Edition No. 3 - February 2001

Introduction

Work has continued in determining the manner in which the nursing care provided by a Registered Nurse in a nursing home can be evaluated. There have now been a total of three Stakeholder Group meetings and one full day and one half day of Work Group sessions involving a wider group of practitioners and other interested parties.

There is no doubt that the Government is committed to creating a process for identifying and evaluating the care provided by a Registered Nurse in the nursing home setting. The mechanism for applying that process still gives some cause for concern, as does the way in which it will be funded.

Workshop - Who Pays for Nursing Care

Rosemary Strange and Frank Ursell were invited to attend a work group held on Wednesday 20 December 2000 to address the challenge of determining a way to place a financial value on the cost of care provided by a Registered Nurse.

The Deputy Chief Nurse, Gillian Stevens, chaired the day and she started by saying that the group was working within two overall common aims, which she identified as being:

• Promoting independence;
• Better integrated services through joint working.

She then outlined what she described as being, the ground rules for the day. These were:

• We would not be revisiting the Government's response to the Royal Commission report;
• The role today is not to develop a brand new assessment process;
• The work will be undertaken in syndicates and although there is limited time for debate in plenary sessions, points recorded on the flip charts will be retained for use by the Department.

Raymond Warburton, of the Department of Health, then gave a policy overview which he started by identifying that the current funding process was confusing and frustrating for all, users and providers alike, due to its piecemeal evolution.

He then went on to pick out those parts of the NHS plan which were pertinent to today, in particular identifying:

• Determining nursing input
• Determining cost of nursing needs
• Determining individual need

Raymond Warburton said that the National Service Framework for Older People, which is in its final stages of agreement prior to publication, will provide a significant improvement on bringing together all of the loose ends in relation to the piecemeal evolution of funding and provision of care. He added that because the NSF for older people has not been finalised and published he had to be careful in his reference to detail.

Hazel Heath, an independent consultant on nursing matters, has been commissioned by the Department of Health to create a framework for the evaluation process and she then outlined the preliminary work she had undertaken.

In essence Hazel Heath had brought together various commonly known factors which could be used as indicators to determine the specific nature of the care provided to an individual such that the care which was the responsibility of the Registered Nurse could be identified and, thereby, valued.

The remainder of the day was spent in work group sessions developing the evaluation process introduced by Hazel Heath. There were about 20 people in each group, together with a co-ordinator from the Department of Health.

As was only to be expected there was a great deal of concern expressed that we were working, to a large extent, in the dark in the absence of any knowledge of the content of the National Service Framework for Older People.

There were two plenary sessions at which the work of each group was shared with the remainder of the delegates. It is difficult to give a concise report of these results as they really are little more than suggestions. There were a large number of civil servants from the Department of Health present who were able to benefit from the wide ranging knowledge that was collected together in the form of all the individuals attending the work group.

The work group met for a further half day session on Thursday 8th February when a revised version of Hazel Heath's evaluation form was considered. This revision introduced three bands of nursing need, low, medium and high. Concern was expressed that this was likely to cause more confusion for patients who were identified as needing nursing home care, but then only a 'low' category of Registered Nurse attention.

National Service Framework for Older People

There is a great deal of public interest being displayed in the principle embodied in this work, but very little real detail has been disclosed, not even to either the Stakeholder Group or the Work Group.

What has become apparent from the debate at the respective meetings is that the National Service Framework for Older People appears as if it will introduce an overall assessment process for every individual as a 'right'. That assessment will arrive at a conclusion, or 'statement of need'. The work being undertaken in relation to who pays for nursing care follows on from that conclusion, or statement of need.

Where the conclusion is that a person is in need of accommodation in a 'registered care home' (new all embracing title introduced by the Care Standards Act) then there will have to be a further - and here there has been a great deal of care taken to ensure that the word 'assessment' is not used again - determination of the value of the Registered Nurse input to that accommodation in a registered care home.

In the absence of the publication of the National Service Framework for Older People there are more questions than answers in such information as is available.

It remains an issue of some concern that all of the major national representative associations, including R.N.H.A., had written to the Minister on the announcement of the formation of a group to determine the National Service Framework for Older People offering their assistance. That offer, by everyone of us, was declined by the Department of Health. It appeared to reaffirm at the time that, despite all the expressions of intention of joint working, our expertise in looking after 500,000 older people was not required by the NHS who, one presumes, believe they know better.
Where will the money come from ?

One of the questions which will have to be addressed lies at the very hear of our current difficulties. That question is what compulsion will there be on social services (if they are to be responsible for the National Service Framework for Older People) to provide a package of care which is consistent with the result of their assessment ?

There is widespread evidence around the country that in every hospital there are beds blocked by people at various stages of the assessment process, but who, in the main, could be accommodated elsewhere than in hospital. It is interesting to note that the emotive term 'bed blocking' has been replaced in Department of Healths speak by 'delayed discharge'.

The Stakeholder Meetings

Once the process for evaluating the specific cost of the care of a Registered Nurse, the next step will be the logistics of making the payment. This issue has already been raised within the Stakeholder Group and there is a growing level of support for some form of standard 'nursing grant' for older people who are identified as being in need of nursing home care.

Although there is support within the Stakeholders for such a 'nursing grant' this is not, at present, meeting with the approval of the Department of Health. It is the Minister's stated intention that the whole purpose of the process is to identify the specific nursing needs of individuals and to place a monetary value on that need.

The pragmatists amongst us have been trying to discover what effect the three categories of nursing care will have on overall fees. If there is, for example, a ?30 difference between low and high nursing care does this mean that Social Services will have to meet the difference. If so, what will Social Services get for ?30 more where there is a 'low' nursing care evaluation ? Will this lead to Social Services setting a fee they will pay for the 'social 'aspects of nursing home care and expect the NHS to meet the other costs ?

It has already been confirmed that, at present, there is no intention to introduce 'new money' into the equation. There is very genuine concern amongst the various Stakeholders that there is still a long way to go in addressing the practicalities of the proposals. On the positive side, however, is the fact that the Government is working hard on this issue and we are confident that the commitment to securing a solution will, at the end of the day, ensure that there is an improvement in the way in which nursing home care is provided and funded.