Ms Jenny Mudge
Health & Social Care Joint Unit
Department of Health
Room 215 Wellington House
133-135 Waterloo Road
London
SE1 8UG
15 July 2002
Dear Ms Mudge,
The Registered Nursing Home Association, uniquely, is the only national association which represents the interests of nursing home owners. Formed more than 30 years ago, in 1968, we have considerable wisdom and knowledge on those matters which are specifically pertinent to the provision of nursing home care. I know I can speak with confidence on behalf of our 1500 members, which in percentage terms equates to 25% of all homes which will be affected by this amendment
On behalf of the Registered Nursing Home Association I am pleased to respond to the consultation document on the amendment to the Care Homes Regulations 2001.
We are, naturally, disappointed that the first amendment to the Regulations should be of such a persecutory nature. We believe that it is totally inappropriate for Government to inflate, out of all proportions, the issue of transparency in relation to the payment of a contribution towards the cost of nursing care. In many cases this payment accounts for no more than 7.5% of the fees payable. The proposals have, rightly, been expressed as being a ‘sledge hammer to crack an egg’
This amendment, together with the reticence on the part of PCTs around the country to agree any payment towards the administration costs of the extra burden of dealing with payments for the nursing contribution, gives the wrong message to a beleaguered long term care sector. This action continues to undermine the confident of the sector and will lead to further lost capacity.
I enclose a detailed response to the consultation document.
Yours sincerely
Frank Ursell
Chief Executive Officer
Response by the Registered Nursing Home Association
to the Consultation on the Amendment to the Care Homes Regulations 2001
Introduction
The Registered Nursing Home Association believes that the proposed amendment of the Care Homes Regulations 2001 is unnecessary, ill timed, inappropriate and, with the exception of the proposed sub paragraph (6), does not address the ‘Issue and Objective’ outlined in the Partial Regulatory Impact Assessment, it should therefore be scrapped.
The acknowledged cause of the perceived need for this amendment is the Government initiative of introducing NHS funded nursing care to patients in independent nursing homes. This initiative was poorly constructed and was introduced in a manner which was in direct contrast to the advice offered by the Steering Group, of which the Registered Nursing Home Association was a member, set up by the Government to advise on the implementation of such an initiative.
Whilst the Registered Nursing Home Association continues to have considerable reservation over the financial value placed upon the NHS contribution to nursing care, this response is focussed upon the advice by the Steering Group on the logistical arrangements for that payment.
The Steering Group recommended a single band payment which should be made direct to the individual. Such an arrangement would have been efficient to administer and would have saved the transaction cost of the assessment, management and payment of NHS funded nursing care.
It would have had the additional advantage of providing individuals with a clear understanding of the financial support available from the government for the payment of NHS funded nursing care.
The requirement by the Government for PCTs to enter into a contractual arrangement with nursing home providers adds to the transaction costs and creates an unnecessary additional burden for providers, with the likelihood of confusion over the various parties to the contract for the provision of care. It would have been sufficient for nursing home providers to invoice PCTs for the assessed amounts.
In order to explain more fully our concerns over these proposals it is necessary to address the Partial Regulatory Impact Assessment. This is particularly relevant because there are, in our opinion, a number of inaccuracies and misrepresentations which compound to give a false impression of the validity of the argument presented.
Partial Regulatory Impact Assessment
Background
Prior to the 1980s it was common place for nursing homes to express their fees on a menu format. ‘Hotel costs’ and nursing care formed the basis of the fees to which were added additional costs such as incontinence products, single rooms, chiropody, even laundry in some cases. There was pressure during the 1980s for fees to be expressed as ‘all inclusive’, the sector responded and this route quickly became the normal method.
It is against this background that the long term care sector now expresses its fees on a weekly, all inclusive basis which is easy for patients, relatives and commissioners to understand.
This change was welcomed by patients and their representatives and we believe that it may well be seen by these people as a retrograde step to require nursing home fees to return to a menu format. Further, it is futile to do so on the assertion that this is for the benefit of the service users when there is no suggestion of introducing a standard format of expressing the various aspects of the nursing care provided, which would be necessary in order for comparisons to be made between alternate providers.
Issue and Objective
Regulation 5 already contains a requirement for provides to make service users aware of the fees they are expected to pay. The only omission is any requirement to identify any payments from other sources. It is significant to note that the proposal only identifies a Health Authority and does not include any other ‘other sources’ specified in the Objective.
Options
The Registered Nursing Home Association believes that Option 1 is satisfactory and that there is not a need for an amendment.
There is genuine and widespread distrust of the regulator having access to the financial information which, in normal businesses, is considered to be commercially sensitive. The Registered Nursing Home Association argues that even in its role as regulator, there is not sufficient evidence to suggest that there is a need for such intrusive powers in order to protect the interests of vulnerable persons.
With a change in the regulator, to the National Care Standards Commission, already having an affect on providers, any additional potential conflict between provider and regulator is to be avoided.
The inference in the explanation of Option 2 that “many care home owners have not been open about their fee arrangements” is a scurrilous slur on the sector in general and nursing home owners in particular and is refuted.
