Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 1 - 19)



  Chairman: Good morning, colleagues. Can I welcome you to this session of the Committee. I think it would be appropriate for me, at the outset, just to pay a brief tribute to our colleague, Audrey Wise, who, as many of you will know, sadly died during the recess period. I knew Audrey for probably round about or not far off 30 years, and I admired her work, that is an understatement, over that period. She was, as some of you will be aware, a member of this Committee from its inception, and I think she was directly responsible for so much of the work that this Committee did over the years. I think it would be appropriate perhaps to mention in particular the maternity report that this Committee did. Audrey, and Nick Winterton, my predecessor but one, would be the first to say this, was the inspiration behind that report, the energy behind that report. I had the privilege of working with Audrey as a member of the Committee at that time on that inquiry, and it did lead to some fundamental changes which I think we can all be very proud of. I will sadly miss her. She was a great support to me as Chair of the Committee, sat to my right, and, obviously, on behalf of the Committee, I wrote to Johnny, her husband, and to the family, expressing our deepest sympathy. She will be very sadly missed by all of us here. Simon, do you want a brief word?

  Mr Burns: Chairman, can I just add my agreement to what the Chairman has just said. Maybe on the floor of the House of Commons her Whips' office may have considered her a member of the awkward squad, but certainly in this Committee she worked as a leading member of a team, whose determination and input into the Committee ensured that we produced reports that I suspect would not have been as good or as incisive if she had not been a member. And she will certainly be a great loss to this Committee, both in a professional capacity but also in a personal capacity.

  Dr Brand: Audrey, of course, is one of these sort of legendary figures, the Rooker-Wise Amendment, and her sheer independence of spirit. But the contributions that she made at this Committee, I think, were not only persistent but pertinent, and we do miss her unique style of questioning and her determination. I think she really represented socialism with a very human face, and her particular slant on the inquiries before us, I think, is going to be very difficult to replace, and she will certainly be very much missed by all of us.

  John Austin: Could I just add something, since I followed Audrey as the candidate for Woolwich, so I have known her over many years. All I would say is, apart from endorsing everything that has been said, Audrey was a very good and close friend, but I think children have lost their greatest champion in Audrey's loss.

  Mrs Gordon: If I could just add, as one of the newer members of the Committee, that in the short time I knew her on the Committee she was always a great support to me and a role model, if you like, I learned an awful lot from her, and she will be sadly missed by us all.


  1. Can I welcome our witnesses this morning, who may well be relieved that Audrey is not in front of them, because she has given some of you a rough time over the years, I am well aware of that.
  (Mr Reeves) And if we can join you in the tributes you have just paid as well.

  2. That is very kind of you, Mr Reeves.
  (Mr Reeves) Certainly from a personal note, I think I have been present at this Committee for the last six years, which means, I think, I have come into contact with Mrs Wise on 12 occasions, and most of them memorable, not necessarily for my ability to explain some of the questions she asked me. But I remember maternity tales with great respect, and also all the work on capitation as between Croydon and Bournemouth, which she asked me every single year, and she was never quite satisfied that she eventually got the right answer. But, very seriously, a great loss, and we would like to join in the tribute to her.

  3. Thank you, Mr Reeves, it is very kind of you. Could I ask you each briefly to introduce yourselves, before we start our questions?
  (Mr Reeves) Perhaps I should start. My name is Colin Reeves, I am the Director of Finance and Performance, since April 1994, at the Department of Health.
  (Mr Walden) I am David Walden, Head of Social Care Policy at the Department of Health.
  (Mr Taylor) Hugh Taylor, Director of Human Resources, Department of Health.
  (Mr McCarthy) I am Bill McCarthy. I am now the Director of Planning and Performance at the Leeds Teaching Hospitals Trust, but up until two weeks ago I was Deputy to Colin Reeves.
  (Mr Coates) I am Peter Coates. I am Head of Private Finance and Capital in the NHS.

