Examination of Witnesses (Questions 20-39)
10 MARCH 2005
MS ELAINE
MCHALE,
MS CATH
ATTLEE, MS
YVONNE COX,
MR MICHAEL
YOUNG AND
MS DENISE
GILLEY
Q20 John Austin: You have no indication
when they are likely to be ready? You have no inside information
about that?
Ms McHale: No, I have not.
Q21 Dr Naysmith: We have had lots of
submissions putting in evidence to the Committee saying that confusion
exists widely between the National Health Service continuing care
system and the registered nursing care contribution framework
I see a few people are nodding, so obviously that exists. Do you
think it is a problem? Does everyone think it is a problem? Is
that generally recognised?
Ms McHale: It is.
Q22 Dr Naysmith: What do we do about
it?
Ms Gilley: It goes slightly wider
than that. One thing we have found is that members of the public
are very confused about some very fundamental things, the most
fundamental being that NHS services are free and social care services
are charged for, so I think that is the first point.
Q23 Dr Naysmith: I was not thinking about
the public but about the people who do the commissioning, but
both will be true, I am sure.
Ms Gilley: The other things flow
from that. Another issue is that different sets of people on occasions
have been looking at nursing care bandings from those who have
done continuing care. We have tired to bring that together so
that, in terms of local decision-making panels, they do both.
They will first and foremost look to see whether an individual
is eligible for continuing health care and only if and when they
have decided that that person is not, will they then look at banding,
if they are in a nursing home.
Q24 Dr Naysmith: That is the way the
system is supposed to work. Why does it not work like that?
Ms Gilley: The system in County
Durham and Tees Valley certainly does now work like that. I cannot
promise that it has always worked like that but that is the premise
upon which we make our local decisions.
Ms McHale: That is correct. It
is supposed to work like that. The Delayed Discharges Act requires
the continuing care assessment to be made first. If you look at
the guidance for the RNCC, it gives definitions and examples of
the highest banding being below that of the Coughlan outcomes.
There is a huge level of confusion about this. The continuing
care banding has to be differentiated from that. I would add that
there is not a proper process for review. If you are in a nursing
home and you are on the high banding of nursing free-funded care,
then if you then deteriorate into continuing care, potentially
there is not the opportunity automatically to have that resolved.
There are issues about that.
Q25 Dr Naysmith: What would you say should
be done about that?
Ms McHale: We have to eliminate
the discrepancy around the examples in the guidance for the higher
level of nursing funding and re-emphasise the requirement for
the continuing care assessments to be done, first and foremost.
There has to be built in the period of review and monitoring,
the availability and accessibility for people to do that automatically.
Q26 Dr Naysmith: Ms Attlee, you wanted
to come in on the general broad thrust.
Ms Attlee: I am slightly surprised
about that because certainly there is a built-in expectation that
a nursing review would be undertaken every year and at any point,
either the inmate or the nursing home can trigger a continuing
care assessment. Again, it may be about practice not reflecting
policy. The framework is such that this should be a regular review
of nursing care application.
Q27 Dr Naysmith: This is the whole area
that we are investigating: why in different places do different
things happen, even though the criteria are supposed to be laid
down. Going on to what is probably a slightly more embarrassing
question for all of you: does some of this have to do with the
fact that primary care trusts have fixed budgets and that one
of them is more expensive than the other, so getting towards the
end of the year—Some people are nodding and some shaking
their heads and saying it is not true.
Ms McHale: There is a big element
of difficulty facing primary care trusts in balancing their budgets
and dealing with the demands that continuing care can make. We
have done some surveys of local authorities. We know there is
at least one PCT which has a cap on how much per person they will
give towards care.
Q28 Dr Naysmith: Can you be explicit
on that?
Ms McHale: I cannot. I would have
to supply that information to the select committee later.
Q29 Dr Naysmith: It would be good if
you could do that. Do you think it never happens, Ms Attlee?
Ms Attlee: No, I am not saying
it never happens. Certainly PCTs have financial problems and that
has a bearing effectively on how things are implemented. I do
not feel in our area that is the reason why differences occur.
Certainly it puts a pressure on the whole issue, and all the more
reason why it has to be done in a joint fashion. Certainly in
our case most of our commissioners who are commissioning long-term
care are jointly employed by health and social care. The issues
about whether it is our budget or your budget are not the key
issues as to why differences occur. That may well be the case
in other parts of the country. I can only speak for north west
London in this regard. We have tried to build into the system
that it is about the needs and the appropriate placement and appropriate
funding source and then, yes, the budget pressures appear, but
they appear as part of our overall position. You may be familiar
with north west London's financial position perhaps as a result
of that.
Q30 Dr Naysmith: You may not realise
but this could well go out on the radio on Sunday night and people
in Hounslow might well write in and say they do not recognise
that system, but you are happy to say that?
Ms Attlee: I am at least confident
in saying that if somebody has been denied NHS full funding in
north west London it is not because we have not got the money;
it is because they do not meet the criteria.
