Care Bill [Lords]

Written evidence submitted by Royal College of Nursing (CB 14)

1.1 With a membership of over 410,000 registered nurses, midwives, health visitors, nursing students and health care assistants, the Royal College of Nursing (RCN) is the voice of nursing across the UK and the largest professional union of nursing staff in the world. RCN members work in a variety of hospital and community settings in the NHS and the independent sector. The RCN promotes patient and nursing interests on a wide range of issues by working closely with the government, the UK parliaments and other national and European political institutions, trade unions, professional bodies and voluntary organisations.


1.2 The RCN has played a significant role in the debate around social care reform due to the key roles nursing staff play working within and across the health and social care systems. We know that nursing staff:

· 1.2.1 play a distinct and critical role in health and social care. They frequently work on the interface of the two care systems and work to ensure that patients do not notice where these start and end. Nursing staff carry out public health work, provide social care (although not officially termed as such), consider a range of safeguarding issues, such as their patient’s practical and emotional needs, and identify and refer patients to a range of different services, including those outside the care systems, such as benefits and welfare support

· 1.2.2 manage patient referral, admission and discharge processes. Nurses are frequently responsible for resolving confusion over where a patient needs to be discharged to and ensuring there are appropriate resources to deal with the patient effectively when they are moved. This can often be complicated; it can be a time consuming, duplicative and a bureaucratic process, which ultimately takes nursing staff away from frontline care delivery

· 1.2.3 deal directly with the impact of delayed discharge of patients from acute to social care or community, stemming in part from disputes over who pays and a lack of capacity in the NHS and local authorities. This is a frustrating occurrence resulting in patients ultimately being cared for in inappropriate care settings

· 1.2.4 too often discharge a healthy patient into the community only to see them readmitted into the acute setting days or weeks later due to inadequate community care and support, the so-called ‘revolving door’

· 1.2.5 improve joint working between the health and social care teams through multidisciplinary team working and single assessment processes. District nurses, community matrons, clinical case managers and other community leaders are notable examples of where nurses take the lead in coordinating care and case management. Nurse specialists also promote all forms of continuity of care and are highly valued by people with long term and complex conditions

· 1.2.6 are vital, clinical and care leads in care homes, providing health and social care to residents in one setting.

Part 1 Care and Support

Funding cap

1.3 The RCN welcomes the government’s intention to introduce a cap on care provision costs to alleviate the financial pressures upon individuals. However, at £75,000 we are concerned about how many people this will positively affect. The RCN believes that too many may be left unaffected and still face agonising decisions over how to pay their care bills. The RCN calls upon the government to reflect on its decision around the figure set as the cap and to revise it to one closer to that advocated by the Dilnot Commission of between £25,000 and £50,000.

1.4 When asked in 2011 what type of funding system they would support in the reform of social care, RCN members overwhelmingly supported a comprehensive system based on the same principle as the NHS. [1] They were particularly concerned that a new system should be fair, and that people should not have to sell their houses to pay for their care.

1.5 In its response to the consultation ‘Caring for our future, implementing funding reform [2] the RCN highlighted its concerns that any funding system that is too complicated or segmented will only exacerbate the current problems faced by the social care and health care systems. For example, duplicative eligibility form-filling and needs assessments, delayed transfers of care, result in many receiving inappropriate care or care in the wrong setting and health care nurses being taken away from frontline care.

Clause 3, Promoting integration of care and support with health services etc.

1.6 We strongly welcome this clause, having repeatedly highlighted the challenges of providing integrated care throughout a patient’s journey across the health and social care systems. [3] However, the RCN believes that whilst the intent of the legislation is laudable there is a need for greater incentives to encourage integrated working and overcome the challenges that have previously prevented joint working. The RCN believes that such incentives will need to be legislated for to ensure the adoption of integrated working nationally.

1.7 While we recognise that localised services best serve local need, integrated care should be provided to a nationally consistent and standardised way of working. This will help people, staff and those in receipt of care, who move from one location to another, to have a clear understanding of how the local system operates and what it delivers.

