Mr Gallagher (Deputy Chairperson)
Mr Berry
Mrs Courtney
Mr Hamilton
Mr J Kelly
Ms McWilliams
Ms Ramsey

Mr P Deazley )
Mr M Hendra ) Departmental Officials
Ms J Hill )
Ms J Thompson )

I welcome Mr Peter Deazley, Mr Mike Hendra, Ms Judith Hill and Ms Jennifer Thompson from the Department of Health, Social Services and Public Safety who will give us their perspective on the Bill.

Article 1 of the Health and Personal Social Services Bill removes trusts' ability to charge for nursing care as part of the cost of care in a nursing home. This removes an anomaly that people in nursing homes are the only people who are expected to make a contribution to health services. The article is quite short and amends article 36 of the Health and Personal Social Services (Northern Ireland) Order 1972.

What is the background to the Bill?

I should have said that article 1 also includes a new paragraph (4A) in article 36 of the 1972 Order, which defines nursing care for this purpose.

The introduction of free nursing care is a response to the recommendations of the Royal Commission, which produced its report in March 1999. The Royal Commission recommended free personal care, but the Government of the time felt that they could not meet the resource requirement to introduce personal care. The Government introduced free nursing care, partly as a response to the Royal Commission's recommendations but also to remove the anomaly that only those in nursing homes are expected to pay for their own care or to make a contribution towards what is considered to be a health service that is free in all other settings.

What is the position in England, Scotland and Wales?

England introduced free nursing care, using the same nursing care definition, from October 2001. Wales introduced free nursing care from December 2001, and Scotland plans to introduce free nursing and personal care in all settings from July 2002.

They are obviously taking different approaches to the issue.

Originally, we intended to introduce free nursing care here in October 2001, but the resources were not available. The Budget of September 2001 made available resources to allow us to introduce this from October 2002, at a cost of £4·5 million for this year and just over £9 million for a full year.

How many people in residential care would benefit?

We estimate that there are about 2,000 people who fund their own care in nursing homes in Northern Ireland. A detailed survey by the personal care group will be carried out in the next few weeks to establish in detail how many people fund their own care and the level of that funding.

I do not wish to detract from the importance of free nursing care: it will benefit about 2,000 residents. However, there is concern about the definition of "nursing care" and "personal care". Clause 1(1) of the Health and Personal Social Services Bill, which inserts a new article 36(4) into the 1972 Order, speaks of

"nursing care by a registered nurse".

The Committee assumes that trusts will inform people of their entitlements. When the Committee discussed the Carers and Direct Payments Bill it asked that that should be the duty of trusts, but I have concerns about people falling through the net. Some nursing home residents may need more help, and that could be defined as "nursing care"; therefore they do not fall into that category.

Homes in England are raising their charges, but not for the benefit of patients and residents. The Northern Ireland Registered Homes Confederation is concerned that the money it gets from the Department is less than that given to statutory homes, and, although I do not suggest that it would not pass on the benefits from increased charges, it is a concern that must be considered.

However, my main concern is the definition of "nursing care" and "personal care". Will the board or trust consider individuals' needs? After all, one person's "nursing care" could be seen as another person's "personal care".

Ms Hill is chairing the group that designed the assessment tool, and it has already been piloted. It will be applied on an individual level - there is no other way of doing it. The assessment will be carried out on the circumstances of each individual.

Will the individual be informed that he or she is entitled to an assessment?

Yes, and it will be an individual assessment. We are aware of the situation in England, and we are also aware of the publicity surrounding homes increasing their charges, now that nursing care is free. We will consider ways to avoid that, but it is an extremely difficult issue. Individuals are already self-funding care and are in personal contracts with nursing homes. It is difficult to differentiate between them; however, we will consider every possibility to prevent that.

It is our intention that, with departmental direction, trusts would be told that they must make all nursing home residents aware of their rights under the legislation.

What arrangements will be put in place to monitor the assessments once they have been carried out? Will they be monitored closely over time?

