further on
this? If you want registration of all health care assistants,
you must surely then be pushing for registration of all social
care assistants. Is that what you are saying?
(Ms Young) Well, the Royal College of Nursing obviously
concentrates on nursing and the people that we work with. I think
there is an issue about the safety of the public, so we do have
to look very carefully at how we vet, if you like, people who
actually go into other people's houses alone. Concentrating on
my field of work, I am talking more specifically about people
who provide personal care because those are the people who are
most likely to work with nurses, but I am not denying the issue
about regulating and monitoring the standards of other services.
Audrey Wise
421. Do you think that there is a case for a
registration system or a regulation system for agencies and everybody
employing such staff, especially with the growth of independent
domiciliary agencies, as well as a case for a careful control
and supervision of training for the individuals involved? I am
back on Robert Walter's point really, that there are individuals
who are doing the work and there are the agencies, so do you think
that there is a case for suitable, different regulation of both
of those factors?
(Ms Young) I think what we have got to consider is
how most of the care is going to be provided in the near future
and beyond and as the institutions close and hospitals decrease
their beds, and that is going to continue and we are approaching
a time when a million people are going to be over 85 and we lack
the family and community structure to actually do the bulk of
the caring, so we will be having to use other people besides families
to do more of that caring, we then have to look as a country very
seriously at how we regulate the army or the industry of caring
people, whether it is social or whether it is health care. Most
people requiring care, some kind of need or some kind of service,
will be within their own homes and they will not be in an institution.
422. Can I move on then to a slightly different
emphasis, again starting with the RCN? You have described the
fall in the numbers of district nurses over the last three years.
Does this mean that the proportion of the NHS budget invested
in district nursing has gone down or what?
(Ms Young) What has happened over the last ten years
is a major de-investment in nurse education. If I can just give
you one figure, in 1984 34,000 nurses qualified, and next year
it will be 9,000, so the whole of the nursing work force is about
to be decimated, so obviously the community has felt that as much
as the hospital sector has. There is another issue about the community,
though, which is that it is predominantly a mature work force,
and there is an enormous number of, in particular, district nurses
that will be retiring in about five, six or seven years' time,
so we really are facing quite a crisis.
423. Do you think that there is the right balance,
any of the witnesses, between the community nursing work force
and the hospital nursing work force?
(Ms Young) It is a long time since I have been in
a hospital, so I am not sure that I am the best person to answer
that.
424. I mean in numbers. Perhaps you would like
to consider this and send us a note.
(Ms Young) Yes.
(Mrs Botes) When you actually consider that primary
care is coming very much into focus, it is essential that the
nursing establishment increases because, as Lynn has said, and
it is the same with health visiting, there is a large number who
are coming towards retirement and there are already decreasing
numbers and it is very, very important that there should be recruitment
of nursing all over, but, in particular, recruitment of nursing
in community nursing, and of course that has got cost implications
because to work in the community as a specialist practitioner,
one needs a second level of qualifications.
425. I notice, and I am back to the RCN evidence,
that in your section on the nursing resource, you go into some
detail about the workload and about the lack of nurses, but you
do not mention children's community nursing. I was somewhat surprised
at that.
(Ms Young) Well, we particularly did not because there
has been a separate Select Committee inquiry into children's health
and you do have the RCN's evidence on children's nursing and children's
health, but I can give you that evidence, if you want it.
426. If I may make a general remark, the fact
that we have had a children's inquiry does not mean that we are
now going to say, "Children, we have done that", and
it is my objective with all organisations to ensure that children
come into all of our inquiries. I notice that the Health Visitors'
Association did mention children, which I was pleased to see,
but more the question of respite care and child protection rather
than the actual hands-on nursing side. I do not know whether you
have got any views about whether there is an adequate service
of actual children's community nursing or whether any of the other
witnesses have.
(Mrs Botes) There is an increase in community paediatric
nurses out in the community, which is very welcomed and they are
extremely welcomed into the nursing team. I would suggest the
health visitor or the school nurse is the generic person for that
family but not when they have a need for a particular nursing
care. In other words, if you have a child with a life-threatening
illness the sort of coping mechanisms for the family would probably
be covered by the health visitor or the school nurse but the child's
care will be enabled by the paediatric nurse. Whenever that sort
of help is needed, or the family get into difficulties with child
care around that specific illness, then the paediatric community
nurse will be brought in. So it is a team work that you have,
the networking within the community, to help that child and the
family to cope with the situation and be able to pull in the different
agencies that will help that family.
427. What you are telling me, it seems to me,
is that if a child has continuing nursing needs, not necessarily
a life-threatening condition but continuing nursing needs, and
there is a community nurse available—which means they are
a very lucky family in most parts of the country—they still
nevertheless need the intervention of a health visitor as well
in order to round out the treatment. Is that what you meant?