1.8 The RCN supports the delivery of integrated health and social care, however with separate funding systems the RCN is mindful of the potential for a blurring or shifting of service responsibility between social and health care services. The RCN strongly supports the principle that nursing care, including when delivered in a social care context, should be universal, provided free at the point of delivery, based on clinical need and not ability to pay, and preferably financed through taxation. Funding being taken from the NHS budget needs to be ring-fenced to guarantee that it is actually being spent on social care provision to ensure the NHS isn’t still faced with filling the gaps in social care.

1.9 The RCN believe that agreeing on an unambiguous definition of integrated care will be vital to ensure patients, staff, carers, governing authorities and external agencies have a common understanding of both the term and its desired outcomes, so that they can work towards a common aim.

Clause 4, Providing information and advice

2.0 As the RCN has repeatedly noted, the current care system is complex and confusing, this is compounded by the lack of information about how the system works. [4] Providing information and advice is crucial in helping people understand the system, know what to expect, and make appropriate choices for their needs. People often need to access care services when they are elderly, frail and vulnerable and with complex and multiple needs. They must, therefore, have access to information and support in a format appropriate to their needs. They will be making decisions that will impact on their health and wellbeing and so need to understand, for instance, why choosing care provided by registered staff and not non-registered staff might be more appropriate. They should be fully made aware of the benefits of some types of care services, and the risks of others.

Clause 5, Promoting diversity and quality in provision of service

2.1 The RCN welcomes this clause, particularly with reference to placing a duty on local authorities to promote quality in the provision of services. However, the RCN does not think it sufficient that the duty merely is the ‘promotion’ of quality. Local authorities are responsible for commissioning services from providers and have a duty to ensuring that these providers and services effectively meet the needs of individuals. The RCN does not believe that local authorities are fulfilling these duties and responsibilities if they commission providers that fail to deliver high quality care, and worse, that provide care that detrimentally impacts on the health and wellbeing of the individuals concerned.

2.2 As commissioners, local authorities must be part of a system-wide approach to safeguarding, and they must be in part held to account. They are also falling negligent of their role if they commission providers and services that are not sustainable in light of the vulnerability of the individual’s for whom services are provided. The potential impact of this was demonstrated through with Southern Cross, where the health and wellbeing and indeed lives of care home residents were put at risk following its business model’s failure.

2.3 During the bill’s passage, the RCN has supported Leonard Cheshire Disability’s ‘Make Care Fair’ campaign to end 15 minute home care visits. The RCN believes that those with a disability should not have to choose between one essential care function or another because visits are scheduled for so little time. Anyone who needs support getting up, washing, dressing, and eating should receive these basic rights with adequate time and dignity. The RCN would support amendments to guarantee the quality of service provision in this setting.

Clause 25, Care and support plan, support plan

2.4 The RCN fully supports people having control over their care and of person-centred or personalised care. [5] With this in mind, the RCN has always maintained that personal budgets and personal health budgets must remain optional, as they may not be the preferred or most appropriate solution for some people, particularly those most vulnerable. However, we have concerns that personalised care and personal budgets are wrongly conflated, personal budgets are just one way to deliver personalised care.

Part 2

Care Standards

2.5 The RCN acknowledges and welcomes the government’s efforts to legislate recommendations of the Francis Report in to Mid Staffordshire NHS Foundation Trust.

2.6 The RCN supports moves that allow for better, clearer information on the quality of provider to be available for patients and stakeholders. We believe the government’s proposals charging the CQC with responsibility to develop performance ratings and introducing a failure regime on the grounds of quality of care are important steps towards addressing the imbalance that financial issues have more weight than quality, experience and care. Whilst we welcome the introduction of a Chief Inspector for Hospitals and Chief Inspector for Social Care, we would like to see more details of the practicalities of their responsibilities, for instance, how they will work with existing National Professional Advisors at CQC and other agencies such as Monitor.

2.7 The RCN believes that monitoring and inspections should bring in as much patient and staff insight as possible. This includes making use of the family and friends test, annual staff surveys, and patient and family complaints.

2.8 The RCN know that ratings work better in some settings than in others. Specific services are often simpler to inspect and rate, such as individual care homes, whereas, multi-service providers such as hospitals present greater complexities.