We have been piloting the tool, and we are developing a training programme to roll out its use. It is used on restricted sites in the statutory and independent sectors. Trusts and homes have been participating in that.

As the procedures, linked with the wider community care assessments under the assessment process, are set up we will put in place appropriate supervision arrangements to ensure feedback and monitoring of the effectiveness of the tool. That will happen at the University of Ulster, which is working with us in evaluating the use of the tool. We will make a judgement about whether we need to continue that evaluation through the first year.

Why, once again, does the Bill have a generic title? It is one of many Bills that will come under the term "health and personal social services". Has the Department a view on how a Bill that concerns free nursing care should be titled? The second part is probably the more difficult part. Increasingly, Bills are being added to and being given generic titles. For example, the title of the previous Bill on payments for carers of the disabled - the Carers and Direct Payments Bill - was changed to reflect its provisions. I hope that we can change the title of the Bill. Having started it, I would hate it if the Bill's title did not change.

What has been the experience of residential nursing homes in England since the introduction of free nursing care? There is now an obvious financial incentive for nursing homes; are people being admitted to a particular type of home as a consequence? What lessons have been learnt?

I met the confederation, and some of its members have welcomed those tools because they had nothing to go on for so long. We welcome the introduction of free nursing care, but we are enormously concerned about its practice. Evidence from Arthritis Care and the Alzheimer's Society in particular suggests that it would be especially difficult to distinguish between people with long-term illnesses on which aspects of their care are nursing and which are personal.

We have no experience of free nursing care in Northern Ireland, but it has been available in England since October 2001. We have only that experience to go on. Are people being shifted around the system?

There is very little evidence on the experience in England. However, Help the Aged and Age Concern have told us of an increase in costs. I have not seen evidence of people being shifted around the system or a tendency to use nursing homes more than residential homes.

There is a difference in the use of residential care between England and Northern Ireland. In England, the tendency has been away from residential care to concentrate on supported accommodation and housing with extra care. Statutory residential care is used much less in England than in Northern Ireland. The use of nursing homes in Northern Ireland is higher pro rata than anywhere else in the United Kingdom. We will certainly monitor the evidence and will consider what can be done to prevent a similar situation arising here.

Evidence shows that there is a higher use here of nursing homes than in England, Scotland and Wales. Can you provide the Committee with figures? It is obviously read-across, and there may be budgetary implications. Why is there a higher use of nursing homes here? What implications will that have for future Budget resources? Will this eat up a substantial part of our Budget in comparison with those of Scotland, England and Wales? Is the difference significant? Will it affect our Budget or is there simply a variation? Is it a historical legacy or do more ill people here require nursing care rather than residential care?

There are many reasons, but I can send the figures to the Committee.

In England, the distinction between nursing homes and residential homes has been removed. The term "care homes" is being considered instead. People will be placed in those homes and will receive the appropriate care, whether that be nursing care or residential care.

Is that an appropriate direction?

England has moved in that direction. I think that time will show that that is the preferred direction.

That is interesting, given that we are discussing legislation that will separate nursing care and personal care.

There has been a move to dual-registered homes, and this action would recognise that.

It is a pity that the legislation does not do that too.

Our legislation does not do anything to increase the divide between residential care and home care. A person in a residential home who requires nursing care will receive nursing care free of charge.

I know that. However, we are trying to define the term "care" and to establish a cut-off point. The term "care home" suggests that the service is more mixed than it is.

I am concerned about how this has been presented and its late introduction. I now have the opportunity to tell you what I have said on the Floor of the House. Resources were set aside for free nursing care in the Budget, but they were surrendered. You are on record today as saying that the resources were surrendered because the total funding was not in place. However, I think that the resources were surrendered because the legislation was not in place. I want to put that on record.

That is accurate. We could not meet the legislation timetable in the first round.

