Examination of Witnesses (Questions 20
- 39)
THURSDAY 2 NOVEMBER 2000
MR COLIN
REEVES CBE, MR
BILL MCCARTHY,
MR DAVID
WALDEN, MR
HUGH TAYLOR
CB AND MR
PETER COATES
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?
Chairman
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.
Chairman
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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