Select Committee on Health Minutes of Evidence


Examination of Witnesses (Questions 260 - 279)

WEDNESDAY 8 NOVEMBER 2000

RT HON ALAN MILBURN, MR JOHN HUTTON, AND MR COLIN REEVES CBE

  260. No, I just wondered if you had a definition of defining personal care.
  (Mr Hutton) I do not.

  261. You do not?
  (Mr Hutton) I do not have a definition of personal care. The care that is not provided in the way that I have outlined by a registered nurse will therefore be care that is, in theory, subject to social services means- testing. It is worth pointing out that currently seven out of ten people, either in residential care or nursing homes, get all or most of their personal costs met by the state as well.

Dr Brand

  262. A very short one in relation to that. Are you going to use that definition for means-testing in the home as well? If you are going to use that definition, people are going to lose out enormously in home care.
  (Mr Hutton) No, because we are not proposing to change the arrangements there.

  263. So you are going to have one definition of nursing care when it is delivered at home and another definition of nursing care when it is done in a residential establishment?
  (Mr Hutton) No. It is currently the NHS that meets that home-based nursing care support already. We are not going to change the arrangements for that.

  264. It is not just nursing care. There is also care provided by non-registered nurse assistants, auxiliary health visitors assistants.
  (Mr Hutton) With respect, we are not changing the arrangements in relation to home based care. What we are trying to do—

  265. So you will have two definitions?
  (Mr Hutton) No. What we are trying to do is to make the charging arrangements in relation to home care services much more consistent and fair across the country. One of the things we are concerned about, and we made it clear in the White Paper Modernising Social Services is the huge scale of variation in charging for domiciliary care at home. It is unacceptable. That is why in the Care Centres Act we have taken the new statutory powers to regulate and try to get greater consistency in charging for home based care. That is a very significant step forward. I hope it is going to be possible through that new guidance to correct some of the anomalies and some of the inconsistencies of how we charge for home based care. The definition we are discussing now, to which I was trying to answer Mr Burns's question, relates to nursing care provided in residential homes. That is the definition, Mr Burns, that we outlined in the NHS plan and what we intend to deliver in the package of reforms we outlined in the NHS plan.

Mr Burns

  266. Would we be right in thinking that the people who are going to interpret this definition will be the front line nursing staff?
  (Mr Hutton) What we intend to develop is a new assessment protocol, a new assessment procedure, which will improve the assessment process generally in relation to people both at home as well as those who are going into residential care, either a residential care home or into a nursing home. Currently, at the moment, there is, again, a significant amount of discretion and variation across the country as to how those assessments take place, which I am sure you will be aware of as a former Minister in the Department. We are not going to, as it were, leave people to their own devices. I think there has been some concern that these changes will be introduced without any central guidance and support from the Department, of course we are not going to do that. We are developing, currently, at the moment, through the chairmanship of the Chief Nursing Officer in England, working with a variety of organisations including the Royal College, Alzheimer's Disease Society, Age Concern, Help the Aged and others, to get the processes right whereby we can make the correct assessments.

  267. Would it be fair to say that what you are seeking through this working party is to come up with a standardised form of assessment?
  (Mr Hutton) That is right.

  268. To try and get continuity and standards.
  (Mr Hutton) Absolutely. It is a fundamental part of the machinery we want to put in place. I think it will address some of the wider concerns too that I think the Committee has about cost shunting. We are not trying to create new perverse incentives, we are not trying to create new anomalies, we are correcting an age old anomaly in the system which has impacted unfairly on people going into nursing homes.
  (Mr Milburn) I think why this will be helpful is that clearly it will be inappropriate for front line clinicians, in this case registered and qualified nurses, to be, if you like, doing an assessment purely in the dark. It is important, therefore, that we have a framework to which they can work. I think that is the right thing to do because it gives them support and it gives them the appropriate framework. I think equally it is important that we all recognise, as I am sure we do, that individual patients will have quite different and individual needs. That is why in the end the best people to undertake the assessments are going to be those responsible for the care vis a vis the individual patient. One very, very important point of detail which I think is absolutely critical about this is just in case there are any concerns about caps on costs or any of that nonsense that sometimes I occasionally hear, there will be no cap on cost for the individual patient. So, for example, if nurse decides that an individual patient needs a particular package of care then, providing that is consistent with the framework, that is what we will provide for them because different patients will have different needs.
  (Mr Hutton) That is right.
  (Mr Milburn) It is that we are hammering out now in discussion with the appropriate patient organisation—Alzheimer's Disease Society, Age Concern, the Royal College of Nursing.

  269. Can I just press you a bit more on your statement that there will be no cap on the costs for the individual patient's care. You are not saying, are you, that the sky is the limit in certain cases if there might be a more cost effective way of providing care for someone?
  (Mr Milburn) Say that again, I did not quite understand.

  270. You said there will be no cap on the costs for an individual.
  (Mr Milburn) For nursing care?

  271. Yes.
  (Mr Milburn) Yes, for the nursing care that is provided.

  272. So will there be a cap though on the total amount of money available for nursing care, not for the individual but in toto for nursing care? Surely you have not got an open ended wallet?
  (Mr Hutton) No. Of course, all resources, by their very nature—

  273. Right, well, how do you square your statement with the Secretary of State's that there will be no cap on the costs for the individual cases?
  (Mr Milburn) It is self-evident. Different individuals will have different care needs. A patient at the terminal stage of Alzheimer's Disease will have a quite different set of circumstances to deal with and their relatives will have a different set of circumstances to deal with than somebody who has lower needs.

  274. Of course.
  (Mr Milburn) Of course they will. Inevitably, the thing is bound to average out, is it not, that is how it will work. The important thing about this, I think, and this is absolutely critical to how this will work on the ground, is to ensure that we get the best of both worlds and I think we can have this by doing what we are proposing to do. One is to get a National Assessment Framework that provides some consistency and ensures that the many thousands of nurses who will be providing the care have some framework which they can operate. Otherwise, frankly, I think it will be unfair for them and unfair for the purchasers of care, firstly. Secondly, we have to be able to achieve individual packages of care and, therefore, individual costs to the needs of the individual patient. If you like, it is the same with the situation that a GP would come across in a surgery. We would not say to a GP "Well, here you go, you can only prescribe to an individual patient a certain level of drugs" when individual patient's needs vary, because they do, do they not?

  275. What about with beta-interferon?
  (Mr Milburn) I am happy to deal with beta-interferon if you would like me to.

  276. That is just to make the point that if certain GPs get patients coming to their surgery now and saying "I would like beta-interferon" they will have great difficulty in some cases getting it, depending on where they live.
  (Mr Milburn) That is precisely why we have referred beta-interferon to the National Institute of Clinical Excellence which is absolutely the right thing to do, precisely to ensure there is greater consistency and care.

  277. I am just simply making the point as of now, when you said someone will not go to their GP and be told they cannot have whatever it is, I was just giving you an example of where they can.
  (Mr Milburn) You would not want to see that lottery of care, that certainly I decry and I guess you do too.

  278. I am just making the point.
  (Mr Milburn) You would not want to see that replicated for patients.

  279. That is what is happening at the moment in the real world.
  (Mr Milburn) That is why the approach which is being taken is to have a National Framework with clear rules, clear standards, a clear assessment protocol too, so that the individual nurse is working to a protocol for the individual patient but that does not inhibit getting the individual patient the right level of care, whether in terms of the package of care or, indeed, in terms of cost.
  (Mr Hutton) Can I say there is one other dimension—
  (Mr Milburn) Unless you think that is wrong.


 
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