Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 20 - 39)



  20. So you are confident that under the new proposals clinical decisions will be far more influential in the ultimate decision than any financial considerations, which is not necessarily the case now?
  (Mr Walden) As I say, I do not want to comment on whether it is or is not the case now, but it will certainly give a more standardised approach across the country, and should give patients and their families more confidence that that will be the case.

Dr Brand

  21. Can I just pick that up, very shortly. Care plans used to be bold, brave and totally patient-centred, until there were a few court cases where authorities were taken to court for not delivering what was in the care plan; and we very quickly saw care plans not being written to reflect the needs of the client, or patient, but reflecting the resources that were available to meet that need. How are you going to see the new arrangement working?
  (Mr Walden) The NHS Plan, the main body of it rather than the response to the Royal Commission, talks about the development of personal care plans, particularly for older people, and the National Service Framework that I mentioned will develop that further; and so it is an important plank of the Government's overall policy.

  22. I am sorry, you are not answering the question, with respect. If the nurse develops a care plan with the family but finds that the resources to deliver it are not there, is she still going to be able to write the plan as she, or he, would like to see it, or will we see it being trimmed down to fit the resources, which is what happened in social services as a result of court action?
  (Mr Walden) I think all clinical professionals, inevitably, take account of the services that are available when drawing up care plans.

  23. I do not; because that nurse should also be the advocate on behalf of that patient?
  (Mr Walden) They are assessing need and assessing how best to meet those needs with services available, pragmatically, in the short term; there may be issues then about the need to develop new services in the future, if important ones are not available. But, pragmatically, it is a meld of judgements about what the needs are or what is possible for them to meet those needs.

  24. In that case, you are going to define nursing need by nursing availability?
  (Mr Walden) No.

  Dr Brand: If I can demonstrate the need for more nurses. I cannot actually find more nurses, necessarily. Now, at the moment, as a GP, I am in a position to press for more resources, and the fundholding actually managed to employ an extra health visitor for my practice because I felt they needed it. Now I cannot actually see this happening under the new arrangement, where this nurse is going to be very constrained in what they can put in the plan, by his, or her, own workload having to deliver that plan?


  25. Peter, can I try to follow it on, just briefly, because it struck me, from the answers that have been given, that there has always been a gatekeeping role, for example, for social workers and nursing staff, but it seems to me that, in what is a pretty fundamental policy shift here, we are really giving the rationing role to people in the front line, in a way that I think could cause some difficulties. Has that been thought through, in that you are saying that they will take account of the wider picture at a local level in coming to their assessments, and implying, by that, that they themselves are kind of partly responsible for managing those wider resources and determining the priorities in those wider resources? Do you think this is appropriate, for practitioners to be used in this way?
  (Mr Walden) If I may say so, I do not think this is a change from current or previous positions or practices, actually. Professionals have to assess the client in front of them and then they have to make a judgement about how to meet those needs and what the best way of meeting those needs might be. And there may be a number of ways in which the outcome for the patient can be achieved, not a single-service solution, if you like, a number of different ways which in different places different professionals might prefer. So I do not think the policy on long-term care that the Government announced in July actually fundamentally alters any of that. What we are trying to do, through the National Service Framework, is to strengthen the assessment process, strengthen care planning, so that what has been long-standing policy is made more effective.

John Austin

  26. I think, Mr Walden, you said that anybody who is receiving nursing and allied care through the community nursing service will continue to do so. Is it not a fact that, at the present time, in different parts of the country, somebody may well be receiving services from the community nursing services which may not be provided in another part of the country, and may be being provided by the local authority and being assessed and charged for? So would it then be possible, under your scenario, for someone who is charged in one authority area for a level of service to say, "Well, hey, in another area . . ."; how are you going to stop this postcode lottery of provision?
  (Mr Walden) I think there are, clearly, distinctions in what services are provided from place to place, whether that is between health authorities or local authorities. I do not think myself that you can substitute very easily, except at the margin, local authority staff for health authority staff, because, obviously, you are talking about different professional skills there, by and large. But if one takes local authority charging, as one part of your question, the Government has committed itself to issuing guidance, and, in fact, took powers in the Care Standards Bill, now the Care Standards Act, to issue statutory guidance, that is binding guidance, to local authorities, to try to narrow the variation in charges that local authorities can levy for domiciliary care. Because the Government took the view, and said so in its White Paper in 1998 on Modernising Social Services, that the variation in charges which—

  27. But this was a question of major differences in charging levels, not the principle of whether they are charged for or not charged for?
  (Mr Walden) The Government wishes to reduce the variation in charging levels; it still remains a discretionary power for local authorities whether or not to charge, but they want to narrow the variation, and will be issuing guidance in due course designed to address that issue, by taking the powers to make that binding on authorities, which they did not have previously. On health and local authorities and interface issues of variability, clearly, there are agreements locally about continuing care, who provides what; and the National Service Framework, again, will give more consistency to health service planning in this area around services for older people.