Mr Young: I would support that
for the Strategic Health Authority.
Q31 Dr Taylor: I live in an area where
I am just on the edge of one strategic health authority abounding
two other strategic health authorities. Like other members, I
do have problems about where the criteria appear to differ. I
quite take the point that you have made that it is very often
the interpretation of the criteria rather than the criteria themselves,
but did our two strategic health authority representatives
take into account the neighbouring strategic health authorities'
plans when they made theirs?
Mr Young: The work in north west
London had started very early, following the 2001 guidance. This
was before my time. Cath Attlee chaired a group on this. I think
other health authorities around—and as London health authorities
we meet with other health authorities—had looked at our
criteria and were seeing what was good and what was relevant to
them. There had been some work done on that.
Q32 Dr Taylor: There was a certain amount
of consistency between areas?
Mr Young: Yes.
Q33 Dr Taylor: What about in the north?
Ms Gilley: I would say something
similar in the sense that we certainly had more detailed discussions
with our more northerly SHA, which is Northumberland, Tyne and
Wear. We did also have some discussions with people from Yorkshire
and also from the north-west to try and find out what other people
were doing, what their approaches were, how they were going about
trying to get consensus to steer the whole process.
Q34 Dr Taylor: Do you come across problems
with cross-boundary flows where somebody is assessed in one area
and goes to a residential home in another area?
Ms Gilley: Yes. It would be foolish
to say that there are not those issues but there have not been
any cases that we have felt have been hugely unresolved. We have
had a number of people who have ended up in acute care in the
north east and who have then wanted to move south to be nearer
relatives, and there has been a negotiation but we have reached
agreement. The person has not ended up remaining in hospital or
going somewhere else; they have gone where they wanted to go.
Q35 Dr Taylor: Again, with the strategic
health authorities, turning to the interpretation of the criteria,
how do you monitor PCTs on their performance?
Ms Gilley: This is the point I
was trying to make earlier. This is going to be important nationally
so that something happens on this. We do have a software programme.
I say that with my fingers crossed. It does exist and it does
work but it does not give us the level of data extraction that
we would like. It is the beginnings of something. To be truthful,
I think that would be the only way in future that you would be
able to do this in terms of looking at spend, numbers of joint
packages, numbers of cases for people who have a learning disability
and through a whole range of issues that you then would want to
pick out and look at. Then, as you would do with any other data,
you can begin to examine the outliers. There might be good reason
why you have particular outliers, but at least it would give you
the prompts to do that.
Mr Young: We are probably not
quite at the stage of having the electronic data but we are looking
at similar issues around placement and getting the financial information.
There are difficulties about financial information in different
PCTs that may be using some money from continuing care budgets
and some money from community nursing budgets. Therefore, it is
about having an understanding both as to how the budgets are put
together and a consistency of understanding of what should be
included in financial measures. We also have the SHA panel which
sees cases. We have been using the panel's test for consistency
of decision-making across primary care trusts. We are also looking,
as part of the training for assessors, at possibly assessing sample
anonymised cases to check that the same results come out.
Q36 Chairman: Would it be fair to say,
comparing your area to Ms Gilley's area, that you would have more
of what she terms outliers? My recollection is that when the community
care changes came in, in looking at the London experience, people
seemed to move much further afield from London than perhaps they
would have done in an area like Durham. With your geographical
area, are you likely to have more people moving out of your area
and therefore you need to deal more with other areas than perhaps
Ms Gilley would in the north east?
Mr Young: Yes, but if they moved
out of our area, they would be assessed under our criteria initially.
This goes back to a previous question: one of the key problems
is not necessarily the difference in criteria but the appearance
of criteria, the way they look in each strategic health authority.
That means that if people move out of area, and particularly in
terms of wanting annual reviews (and it is very hard in London
to do the annual reviews as we do send a lot of people out of
area) someone who understands our criteria and our assessment
tools would need to be able to assess them.
Q37 Dr Taylor: On the same lines, please
help me to understand this. The responsibility remains with the
PCT but presumably it is usually hospital staff, trust staff,
who do the assessment. Is that right?
Ms Attlee: It is usually a multidisciplinary
set of staff, so it may be a social worker and a hospital nurse
or therapist, or, if the person is in the community already, a
community-based nurse.
Q38 Dr Taylor: The team would include
people from the acute hospital trusts?
Ms Attlee: If the person was in
hospital, yes.
Q39 Dr Taylor: I hate the phrase "toolkit"
but there are various toolkits for this sort of purpose. Do you
take note of which they use? Do you try to get them to use a particular
toolkit across the patch?
Ms Attlee: We have a standard
health needs' assessment form which we ask all staff doing the
health component of the needs' assessment to use, or they may
use something very similar. Some of the hospitals in London have
something very similar. As long as it produces the same set of
needs' data, that is fine. They need to be able to produce a needs'
assessment that is able to be summarised in the standard format
that we use for the north west London criteria.
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