I hope that this does not reoccur. I must choose my words carefully. I am on record as saying that we must not lead the public into thinking that there was no money for free nursing care. In fact, having asked questions, I discovered that, at that stage, there was an initial funding package to introduce it. That package later had to be surrendered. We could have been more transparent about why free nursing care was not introduced. Lobby groups felt that their voices had been heard, whereas the Executive had not agreed the legislation and the dilatoriness of the legislation is one of the reasons why we are dealing with this at such a late stage compared with England, Wales and Scotland.

You are absolutely right. It simply slipped my mind when I detailed the chronology of the process that £3·3 million had been allocated for October 2001.

The Alzheimer's Society wrote to us on the matter. The assessment tool takes into account the physical, mental and social needs of people in care as well as those of their carers - it covers everything. The assessment tool will be submitted for consultation soon so that the Alzheimer's Society can examine it and give us its advice. It has been designed to consider all needs, including those of people with Alzheimer's disease or dementia, and it has been tested by these clients.

May the Committee have a copy of the assessment tool when it is published?

Absolutely.

Funding arrangements and the cost of free nursing care must be balanced against the likely cost of personal care, if the Committee were to support the introduction of free personal care. According to the explanatory and financial memorandum, the cost of free nursing care would require an extra £4·5 million between October 2002 and March 2003.

It has been assessed that the rates of funding set in England and Wales make only a contribution towards the cost and do not reflect the true cost of nursing care. What will the cost a year be over the next three years? How confident is the Department that the full year cost will be confined to the identified estimate? For example, £9 million has been estimated for 2002 and 2003. How far does the Department's estimated cost reflect the true cost of nursing care? Is there a danger that, once the process has been implemented, the cost will grow?

Our cost estimates were based on the most recent estimates from the work that was done in England, which estimated £85 per week per person towards the cost of nursing care. That was multiplied by the number of people who were funding their own care in nursing homes in Northern Ireland. The calculation of the total cost is based on 2,000 people multiplied by 52 weeks multiplied by £85.

Any of the factors in that calculation can change the cost. For example, if the number of self-funding patients increases or decreases, the cost will change. The Department does not think that it will vary significantly. A decision by the Minister to raise or lower the contribution would affect the cost.

Is there a danger that the cost will increase once the process has been implemented?

Only if the number of people who fund their own care increased disproportionately. The number of self-funding patients in Northern Ireland is substantially lower than the average for the rest of the United Kingdom.

How does one differentiate between the care given by a registered nurse as opposed to that given by a nursing assistant? In most nursing homes there may be only one registered nurse in charge - especially at night - and the rest of the staff may be nursing assistants.

What guidance will the Department provide? Will it involve further administration costs, as changes will cost the providers money? How strong a distinction will be made between the definitions of nursing and personal care?

Professionals have designed a detailed assessment tool with the assistance of the University of Ulster. The process has been designed to ensure that we minimise bureaucracy and the costs associated with it. Work has begun on guidance, which will be extremely detailed and will be issued for consultation with the assessment tool. There will be an intensive training programme for those who will use the assessment tool, and the owners of the private sector nursing homes will continue to be involved in that.

When will the consultation start?

The consultation document is being drafted, and we hope to provide the Minister with it by the end of this month.

You mentioned a figure of £85, which concerned me. I accept that the private sector is involved, and that the Department depends heavily on its accommodating a lot of people who require nursing care. However, if statutory homes are paid more per head than those in the private sector, are homes in the private sector likely in time to approach the Committee with news of imminent closure because the Department does not provide them with adequate finance to maintain the provision of free nursing care?

There are two issues. The key issue is not the level at which nursing care will be paid; it is a total fee structure that will be paid to the independent sector. As regards self-funders, who now pay the full amount for their own nursing care, the amount of money that the nursing home receives would not change. It would receive part of the weekly payment from the resident and the remaining contribution from the health trust. Therefore, the new arrangements should not impact on the level of income received by private sector nursing homes.

That does not take away from the fact that the Department relies heavily on homes in the private sector, which, at the minute, are being forced to close due to the level of funding that they are receiving.

That issue should be addressed by measures other than this legislation. For example, the Minister has made a further £3·6 million available to increase fee structures in the coming year.

