Select Committee on Health Minutes of Evidence


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.


 
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