  4. Thank you. Can I begin, obviously this is a wide-ranging session and, you are well aware, we wander over all sorts of issues which are of some concern to the Committee, but we have taken a close interest, as a Committee, in the issue of long-term care, as you know, when we have produced certain reports, including one broadly endorsing the majority thinking of the Royal Commission. When the Prime Minister, in July, made the Statement on the National Plan and Long Term Care, I specifically asked him, in response to an answer he had given to Charles Kennedy, the Leader of the Liberal Democrats, about the definition of the free nursing care question and the charged personal care, because the answer that he gave in that Statement indicated that the determination of whether we are talking here about personal care or nursing care would be a matter for the individual nurse. Now I raised with him my concern at the time that I felt that that position was unsustainable, in that we would end up with significant differences in the boundary, not just from sort of geographical area to area but from nurse to nurse. The Prime Minister undertook, in that Statement, to write to me with more information, and towards the end of August he wrote to me indicating that there was a working group looking at this issue which would offer advice on the criteria to be used by individual nurses. I am assuming it is probably your area, Mr Walden, is it, this; can you advise me whether that working group has come to any conclusions, and if so what those conclusions are, in respect of the definition of this boundary, and whether we are still leaving it to individual nursing staff at local level to determine whether, in fact, people receive free care or have to pay for it?
  (Mr Walden) Chairman, the working group has only met once, on 23 October, so far, and is looking at how to make the decisions that the Government announced in the NHS Plan in its response to the Royal Commission, how to make those effective and workable on the ground. The Government set out its view of what the definition of nursing care was that it was planning to use, but wanted to take advice from a range of interested organisations and stakeholders as to how to make that operationally effective and equitable. There will always be a role for the individual nurse in assessing the need of an individual client, or patient; what we are looking at is how to develop a standardised assessment process, using perhaps a standardised assessment tool, or tools, to guide those professional judgements that individual nurses will have to make, so that there are not gross differences of view between individual professionals that cannot be justified by reference to standard ways of assessing need.

  5. So this working group has met on one occasion, last month; when is it likely to reach its final conclusions?
  (Mr Walden) It met on 23 October and it has other meetings planned. The Government has said that, subject to securing the necessary legislation which it needs, it plans to make nursing care free in all settings from October 2001. And, clearly, there needs to be legislation and there needs to be a period of training and discussion with the professional interests before that policy can be implemented. So we have got a period from now until October 2001 to get the various processes and procedures and the training that will need to follow in place.

  6. Do you think it will be genuinely possible to offer a clear definition that enables people at local level to work to a consistent pattern of determining whether people receive free care or charged care?
  (Mr Walden) There is a definition set out in the Government's response. The Royal Commission itself believed that it was possible to distinguish nursing care and personal care, and said, at one stage, that it would be happy for nursing care, that bit of its recommendations, to be implemented, but obviously wanted to go further. So the issue is not, I think, whether there is a definition that can be sensibly derived, but how, in practice, that will be implemented, and that is why we are looking at a standardised assessment process that will guide professional judgement in individual cases.

  7. I have a lasting memory of the previous Secretary of State giving me an answer in this Committee that, frankly, it was impossible to offer such a definition; it was a very honest answer, typically honest answer, from a Secretary of State, because he could not offer a definition, and, frankly, as somebody who has worked in the social care field, I could not offer a definition. But you are optimistic that we will get to the pot of gold with this working group in the near future, and will come up with a cast-iron definition that will resolve all these problems we have had over so many years?
  (Mr Walden) The Government has already come up with a definition; and this is about the boundary between paid-for care, if you have the means, and free care by the NHS. So the Government has said, in its NHS Plan response to the Royal Commission, how it proposes to define nursing care for that purpose; and the issue now is how to operationalise that.

Dr Brand

  8. I am fascinated by this confidence that you have in this. You mentioned this working party looking at assessment of need; the assessment of need is not the problem, it is the assessment as to who delivers the treatment to meet that need that is the real difficulty. And, clearly, if that is going to be left to individual nurses, it depends very much on what sort of provision you have in nursing as to how flexible that definition is going to be. And I am really quite worried if the restriction is going to be that it is only that care delivered by a registered nurse, himself or herself, because that will be determined very much by the availability of those nurses. It will also mean a tremendous step back in team working between nurse assistants, health visitor assistants and registered nurses and the sort of integration of the primary care team, which many of us have worked towards for a very long time, and I believe to be departmental policy?
  (Mr Walden) We are very anxious not to fragment the delivery of care and not to fragment the assessment of need that leads to a care package being agreed; and it has been policy for a number of years, as you say, that where someone might be in need of nursing home care there should be a multi-disciplinary assessment across a range of professionals to get a proper view about what the varied needs of that patient might be. The National Service Framework for Older People, which is coming out in due course, is going to say quite a lot about assessment. I think assessment processes and procedures are very important, and one of the reasons why the Government decided to go for this approach was that it wanted to give the Health Service a stronger interest in the quality and type of care that was delivered in nursing homes, and to give incentives to get properly engaged in multi-disciplinary assessment.

  9. Sorry, but you are talking about nursing homes, I am more concentrating on people's care in the home, where you have a nursing team going in, which usually consists of a senior nurse, junior nurse and a couple of auxiliaries. Now, under your definition, are the auxiliaries going to be providing nursing care, or, because they are not qualified nurses, will that be non-nursing care? This actually will confuse the issue more than it is currently.
  (Mr Walden) My understanding is that people who receive community health services in their own homes currently, whether from qualified nurses, unqualified auxiliaries, care assistants, or whatever, if that is provided by the NHS community health service then they do not pay for that in any case, and that will continue to be the case.