  28. You are suggesting that it appears a relatively simple operation, and yet we were told, originally, that the National Service Framework would be published before the recess, and it has not come yet, and there are considerable rumours that there has been some conflict within the working group which is charged with the responsibility of drawing up the National Service Framework, which might seem to suggest that it is not as easy as you are suggesting?
  (Mr Walden) I was not trying to suggest it was easy or difficult, I was simply saying that it will, when it is published, help to give—

  29. When will that be published?
  (Mr Walden) I think Ministers have said that they hope to publish it later in the year.

  30. Can I ask, on the question of the criteria, will the patients, or their carers, be told the criteria, and will there be a right of appeal?
  (Mr Walden) Sorry, the criteria for what?

  31. The assessment of eligibility for . . .
  (Mr Walden) I think it would be good practice, obviously, and we would be encouraging this and pushing this, that patients and their relatives are fully engaged in the assessment process. We know, in many cases, particularly for care at home, that the input of the informal carer, the family member, and so on, is vitally important as a component of that care plan; so, yes, we will certainly be encouraging engagement with family.

  32. And will there be a right of appeal?
  (Mr Walden) On the nursing assessment itself, I do not know the answer to that, I am afraid, I think we will have to send you a note about that, because it is one of the issues we will be working through with the stakeholder group that I mentioned to the Chairman at the beginning; we have not reached conclusions on that.

  33. Presumably, the patient, or their carer, would have a right to see the assessment?
  (Mr Walden) Yes, because it will form part of the care plan, which it is certainly their right to have.


  34. So the working group will come up with a definition, and that definition will be quite detailed, presumably, involving things like incontinence. I go back far enough to remember when there was a very clear division between nursing and social care on the basis of incontinence; things have changed since then. But will we get to that kind of degree of detail in what will eventually be put forward?
  (Mr Walden) As I said at the beginning, the Government has set out pretty much what it feels the definition should be, and the working group primarily is looking at how to operationalise that definition in real-life situations. Where there is scope for discussion, around the sorts of areas you imply, because the definition talks about the specialist equipment used by nurses, clearly we need to discuss with the stakeholder group and the working group precisely what that should cover, and those discussions are still ongoing, as you say.

John Austin

  35. And, presumably, provision of incontinence pads is an NHS responsibility, is it?
  (Mr Walden) I think, in nursing homes, it is part of the fee that the nursing home itself charges; so that is one of the issues we need to work through, in terms of, if one makes nursing care in nursing homes free for the first time, what are the implications of that.

  36. And who will be responsible for providing an incontinence laundry service?
  (Mr Walden) Again, we have set up the group in order to work through the detailed implications of the definition.

Mrs Gordon

  37. Can I just ask, what accountability and feedback will there be from the nurses who are making these decisions? Just listening, it seems that some of these decisions are going to be made pragmatically on what resources are available within that community; which means that there could be a shortfall in resources that is not being identified. So what accountability will those nurses have, and how will you know what the real situation is?
  (Mr Walden) Again, I do not think anything has been changed by what the Government said in July; this is the case now and it has been the case for some time. And I would hope that, in drawing up its Joint Investment Plan for Older People, for example, the local authority, working together with the health authority, the voluntary sector, and other players in that local health economy, would get feedback from individual practitioners and others as to where there are service gaps of the sort you describe, so that in their investment decisions for the future they can decide how best to fill those gaps. And, of course, there is not necessarily a single answer in every place as to what to do if you find you want a different mix of services; that is a local judgement that the Health Improvement Programme and, as I say, the Joint Investment Plan should tease out.

Dr Brand

  38. But, Mr Chairman, that is an enormous change, that is an extended entitlement to nursing care that did not exist before. My worry is that we are altering the definition of nursing care actually to make that change almost meaningless. Can I ask how much money is being put in the pot to extend the nursing entitlement?
  (Mr Walden) Sorry, I did not want to imply that the change to make nursing care free was not a very important and significant change, clearly it is.

  39. Clearly, it might not be, if it is so restricted that nursing care is even more restricted in its definition than it is currently; it is fairly restricted now?
  (Mr Walden) What I was trying to get across, I am sorry, obviously I did not, was that, in terms of assessing gaps in provision and need for investment in a different mix of services, that position has not changed, that exists currently and we have got processes for dealing with it, and those will continue into the future. As far as how much is going in, the response to the Royal Commission talked of £360 million, but, of course, that was excluding the money that was going to be made available for development of services, such as intermediate care, which obviously benefit the same client groups; £360 million a year by 2003-04 to tackle long-term care funding issues.

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