Could you clarify the process that nursing homes in all sectors will go through? Ms Hill mentioned measures such as training, assessment and, at a later stage, monitoring. Will fees be in place? Nursing home owners told the Committee that they feel that they are paying a range of fees to different bodies for statutory reasons such as inspections and fire safety. Now, they must begin another process. I hope that the training necessary for the new arrangements will not be seen as a means by which many more homes will be forced to close. To adhere with the new arrangements, homes in the independent sector will incur costs.

They should not.

Ms Hill mentioned that all staff in those homes must be trained in the use of the new assessment tool.

The only cost will be for staff release, and it is dependent on whether homes have sufficient staff to allow them to release a number of them for training. Legions of assessors are not required; only a small number of personnel - to be determined through our discussions with representatives of the trusts and the nursing homes - will be trained. As the Department is providing resources for education and training, the main issue will be the costs involved in the release of staff. Most homes should already have a training and development programme for staff, and the Department will aim to fit in with that.

I agree with you that they should have, but even in the public sector, training and development is first to be cut when there are cutbacks, giving rise to concern that variation may occur in the implementation of assessment across the sector. Who monitors that? Will it form part of the inspection?

I am sure that it will be part of wider care-management activity. Self-funders do not come into that, but the process of assessment for nursing comes under the arrangements that trusts operate for care management. The relationship with the nursing home sector will be discussed with them, as representatives of the nursing home sector are on our steering group.

They have raised that point with me.

We will ensure that it is on the agenda of the next meeting of the steering group.

How does one appeal against an assessment of nursing care?

The health and social services have a procedure that deals with complaints ranging from the informal through to those that must come before a panel or board. That is the normal process. If people are unhappy with their assessment they can discuss the nursing care level at which they have been assessed. Once a decision has been taken, it will go through the informal and formal complaints procedure.

Is that adequate for elderly people who may become anxious going through such a process?

One important requirement of the assessment tool is the involvement of the nursing home resident and the carer, advocate or other individual who represents the resident at every stage of the assessment.

One hopes that if there were an appeal the necessary support would be available.

Let us now consider clause 2 and the schedule of the Bill.

It is proposed that a Northern Ireland practice and education council for nursing and midwifery be established. A major review of nursing and midwifery regulations was undertaken across the United Kingdom, resulting in the disestablishment of the United Kingdom Central Council for Nursing, Midwifery and Health Visiting and the four national boards for England, Scotland, Wales and Northern Ireland that had been responsible for setting standards for education and quality assurance. The new Nursing and Midwifery Council came into being on 1 April 2002.

The Conservative Government started the review before devolution. As we moved forward into devolution, we felt the need for a local organisation that would provide a focus for the development of professions here and link with the UK Central Council, replaced this month by the UK-wide Nursing and Midwifery Council, which is responsible for the registration of nurses and midwives. It gives them their licence to practise.

The changing nature of health and social services means that we need to continually develop both the roles and practice that our nurses and midwives undertake, and their education - beyond the point of registration. The purpose of this new local council is to support that development, so that we have a workforce that is shaped to deliver health and social care services in Northern Ireland, within the wider regulatory framework of the Nursing and Midwifery Council arrangements and registration. That registration gives protection to the public. The focus of the NI Practice and Education Council (NIPEC) is on the ongoing development of the professions in Northern Ireland.

We expect the new council to focus on practice development; on new things that nurses and midwives need to do; on the establishment of new knowledge and technologies; on developing the educational process for continuing professional development; on undertaking work on behalf of the Nursing and Midwifery Council in relation to pre-registration education; and on enhancing the performance of the professions. The third part involves attending specifically to the performance of nursing and midwifery services within our wider quality framework for the whole performance of the service.

We envisage a close and responsive relationship between the body and the service on the ground, which will shape the body's work. In that way, the body is alive and proactive in supporting the workforce and contributing to service developments.

