Examination of Witnesses (Questions 128-139)
10 MARCH 2005
MR JOHN
PYE, MR
MARTIN GREEN,
DR JACKIE
MORRIS AND
MS JO
PECK
Q128 Chairman: Welcome to our last group
of witnesses. Will you briefly introduce yourselves to the Committee?
Mr Pye: My name is John Pye, I
am presently employed as Head of the Commission for Continuing
Healthcare for Cheshire and I am here representing the Royal College
of Nurses.
Ms Peck: I am Jo Peck, Head of
Nursing for Medicine at Lewisham NHS Trust.
Dr Morris: I am Dr Jackie Morris.
I am a jobbing consultant geriatrician, and deputy chairman of
the policy group at the British Geriatrics Society.
Mr Green: I am Martin Green, Chief
Executive of the English Community Care Association, and a trustee
of Age Concern England.
Q129 Chairman: Can you say a little bit
about the Association, Mr Green?
Mr Green: We are the largest represented
body for the community care sector in England and we have about
2,000 residential homes, which represent about 110,000 beds in
membership. Our membership goes right across the board, so we
have charitable and voluntary sector providers; we have large
corporates and we have quite a lot of individual small home-owners.
Q130 Chairman: Would you include members
of the National Care Homes Association, or would they be separately
organised from you?
Mr Green: That is a separate organisation,
although we do have some cross-over members and some people are
members of several umbrella bodies.
Q131 Chairman: Can I thank you all for
contributing to our inquiry, and for your evidence we are most
grateful. Mr Pye, I recall, going back some years, when community
care arrangements evolved from 1981 where people could go into
care or nursing homes and get a top-up from the DSS system towards
the cost. The argument was that that incentivised people to enter
institutional care who frequently did not need to be in there,
because it was easier to get care in a home than support and care
to remain in your own home from the state. In your evidence you
state that the registered nursing care contribution framework
rewards dependency and fails to provide any incentives for recovery
or rehabilitation. How do you think this perverse incentive might
be tackled?
Mr Pye: I think it is a perverse
incentive, and I like yourself, Chairman, have been around the
Health Service a long time, and I was party in the early 80s and
1990s when community care came out. When the RNCC first came into
being it laid down what we believe was perversity in that we reward
people's dependency rather than their potential to improve. If
I may, Chairman, I will give you an example of that in my local
area. We have a number of patients who we have assessed using
the RNCC and those assessments were made on the wards in hospitals
and were high bands. We placed them into our local nearby nursing
homes where they have very good care, and their dementia has been
treated accordingly. They are now improving substantially, and
we have now gone in and re-banded those patients and given less
finance to the nursing home to look after them, which has a massive
detrimental effect both upon the individuals themselves potentially
but also on the business of the nursing home to try and maintain
the same level of standards which they wish to have. That is the
main issue as far as I am concerned. With the policy we now have,
we have no alternative but to use it as a perverse system; that
if people do offer over and above what people generally get, and
people do improve and rehabilitate, we go in there and disinvest
and remove the awards that we have made to the homes.
Q132 Chairman: The whole system basically
is working against rehabilitation and helping people, moving them
towards independence in some respects.
Mr Pye: Absolutely, and like a
lot of initiatives that have come out quite recently it is a reaction
to an issue and a problem. The reaction to the long-term commissions
report was, "we will fund nursing care". That was patently
obviously not going to happen, and we are now not funding nursing
care, we are funding a proportion of nursing care. That came along
as a reaction to the long-term commission. It also did not take
into account the policy we already had in place for continuing
health care, and the two sides have never married up. I was listening
to previous speakers about the combinations and the relationship
between the RNCC and continuing healthcare. It was never thought
about when RNCC came out, and we have ended up with two policies
and two procedures matching in everything including the words,
which places a great difficulty on us within the nursing sector
and certainly within PCTs in trying to disseminate and make decisions
on who funds and who does not.
Q133 Chairman: You have argued that the
changes to continuing healthcare criteria will not resolve wider
problems of access to healthcare "unless there is a far greater
agreement about what constitutes health care and what constitutes
nursing care". That is at the heart of what we have been
talking about all morning. What do you mean by this? What do you
feel are the implications for patients who practise and how might
we resolve the issue?
Mr Pye: I was kind of hoping that
was your first question this morning, Chairman, to see if we could
identify what was health and what was social care. I have been
in the Health Service 37 years and I am no closer to finding the
answers to what is health and social care. That is a perversity
we have in dealing with probably our most dependent population.
These people require continuing care. Whether it is continuing
healthcare or continuing social care is a bit of a red herring
really. These are individuals who previously would have been in
a long-stay hospital under the guidance and supervision of doctors,
consultants and specialist staff. We no longer have that provision
for them. We put them into the independent sector, and very good
as it is, it detaches them from the National Health Service, and
that is inherently what we have got. We have our most dependent
individuals in the care of non-NHS staff, with little or relatively
small amounts of support and guidance given to those individuals.
You suggested we move the demarcation line between health and
social care, and I think we need to do that. We need to look at
people holistically and see what their needs and care needs are.
