Examination of Witnesses (Question Numbers
480-499)
MS SHEILA
SCOTT OBE, MR
MARTIN GREEN
AND MR
COLIN ANGEL
19 NOVEMBER 2009
Q480 Dr Taylor: As opposed to a sea
view, it could be a single room rather than a shared room, those
sorts of things?
Ms Scott: Yes.
Q481 Dr Taylor: Sheila, I think you
said you did not really think that self-funders subsidise the
other people, and I think you, Martin, rather disagreed with that.
Mr Green: Yes. I think, inevitably,
there are differences in terms of where self-funders are positioned,
as opposed to where local authority residents are positioned,
because local authorities use their power to force down costs
of care and, in some cases, do not pay the amounts that are required.
If you look at that benchmark of £785, which is what they
pay themselves, and then compare that to being in the community
having to deliver care at £400, there is a great difference.
Some of that difference will be about a whole raft of things that
do not make an impact on the service, but some of the difference
will be about service issues, and if the local authority is funding
at a lower level, then there has got to be some way in order to
fund the cost of a quality service.
Q482 Dr Taylor: One of the themes
behind the National Care Service is fair funding and the national
system. If it was a more universal funding system, would this
reduce the need for cross-subsidisation?
Mr Green: It would if it was based
on a proper approach to having a costs of care exercise. My concern
about this idea of a National Care Service is that nobody has
yet told me how it is going to be delivered against the backdrop
of having 350 local authorities, many of whom seem to be laws
unto themselves, delivering what they think they will deliver
without any clear justification as to why the difference. It is
not even on the basis of a justify and explain policy. I was recently
in Surrey, and they deliver different services to the people in
Lambeth, for example, but when I tried to unpick with the chief
executive and directors why that was, nobody seemed to know, other
than to say, "This is the way we do it here." So, if
you get a National Care Service, there has to be a lot of structural
work that lies behind it because one of the things that is unfortunate
is that people in Parliament think an announcement is delivery,
and there is a lot of work between announcement and delivery,
and if we are going to turn this from a promise to a reality there
is a lot of work to be done and a lot of that is going to have
to be structural, I am afraid.
Q483 Dr Taylor: Words to action!
Mr Green: Absolutely.
Q484 Dr Taylor: A huge difference.
Thank you very much.
Ms Scott: The key word, a word
that recurs again and again in the Green Paper, is "basic".
This is a "basic" care service. I guess that those people
with their own funds will still buy extra parts.
Q485 Sandra Gidley: A question to
Sheila Scott. In your submission you say, "We are seeing
NHS funding being denied more and more to patients, with many
decisions blatantly ignoring national guidance about National
Health Service responsibilities", and yet Laing and Buisson's
report seems to indicate that there are now a lot more people
receiving NHS funded continuing care. For example, in 2009 there
were 47,000, compared to only 21,000 in 2005. What is your evidence
for your rather sweeping statement?
Ms Scott: We believe, there are
some new criteria. We are seeing reassessments of people.
Q486 Sandra Gidley: I am sorry; you
believe there are some new criteria. There were some national
criteria introduced.
Ms Scott: Yes, and we believe
they have been amended.
Q487 Sandra Gidley: Are you saying
those have been amended?
Ms Scott: We think they may have
been, yes.
Q488 Sandra Gidley: Surely we can
check this. You do not know; you just think. Why do you think
they have been amended?
Ms Scott: My members on the ground
understand there are new criteria. I have not seen that evidence.
They understand there are new criteria. People are reassessed
regularly under this system and, particularly in dementia care,
if you have somebody with continuing health needs who goes into
a dementia care nursing home there is some stability about the
service: the same faces, people have usually come from the NHS.
There is some improvement, but these are still people with very
complex needs, but at reassessment my members (and it is not just
in one area, it is certainly across the West Midlands and the
East Midlands, but I am sure it is much wider than that) are finding
some improvement in condition and, therefore, the award is being
removed. Where does that money go?
Q489 Sandra Gidley: You are saying
there is no incentive to do a good job?
Ms Scott: Somebody actually said
this to me: "This could be a disincentive to the unscrupulous."
That is not what is happening at the moment, but there is some
concern, because, of course, if you have a healthcare award that
is significantly more to provide the service than if you are providing
social care to the same person, there is a difference yet the
service has to remain the same. There is some genuine concern.
Somebody I spoke to very briefly this morning said, "Where
are those people to go to?" They are going through appeal
systems, et cetera, at the moment. No provider would like to ask
somebody to leave, but if it becomes widespread then they may
have to ask them to leave and their condition would then, of course,
deteriorate again.
Q490 Sandra Gidley: So this is anecdotal
evidence at the moment. You are not able to quantify it in any
way.