As I said earlier, I struggled to find a short title that would accommodate this subject. The only one that I can come up with is "Nursing and Midwifery Council Arrangements Bill", which would be the second part of the Bill. We will revisit that, because it is important to name the new agency.

I find the description of the chief officer in the explanatory document amusing. This legislative language continues to insist that all of these people will be men. It states that the chief officer will "assist his Chairman". Given that we are talking about midwifery, nursing and health visiting, that type of language never ceases to amuse me. However, we must live with this language until such times as the drafters elsewhere decide -

That is why the men do not like the word "matron".

Ms Hill, has this difficulty been resolved? I remember receiving some material on it much earlier when health visiting was being debated elsewhere. The health visitors in particular raised the issue that they somehow have got lost in here. How have you resolved that as you have taken this consultation forward?

We have resolved it in matching it with the title of the Nursing and Midwifery Council. There was considerable debate about this as that passed through Westminster. The Community Practitioners' and Health Visitors' Association recognises that the role within community practice and public health is developing fast. Therefore, the need to support that, through recognition in an additional part of the register, was seen as important.

That was seen as something that includes not only nurses and health visitors, but other community nursing disciplines. I was not present during the discussions, but I hope that I am reporting accurately that health visitors, through that association, recognised that the additional part of the register allowed further development in public health - to which nurses, midwives and health visitors contributed. They felt that that was the trade-off to keeping the title succinct at nursing and midwifery.

However, there is a separate part of the register for health visitors, and an additional part enables the development of new roles in public health and community nursing. The multi-professional team that we want to develop in primary care will have different elements that can and cannot be registered. That was the difficulty in community nursing; it created team difficulties.

It was a difficult discussion, but in the end it was agreed that, with additional changes to the register, health visiting was secured. The opportunity to develop new roles was also secured and was seen as important for other community practitioners. We have maintained that approach and kept nursing and midwifery as a succinct title. However, we recognise that we are dealing with all registrants to the Nursing and Midwifery Council.

Are health visitors consulted with in Northern Ireland? Are they satisfied now that this is the way forward?

The information has been sent out, and we have provided regular updates.

We have received feedback on the consultation process, and people have been informed that this is the title. We have not had any further challenge.

We have not had any comeback or opposition.

When the title was initially discussed, health visitors felt that they were being sidelined, as they were not to be included in the title. Members were asked to lobby MPs and write to Westminster prior to the debate, and I lobbied on their behalf. I heard nothing from Westminster to say whether it had been accepted. The view of many health visitors is that they may have received the information locally, but it is not what they originally set out to achieve, which was to ensure that health visiting was still included in the title and that they were entitled by right to a place on the board. That was not clarified at that stage. It is stated somewhere that 60% of health visitors will be registered. Does that ensure a place for health visitors on the board?

We have not designated any places for the registration titles, because we were keen to have as wide a membership as possible and for the membership to be based on the merit of individuals and on their ability to contribute to a corporate council as opposed to giving seats. There are relatively few seats for the professionals, and we need to have a broad spectrum of input. We expect people from primary care and community nursing across the disciplines to be members of the new council, but there is no designated seat for a midwife or health visitor. To that extent there is no designated seat for a nurse, but we expect to have the full range of registrants as members. The shadow chairperson of the council is a health visitor.

I am confused. Would it be possible to get clarification on the point that health visitors in Northern Ireland are satisfied with the debate? I have my doubts about some of them getting that feedback and being allowed to put forward their views again.

We will look into that.

What are the costs?

We have an estimated budget of about £1 million for the new body. Funding will come from the money that was available for the national board, which is being stood down from 31 March, but it is less than the funding that the national board received. The body will have a core staff of professionals, but it will bring people in and out from the service on secondment as part-time associate members or members of expert panels to develop the initial work of the body. As the body develops its own role, agenda and profile in the service, it will be able to bid for more moneys to build up its budget.

I would like to thank you for your presentation and for getting the Consideration Stage of the Bill off to a start.

6 March 2002 /Menu / 17 April 2002 (i)