Q134 Chairman: You also need to have
a holistic professional, and the more I stick around in this area,
the more I think the future professional roles will be markedly
different from what we have now probably. Doug Naysmith and I
have been serving on a committee evaluating the Draft Mental Health
Bill, and of course the proposal in that Bill is to move away
from the approved social worker role in sectioning people to the
approved mental health professional because there is a recognition
of people working much more closely together, and in a sense we
are moving towards one professional. Do you see that as a means
of responding to some of the demarcation problems we have got
over and above the funding issues, but the actual practice of
people. What is your view as to what that future professional
might be?
Mr Pye: That is crucial too. It
has happened over a long period of time. I was a community nurse
in Liverpool way back in the 80s and 90s where we did merge the
carers, the health and social care staff, because we had those
disputes about who gives eye drops, who washes hair and their
feet, and all those issues. We created a generic worker at that
time, and they are spread round the National Health Service, the
social services now anyway, particularly around the elderly. The
only way forward is to come together and provide a generic workforce
for the elderly with the specialist people involved in their care
as well. Continuing health care gives an opportunity now towards
the creation of that.
Q135 Dr Taylor: Can we explore definitions
a little further, and it is really the definition of "nursing
care". We have heard from our previous group that if a nurse
gives it, it is nursing care, and if somebody else gives the same
care, it is not. How should we be recommending that this is altered,
if it is altered, when it is used for the determination of registered
nursing care contribution?
Mr Pye: It is crucial we understand
what we mean by "nursing care". As a couple of previous
speakers clearly said, they provide quite a high level of nursing
care to their loved ones and their families and friends. The vast
majority of their care is provided by the mother and father. They
carry out tracheostomy changes; they carry out ventilatory procedures
on their own children. It does not stop becoming a nursing task
simply because the carers do it, but they do so under the guidance,
supervision and training of the qualified nurses. It does not
stop becoming a nursing task. The 2001 definitions of nursing
care included those tasks delegated and supervised by nurses;
however, when it comes to the funding issues around that care
it ceases to be. The continuing health care and the RNCC clearly
specify it is the work carried out by registered nurses. If you
are not a registered nurse, you cannot carry out nursing care.
Q136 Dr Taylor: So we do come down to
what our previous witnesses said; that if it is carried out by
a nurse, it is nursing care.
Mr Pye: Yes. If it—
Q137 Dr Taylor: If it is the same duties
carried out by a care assistant or a carer, completely unqualified,
it is not.
Mr Pye: Sure. I guess all care
provided by a nurse does not necessarily need to be nursing care.
Q138 Dr Taylor: Any help from the British
Geriatric Society?
Dr Morris: I have always had a
problem with this. I was at a meeting talking about dementia and
the needs of older people with dementia the other day, and we
have major concerns that the most frail older people are given
over to the care of the least trained and the least qualified
to deliver that care. If you were talking about people with cancer,
we would not be saying this was acceptable, and I think there
is a perverse incentive to give people the cheapest care and the
most untrained care. That is not saying that in some circumstances
it is not very good, and I have spent lots of time visiting and
supporting care homes, and they deliver amazing care and often
in a much better environment than the traditional long-stay hospitals.
However, I think we have thrown the baby out with the bath water.
We have documented in our statement that we think it is the responsibility
of the NHS to earmark and dedicate a specifically trained group
of staff of specialists to support this vulnerable group of people.
As has already been expressed so frequently this morning, it is
very difficult to tell who is NHS continuing care and who is not.
Older people in nursing homes and care homes are very major users—and
this has not been said—of the acute sector, because often
their health needs have not been identified early enough and sorted
out early enough; so this is a problem. The other thing is that
the British Geriatric Society would like you to appreciate what
is a comprehensive geriatric assessment. I have been looking up
to make sure that I have the right terms, but it is very important
for everybody to appreciate that there needs to be a co-ordinated
approach to an older person, where a team of professionals assess
an older person's health, medical, emotional, cognitive and functional
needs, to identify reversible problems, to review their medication
and allow that patient and individual to achieve their maximum
potential. This process has been proven to work. It does not necessarily
reduce mortality but it reduces institutionalisation and improves
outcomes. We think it is very important that specialists are involved
in this process. Often in hospital, the assessment process leading
to continuing care or nursing home care does not necessarily involve
a specialist geriatrician. As has been described, there are major
problems with how assessment prior to placement and continuing
care is done, and poor documentation. We believe the system should
very much involve the patient and the carer and that there should
be good documentation. We also think that you cannot just do one
comprehensive assessment; that assessment and review—there
needs to be a dynamic process. You need to assess people, and
then if the decision is made—and you need to make sure they
have achieved their maximum goals and potential—you need
to take into account the complexity of their needs and the relationship
between disease, impairment disability and handicap. I hope I
am being clear.
Q139 Chairman: You presumably accept
the point that Mr Pye made, that your assessment process could
have a detrimental effect on the funding circumstances of the
individual patients.
Dr Morris: Yes.
| 