(Mrs Botes) I am saying that the family needs the
health visitor in the background as somebody they can go to and
say, "I have this problem". It may not be anything to
do with the child's care but the family have the problem because
of the child being a sick child in the community. For example,
transport to nursery school or something like that. The health
visitor will be the person who has that network which can enable
that family to survive well, but on the care of the child—I
do not quite know what sort of example you are thinking of but
if there needs to be care for that child -the paediatric nurse
will be the expert person to give advice for that child; coping
mechanisms for the family, so she can call in on the health visitor
to say, "Help, I need ..." whatever.
(Mrs Duffy) I feel there is a need for a lot more
community paediatric nurses here in this country. Each area has
a few but not nearly enough. District nurses are still nursing
quite a high proportion of sick children, sick teenagers, in their
caseloads. They would certainly welcome much more money being
invested in community paediatric nurses.
428. When we did the inquiry into child health
it appeared that the training for district nursing, health visiting,
probably the school nursing and the community children's nursing,
was kind of forced into a competitive situation because it was
all having to come out of one pot. This distorted sometimes the
ability to commission the right balance of training. Do you think
there is a case for more resources specifically to be allocated
for these kinds of training so that if you get a few more community
children's nurses you are not going to have fewer health visitors
or whatever?
(Mrs Botes) I think that the consortia should be very
clear about what is needed in that particular area and they should
go for what they need. If they have not got a community paediatric
nurse and they need one, they should have that sort of training
at the top of the list, and then they look to see what other money
there is to be able to put in the other community nursing. But
there does need to be an investment in community nursing training
certainly.
(Mr Wing) I obviously think the local consortia have
a very important role in identifying future need, but I did want
to come back on the point which was made earlier about both the
ageing workforce and the fact that there are widespread shortages
of nursing staff throughout the NHS. The fact is—and I know
that pay and conditions is an issue which was identified and which
the Select Committee were concerned about looking at—although
the numbers qualifying this year will be 9,000 as compared to
34,000 in 1984, what we also have to face up to is the fact that
the number of applicants for the number of commissions last year
fell short, in other words there were fewer applicants for the
student nurse places than there were actually places themselves.
The problem is that nursing is becoming increasingly a poor choice
in career terms because of the problem around poor pay and conditions.
I think that issue does certainly need to be addressed. The Review
Body this year, as you know, did make a recommended award of 3.8
per cent but the fact that it was staged is certainly not going
to help the recruitment and retention problems which are being
faced by community and acute trusts.
429. I have some sympathy with that point but
we also had specific evidence relating to real areas where there
were training places available, there were applicants but there
were not sufficient commissions, as it were, so the applicants
could not take up the places because there was not a commissioning
for community children's nursing. When you say the local consortia
should look at what they need in the area, which will vary from
area to area no doubt, and then go ahead and commission the appropriate
training places, do you think they have got enough resources to
do that?
(Ms Young) There is never enough.
(Mrs Botes) Definitely not.
430. If they give priority to the speciality
which is the shortest, then of course it will all be to the domiciliary
community children's nurses because they are the shortest throughout
the country.
(Ms Young) Yes. I think half the country is without
access to a community children's nurse, and I think that is really
quite salutary. We are about to get some money from Diana's Fund
actually to pay for the training and employment of quite a few
children's community nurses.
431. We would quite like to know what levels
of staffing you would consider necessary to meet the demands for
community nursing, children and the rest. We have got from the
RCN an estimate for the children's nurse, but we would not mind
having it again. I realise you might not be prepared for such
a specific question. If you are, tell us. If not, could you send
us some estimate, if you want to consult others in your organisations?
(Ms Young) We have actually called for double the
number of CPNs, because we are so terribly short of CPNs. I think
there is an issue about what we are looking for. Are we looking
for a five-star service, a three-star service, a pretty basic
service? I have a big problem about the word "enough".
The workload in the community depends also on what is going on
in the hospital. Where you have a hospital that actually is pretty
good at discharging quite dependent people very, very quickly—and
I am not talking about long-term chronically sick people but people
with very acute, high-intensive but short-term needs—that
adds very much to the nursing workload in the community. So there
are so many factors which are really relevant to the community
nurse workload.
(Mrs Duffy) I think the main point to make is the
dependency of the patients we are nursing in the community. The
CDNA are driving forward our aim to achieve 24 hour nursing care
throughout the country, so that every area will have access to
24 hour nursing care in the community, but patient dependency
plays a huge part in this rather than the size of the practice
population. Really we should be looking at assessment of need
and reaching 24 hour community nursing care for everybody.
432. I am grateful for your mention of community
psychiatric nurses, which has not really cropped up in evidence
before in this inquiry as far as I remember. Would you like to
expand on that? Have any of the witnesses any views on the state
and the pattern of that service?