  10. But it is not, according to Mr Blair's definition of nursing care. Nursing care, we have been told, is that care that is delivered by a nurse, not auxiliaries. But, obviously, this is something that has got to be resolved. Can I ask a second, very short, question. You were talking about nursing homes. I think, with the passing of the Care Standards Bill, there is now no definition of `nursing home', and I know that creates a lot of anxiety in people who run nursing homes because they cannot any longer put out their wares by saying "We are a fully-staffed, nurse-staffed, establishment." Has the Department thought about that?
  (Mr Walden) Obviously, we are keen to ensure that changes in practice and delivery of care are not inhibited by rigid definitions of types of home that might do that.

  11. But you have just used them yourself?
  (Mr Walden) What I was going to say was that the minimum standards against which the National Care Standards Commission will inspect and regulate care homes will still have different levels, so that homes that can provide a minimum residential level of care, if you like, will be assessed against the standards that apply to those.

  12. But, by definition, they will not be able to provide NHS paid-for care; so how do you determine what becomes NHS paid-for care in different establishments, or is it a decision for each individual patient?
  (Mr Walden) No, because there will be national minimum standards that also say that if you wish to provide nursing care in the home, as opposed to having it provided by the community health services, you will have to meet additional standards about presence of registered nurses, not dissimilar from the current position. And I do not see any reason why a care home that provides levels of care to that higher level will not be able to advertise itself on a similar basis as they do now.

  13. So there is a prospect then of protecting the title of `nursing home', because I know there is a lot of concern amongst the providers of nursing home services?
  (Mr Walden) I think, if that is used as shorthand for a care home that provides an enhanced level of nursing care, that is absolutely fine and there will be no reason why they should not advertise themselves as nursing homes. The reason we have abolished the distinction is partly to ensure that homes can switch more easily, and if they want to start providing nursing care the whole process is made rather simpler.

Mr Burns

  14. I just wonder if I could ask, with the Government's definition of nursing care, what protection is there within that definition, if there is any protection, to prevent what happens at the moment, which is that, with some patients requiring nursing care, despite what the clinical decision might be in the multi-disciplinary assessment, the social services department will categorise the patient as needing residential care rather than nursing care because it saves money on their hard-pressed budgets? And, if I can just guide you in how you are going to answer this question, please do not fall into the trap of social services, who will categorically, with a blanket assurance, say it does not happen; because if you were to go to residential nursing homes up and down the country you would find that it does happen, despite what they say.
  (Mr Walden) I do not want to get drawn into that, obviously, because I have not got chapter and verse across the whole of the country. We have to rely on setting a framework which professionals use their professional judgement to operate. What I would say is that, by making nursing care in nursing homes an NHS responsibility in due course, we will be giving the NHS more incentives to get involved in that provision of care, more interest in what happens. And if you are saying that health professionals' views are not taken due account of, I cannot comment on that; they are going to have a much bigger say in those assessment and placement decisions in the future.

  15. Right; but what protections are there against what could be a conflict of interest, in that, if there were to be a time when the health service budgets were under severe strain, one way of seeking to save money would be when taking a decision on an individual whether they qualified for nursing care or residential care then the decision will be taken in favour of residential care, because, of course, (a) it is cheaper, but (b) it would not be costing the NHS anything?
  (Mr Walden) That is the other side of the same coin that you were describing.

  16. Indeed, I was trying to pinpoint you.
  (Mr Walden) I think the protection is the assessment process and the tools that guide professional judgements that make it clear to everybody, including the patients and their families, the basis on which a judgement has been made. And it will not be possible, I hope, to assess someone using that process and those tools, make it clear that they need a level of nursing care and then say that that cannot be provided; because we would be guiding in a more standardised way the professional judgement around assessment.

  17. Who will actually be making the assessment under the new regime; will it simply be clinical practitioners, or will it be clinical practitioners, managers, within the health service, as well?
  (Mr Walden) No, it will be clinical professionals.

  18. Solely?
  (Mr Walden) If you include social workers in that, because they obviously need to do the social care assessments, it will be professionals.

  19. Presumably, under the new regime, the relevance from a financial point of view of social workers is greatly reduced, or the problems, because the NHS are picking up the bill, so there are no pressures on anyone from social services to try to minimise the bill?
  (Mr Walden) All the parties, whether health or social care, will have a professional interest in the outcome, and their organisations, on a managerial basis, obviously, will have a financial interest in what happens in terms of numbers overall. But by developing and strengthening assessment processes we will be putting the clinical professional judgement in a stronger position, I think.

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