Clause 118, Trust Special Administrator

2.9 Undoubtedly the Trust Special Administrator (TSA) does have a place in the process of rectifying failing trusts and there will be occasions when it is important that speedy decisions are taken to address organisational failure. However, the RCN believes this should only be rarely enacted, as an option of last resort, in cases of significant debt or deficit, and not for relatively small or moderate financial challenges. The TSA’s ability to make decisions quickly restricts the time available for consultation with the public and clinicians. A significantly time constrained consultation process is not optimal, and should only be used in exceptional circumstances. The TSA must not become the mechanism of choice to routinely reorganise structures.

3.0 The RCN believes that any organisational and service reconfiguration should be considered on a local health economy and population basis, with key organisations coming together to lead the process and any decisions on change. We would expect Clinical Commissioning Groups (CCGs) to be a significant part of this process. When looking at a provider from a commissioner’s point of view it is vital to also consider it’s sustainability in the long term in the context of the local health economy. The RCN would like to see reconfiguration decisions being clinically led so that voices of clinicians are pivotal when shaping major service change. If there are savings to be made, and changes are inevitable because of financial constraints, it is important that politicians and trusts have an honest conversation with the public and clinicians about these savings and how they will be made.

Part 3

Health Education England

3.1 The RCN welcomes the establishment of Health Education England (HEE) and its responsibility for national oversight of education and training. It is an important development which will help protect funding for education and training and ensure it is spent efficiently and effectively on a national scale. The establishment of HEE presents a real opportunity to adopt an independent and comprehensive approach to health workforce planning that is responsive to both national and local issues around supply and demand.

Care Certificate for HCSWs

3.2 The RCN supported a number of amendments to the bill during its passage through the House of Lords, which called for mandatory training of health care support workers (HCSWs). To ensure the very best in patient care and accountability, it is crucial that this group of individuals, who are often working with the most vulnerable in our society, are trained and regulated properly. The RCN has long called for mandatory registration and training of HCSWs and we believe the government should introduce mandatory registration and regulation for this group. Throughout the longstanding debate on introducing a register of HCSWs, the RCN has stated that one of the overriding reasons is to ensure basic standardised training.

3.3 Therefore, the RCN particularly welcomed the government’s commitment at report stage of the bill in the House of Lords and in its full response to the Francis report, that it will be introducing a care certificate for HCSWs. Standardised training and national standards for HCSWs, who often care for the most vulnerable in our society, is absolutely essential and a certificated training programme is a notable step towards regulating this workforce.

The RCN believes that HCSWs should only be allowed access to patients once they have proved themselves competent after completion of robust training that includes, but is not limited to, mandatory topics such as health and safety; basic life support; and moving and handling. This training should also include skills and knowledge development, which will enable the individual to care for patients in a dignified and compassionate manner. The RCN is working with HEE and other stakeholders to devise the structure of the certificate and implement the Cavendish review further.

Part 4

Health Research Authority

Clause 109 Co-ordinating and promoting regulatory practice etc

3.4 Part 4 of the bill establishes the Health Research Authority (HRA) as a non-departmental public body. Clause 109 refers to the organisations and people which the HRA should co-operate with in respect of its functions. The list includes, amongst others, the CQC, the Human Tissue Authority, the Human Fertilisation and Embryology Authority and the Chief Medical Officer. Whilst the Chief Medical Officer is included, the Chief Nursing Officer is not, an oversight which the RCN believes should be put right for a number of reasons outlined below. The RCN is seeking to amend this section of the bill.

3.5 The nursing profession has a fundamentally important contribution to make in health and social care research, recognised by the UK Clinical Research Collaboration (UKCRC) and National Institute for Health Research (NIHR).

3.6 The paucity of evidence of what works in care and caring practices could be a factor in identifying what constitutes good levels of care. In times of austerity when resources are limited it is more important than ever to ensure that care and caring practices are both compassionate and effective. Research is essential to develop the knowledge base to underpin nursing practice and ensure that the deployment and interventions of the largest health care workforce are both efficient and effective.

3.7 Nurses play a central and fundamental role in achieving the government’s ambition for wealth creation through clinical and biomedical research. The nursing research workforce is recognised within NIHR as pivotal to the wider health and social care clinical research agenda, which in turn is recognised as a major contributor to the UK economy. Much of the bill talks of promoting integration, it is therefore important that the representative boards are multi-professional.

January 2014

Prepared 17th January 2014