Ms Scott: No, but I have an offer
for you to go and visit one or two places where this is happening.
Q491 Sandra Gidley: But you are saying
national guidance is being ignored. That is rather different to
what you have just said. In your submission you say national guidance
is being ignored at 2.22.
Ms Scott: Yes. That was a very
sweeping statement, I think. I have got my evidence here somewhere.
Mr Green: There is also a general
point about the interface between care services and health services.
Lots of care homes, for example, are asked to pay for GP services,
and this is something we have raised on numerous occasions.
Q492 Sandra Gidley: They are being
asked to pay for GP services?
Mr Green: Yes. We have produced
a report recently and several reports have identified this. If
you consider that people in care homes are seen as being in the
community and everybody is told that healthcare is free at the
point of need, yet GPs are asking for sometimes very significant
amounts.
Q493 Sandra Gidley: I do not doubt
it.
Mr Green: For example, £69,000
was one case I saw. This also has a real knock-on effect in terms
of how we are able to deliver to people with complex needs when
we have not got the support of primary care. We have done some
research where we have found there is a lot of this going on,
but there is also a lot of ignorance within the PCTs that is going
on.
Q494 Sandra Gidley: That seems to
me to be clearly unacceptable. I wonder if Sheila wanted to come
back on the decisions being blatantly ignored.
Ms Scott: I was just thinking
how to put it because I have only just found the part in the evidence.
We think that the welfare of people is being ignored for financial
reasons. That is really where we are coming from. I may not have
put it quite like that in the evidence that we supplied to you,
but we do think that there is a financial issue here which is
affecting the long-term welfare of people with what we believe
to be continuing healthcare needs. The people that I am talking
about (and, you are right, it is anecdotal) are extremely worried
about what is happening. People are being reassessed after six
months, which the people that I have been talking to think is
quite early, and their actual healthcare of the person is not
being taken into account. Of course people may improve with good
quality care, but when that changes then everything can change.
My members think that money is the lead on this rather than welfare
of people.
Q495 Sandra Gidley: Okay. A question
to Colin Angel. In the submission from your organisation you say
that homecare workers are more and more taking on the responsibilities
that were previously in the domain of district nurses. Could you
explain or describe what evidence there is for that and, actually,
if homecare workers can do it well, does it matter? Was it a bad
use of the district nurses' time in the past?
Mr Angel: I will consider your
last question and respond at the end. I think it is quite clear,
as a registered nurse qualifying 20 years ago although no longer
practising, what homecare workers do now are activities that in
my early days as qualified nurse would have certainly been left
to nurses.
Q496 Sandra Gidley: Can you describe
what those are, because I am not clear?
Mr Angel: Particularly medication
administration. When I surveyed the homecare sector in 2008 I
found 100% of providers are doing something connected with assisting
users with their medicine and 48% of providers are doing what
we would regard as full administration, which to my mind is a
nursing responsibility.
Q497 Sandra Gidley: I thought that
was not allowed.
Mr Angel: If we are talking about
the same type of administration, there is no reservation on activities
for registered nurses. So 50% were doing full administration.
When I had asked that question two years previously, only 25%
of providers said they were undertaking administration. We see
a number of other activities, one of which is maintaining enteral
feeding lines—that is supplying nutritional supplements
through a tube into the gastrointestinal tract—frequent
injection of insulin and managing pressure sores and wound dressings
independently. What concerns me is actually that these roles are
not necessarily requested by the purchaser and, unfortunately,
we see district nurses handing over those activities because there
is a care worker going into the home as well. That creates vulnerability
for providers. They are taking on roles that their purchaser has
not asked them to do, they are probably not getting paid for the
time that is spent doing those activities and if they are that
could actually reduce the time available for the activities that
were actually commissioned. It is an uncomfortable situation for
our members at present.
Q498 Sandra Gidley: Presumably the
homecare workers are not being trained either in these roles;
rather that it is an informal sort of training of variable quality,
I would suspect.
Mr Angel: It is likely to be on-the-job
training, it is likely to be observing practice on a number of
occasions, having the theory explained and then having a period
of supervision.
Sandra Gidley: Thank you.
Q499 Charlotte Atkins: Martin, you
were saying earlier on that PCTs are often not aware of the activities
of GPs in terms of charging care homes. What is your Association
doing to alert PCTs of this practice when you come across it?
Mr Green: We have just done a
report. We did a report which benchmarked from our membership
who was paying for GP services. We then did another report where
we wrote to all the PCTs that were involved in the first report
asking them whether they knew that this practice was going on.
From that we sent the report to the chief executives of the PCTS
and requested action and, thus far, we have had no responses.
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