(Ms Young) I think what we hear more and more is how
there is a call to have much more psychiatric nursing input within
general practice and I think local GPs are saying, "For heaven's
sake, all I want is a CPN attached to my practice, but can we
find one?" There is such a terrible shortage of CPNs that
it really is an impossible thing to achieve, but I think the demand
for mental health care within primary health care is really very,
very great and we really are not providing that level of care
and the result of that is that people are unnecessarily ill and
there are preventable hospital admissions. I think that this is
the point which has to be made, that when you do not provide adequate
care in the community, you do not save money, but the money is
spent and more money is spent elsewhere. You do not save money
at all. In fact you have actually used more of the resources than
you would need to.
(Mrs Botes) I think the other thing about CPNs is
that they are predominantly working with the acutely ill rather
than actually being able to do any preventative work and, as Lynn
said, this is just trying to stop the avalanche rather than getting
to the root of the problem and I think there should be far, far
more people who are able to work at the early intervention stages.
Ann Keen
433. Just to go back to the community paediatric
nurses, would you think it was acceptable in hospital for you
to be moved as a nurse to suddenly work in a paediatric ward?
Would that be considered a safe practice?
(Ms Young) To go from a paediatric ward straight into
the community?
434. No, to actually be working on a general
adult ward and to be asked to work in a paediatric ward without
any specific training. Would you consider that to be a safe practice?
(Ms Young) Absolutely not. You have to be a dedicated
children's nurse. Children are different.
435. Therefore, would you say it was a safe
practice that actually, as you said, over half the country is
without a community paediatric nurse? Would you like to express
a view of the seriousness of that?
(Ms Young) I think one of the problems is that where
people or families do not have access to a community children's
nurse, the child is unnecessarily in hospital occupying a hospital
bed and really every child, if at all possible, if it is safe
for that child, should be cared for at home and we would like
to see a time when you have fewer children's beds, but a greater,
more comprehensive, more accessible children's paediatric nursing
service so that the children are looked after at home where they
want to be.
436. But if it is a National Health Service,
why has only half the population got access to a community paediatric
nurse? What do you think has caused this?
(Ms Young) I think it is the inability of the service
to actually shift the funding where people need to be, so an enormous
resource gets locked into the hospital sector and it seems to
be a weakness of our system even with the purchaser/provider split,
which was actually brought in to help money follow the patient,
which in fact was not as successful as we would have liked it
to have been, so money gets locked into this very hungry building
and we do not seem to be able to quickly release that funding
to where we would like to nurse people.
Julia Drown
437. Just following up briefly on these points,
I wonder if any of our witnesses have evidence to show that where
there is 24-hour nursing services, be they adult services or children's
services, the resulting pressure on the hospitals is reduced,
ie, there are less beds used in the hospital and waiting lists
are lower in areas where there are more 24-hour community nurses?
(Ms Young) What I do not have are any figures, but
I think we can all find many, many examples that if there is no
24-hour nursing service, that patient would have to occupy a hospital
bed. I could actually look into this for you, but I actually do
not have the figures to hand, but certainly the experience is
that we can all identify people that had the community nursing
service not been there, that person would have had to be in hospital.
438. I think it would be useful for us to see
that.
(Ms Young) Yes, I can certainly find that for you.
Mr Walter
439. Can I, Mrs Duffy, take you to a section
of your recommendations in the paper which you have presented
for us. You say, "Working together between health and social
services is the key to success and adequate support and care for
those in need". Then you go on to say, "Restructuring
and reorganising is not necessarily the answer", and I wondered
if you could give us your view of what changes are needed, if
you are not going to restructure and reorganise, to improve that
joint working, whether you can suggest mechanisms by which the
sort of personal relationships between those involved in the service
could be improved and fostered and whether you have examples of
good practice that you would like to tell us about?
(Mrs Duffy) Yes, I would go back again to start with
joint training. I think there should be money spent and added
resources given to joint training for health and social services
staff to get together and have sessions on a regular basis to
regularly update staff, with a clarification of each other's roles,
learning assessment together and actually doing joint visits and
going to see patients together. I think that this would certainly
help strengthen good working together relationships. In my experience
in Gloucestershire, pilots are ongoing at the minute for assessing
need for patients going into nursing homes and residential care.
Until recently, the panel that made the overall decisions after
the district nurse had contributed a nursing assessment and social
services had done their assessment, these assessments were usually
all collected together and taken off and it was social services-led
totally as to who made the decisions as to who met the criteria
for funding, and there were no health people included on the panel,
so in recent months they have invited health professionals to
come and sit on the panels and this appears to be working very
well together. It is getting the staff familiar with each other,
so they are not just a voice at the end of a telephone. As I say,
they have gone out and done joint visits. They put in together
joint policies, looking at eligibility criteria, and all this
is joint working together and certainly there is a shift towards
helping breaking down barriers without any major restructuring
or reorganisation.
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