The Registered Nursing Home Association believes that the statement “it is clear that providers would not have been complying with minimum standard 2 if this had been in place before 1 April” is inaccurate and misleading. As such, it has no place in an official government document and should be retracted.
Standard 2 requires, in relation to financial matters, inclusion in the statement of terms and conditions of:
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“fees payable and by whom (service user, local or health authority, relative or another) additional services (including food and equipment) to be paid for over and above those included in the fees”
It can be seen that the minimum standard actually goes further than Regulation 5 and includes the requirement now to be found in the proposed sub clause (6)
The various statements made in the further explanation of Option 2 are considered to be political in nature to defend the inefficient manner in which NHS funded nursing care in nursing homes has been introduced. It has no place in this document.
Issues of Equity and Fairness
It is difficult to understand the purpose of this section. It seems to be saying that providers who are not complying now with Standard 2 are “getting away without meeting them”- which is a ‘policing’ issue. Changing the regulation will not, of itself, change the policing of the standard.
The section is superfluous.
Identifying the benefits
There is no genuine comparison between the options, simply a repetition of rhetoric. Policing of standards is what ensures compliance, not changing the regulations.
Quantifying and Valuing the benefits.
Option 1
It necessarily follows that as Option 1 is the ‘no change’ option there will be no additional benefits to the service user. However, history will record that these changes to the Regulations are perceived by the nursing home sector as a ‘knee jerk’ reaction by the Minister to a problem of the Government’s own making.
To adopt Option 1 would be seen by the sector as a statement of intent, a willingness to work with the nursing home provider in a collaborative manner and would begin to address the perceived under mining of the value of the independent nursing home sector and go some way towards restoring confidence. In this context it would have immeasurable value.
Option 2
This significantly distorts the truth. Each patient who qualifies for assessment under the NHS funded nursing home care initiative will be provided with a statement from the funding PCT as to the band assessed and the fee which will be paid. There is no lack of information or misunderstanding.
The references in Option 2 to the costs of nursing care continue to be fallacious and unnecessary. It is not doubted that upwards of £14,000 “can represent a significant annual commitment”, but £14,000 pales into insignificance when it is compared with the cost of providing similar nursing care in an NHS long term ward at £64,000 per year !
There is an inappropriate linking between the costs met by providers and the fees payable. The Registered Nursing Home endorses that there should be a transparency between fees set. However, where there are increases in costs there must be corresponding increases in fees or the nursing home will close.
There is even more discrepancy between the banding levels assessed by PCTs than there is between what individuals can expect to pay. In the West Midlands the average percentage of the higher band assessments was 24%. In Worcestershire they recorded 12% at the higher band and in Shropshire 48%. On a percentage basis, twice as many patients in Shropshire received the maximum payment than in Worcestershire.
Business Sectors Affected
Whilst our observations may be purely academic, of the various totals of homes quoted, only the 5,900 care homes providing nursing would be affected. Nursing care to the other homes is provided either by the District Nursing service or by Practice Nurses.
Conclusion
It is difficult to determine what advantage will be achieved from this amendment other than to continue to indicate to the nursing home sector that it is suffered only because it is a ‘necessary evil’
It is perceived that the intention is to require nursing homes owners to give a cost by cost analysis of how the nursing home fee is made up. In an industry which is already over regulated this is yet another onerous requirement which will attract a transaction cost but offer nothing by way of additional benefit in the care provided.
More pertinently, the lack of sensitivity displayed by Government, both in this and in other regulations concerning financial viability over the confidentiality of fee levels, the relationship to costs is incomprehensible. Is a hotel required to give a breakdown of how its fees are determined ? Should Virgin Trains be required to give an analysis of how rail fares are determined to every purchaser of a rail ticket ? If not, why not ?
This lack of sensitivity is compounded by giving to the regulator a responsibility for inspecting this aspect of the provision of care by including it in the regulations. The relationship between provider and inspector is already strained, in many cases this will be simply be a short route to confrontation.
If greater detail of how fees are determined is the objective, and if compliance to the proposed new amendment can be achieved by the following extract from a model contract, then, as no detailed information is imparted, one must question what advantage has been gained:
a) The fees payable are £459 per week payable monthly in advance by the service user, or any other person authorised by the service user and duly agreed by the provider.
a) Such fees include all accommodation, including the provision of food, nursing and personal care which shall be provided at (any) nursing home.
a) The facilities and services provided will be as indicated in the service user’s guide.
a) Any payment received from (any) PCT on behalf of the service user will be discounted against the next payment due. Any adjustment necessary will be qualified.
a) One month’s notice will be given in writing of any proposed increase in fees or changes to the facilities and services included in the service user’s guide.
Finally, should it become necessary to give an analysis of our fees to service users we will, of course, be able to identify and make transparent exactly what our costs are in relation to the Government’s contribution to NHS funded nursing care. Those costs will be the real costs of providing nursing care as opposed to the falsely limited definitions used by the Government which have resulted in the derisory bands of £35, £70 or £110 per week.
Frank Ursell
Chief Executive Officer
16 July 2002
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