Examination of Witnesses (Questions 1
- 19)
THURSDAY 2 NOVEMBER 2000
MR COLIN
REEVES CBE, MR
BILL MCCARTHY,
MR DAVID
WALDEN, MR
HUGH TAYLOR
CB AND MR
PETER COATES
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.
Chairman
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.
|
