Mr Gallagher (Deputy Chairperson)
Ms Armitage
Mr Berry
Rev Robert Coulter
Mrs Courtney
Mr J Kelly
Ms McWilliams
Ms Ramsey

Prof R Stout ) Department of Geriatric Medicine, ) Queen's University Belfast

I welcome Prof Robert Stout from the Department of Geriatric Medicine at Queen's University Belfast.

Thank you for your invitation. I will talk specifically on free nursing care for the elderly and not on the other parts of the Bill.

I am Professor of Geriatric Medicine at Queen's University, and my clinical and academic interests concern the healthcare of elderly people. I was a member of the Royal Commission on Long Term Care for the Elderly, and some of my proposals come from its recommendations.

The Labour Government set up the commission after coming into office in 1997, honouring a manifesto pledge. There was much resentment in the community among elderly people and their relatives about the system that existed then, and still exists in Northern Ireland. There was a great sense of a betrayal of elderly people. The current generation of elderly people has lived through the history of the National Health Service, and they paid their taxes in the belief that they would receive free health care from the cradle to the grave. However, they found that when they became elderly and needed extra help, they were asked to pay for it. They were even asked to sell their homes to pay for care, and that caused resentment.

To some extent that sense of betrayal was a misunderstanding of the difference between healthcare and social care. Healthcare has been free since the onset of the National Health Service, apart from some charges. Social care has never been free; social care is paid for unless the person is unable to afford it, and that is demonstrated by a means test.

However, there was some justification for the sense of betrayal. In the 1980s there was a change in policy that moved some of the care of the elderly from healthcare to social care. A change in social security regulations allowed nursing homes to charge social security for the care element of looking after people in nursing homes. That was introduced as a change in regulations without any debate in Parliament or electoral manifestos. It was almost introduced by sleight of hand.

At the same time money was becoming scarce in the Health Service. It saw an opportunity for removing large numbers of elderly people from the health budget - people who had previously received free long-term care in hospital. Those people went to nursing homes, and unless they fell below the lower limits of the means test, they had to pay for their care according to their means, and some people had to sell their homes. Resentment built up against that.

The Royal Commission was set up to examine that issue, and its main remit was to recommend a new system of funding long-term care that would be seen to be fair. The commission spent a year taking evidence from different groups. It asked for written evidence and received 1,600 letters - many of them handwritten - from older people or their relatives, expressing a sense of resentment and betrayal from the current system. The report was published in 1999 and the Government took a long time to respond to it.

There were two main elements to the funding recommendations. First, after considering various types of funding, including private insurance and social insurance, the commission recommended that long-term care should continue to be paid for out of general taxation. The reasons were that taxation is progressive, pensioners pay tax if they earn enough, and as it comes out of general Government income, flexibility is built in. For example, if a drug became available that was effective against Alzheimer's disease, money could be moved to increase the drug budget and reduce the long-term-care budget.

The other question was: what should be paid for? The Royal Commission examined long-term care and decided that it could be divided into three elements. The first element was accommodation - the roof over your head: everyone has to pay for that. There is no reason why those receiving long-term care should not continue to pay for accommodation, and if that meant that they had to sell their homes to pay for it, that was the same as anyone moving home, where they sell their previous home and they put the money into the new one.

The second element was ordinary living costs, such as food and clothing - the items that everyone has to pay for. The Royal Commission recommended that people requiring long-term care should continue to pay for those items.

The third element was the additional care that people who are dependent or disabled need to look after themselves - in other words, the requirement for long-term care as opposed to continuing to live independently at home. The Royal Commission recommended that that should be paid for out of taxation. The accommodation and the living costs should be paid for by the individuals, with a means test being applied as before, and the personal care costs ought to be paid for by the state.

The commission felt that the state ought to pay for personal care because when one considers the need for long-term care, it is not an inevitable consequence of growing old. Long-term care is required because of the effects of a disease or a combination of diseases. Those diseases attack people at random. About 20% to 25% of people aged 65 and over require long-term care, but it is totally by chance whether any individual is within that 25%, or in the 75% who do not need it. It is a considerable risk, but one that should be insured against. The commission felt that it was the type of risk that the community as a whole ought to take on board. The main recommendation of the Royal Commission was, therefore, that the personal care element of long-term care should be funded, after assessment, to ensure that the person needed that type of care, and that accommodation and living expenses should continue to be paid for by the individual.

The total cost for that arrangement for the UK as a whole at that time was around £1·1 billion, which is a considerable sum of money. However, it is clearly affordable. At the last Budget, the Chancellor of the Exchequer had £10 billion to give away. He was supposed to have had a war chest of £17 billion at the last election. Therefore, it is purely a political question as to whether it should be spent on this issue or on something else.

I am not opposed to the provision of free nursing care, which is being advocated in the Bill. However, I believe that that system is both unworkable and unfair. It is unworkable because someone has to come up with a definition of nursing care and a definition of what is non-nursing personal care. That is a difficult thing to do. There are many types of personal care that nurses provide that can also be provided by care assistants. The definition that has been offered is that nursing care is care that is given by a registered nurse, or under the supervision of, or delegated by, a registered nurse. In the case of a care assistant who provides care in a nursing home where a registered nurse is employed, that care would be free of charge; but the same type of care provided by a care assistant in a residential home or in the person's own home would have to be paid for. That seems to be a totally unworkable definition.

The second reason for my opposition to the funding of nursing care rather than personal care is its unfairness. It depends on the disability whether or not one receives free care. An old person who has cancer or a serious heart disease will usually need treatment from the Health Service and will often need hospital treatment, which will be free. An old person with Alzheimer's disease will not usually need hospital treatment, and only in the most advanced stages will he or she need a registered nurse. However, people who have Alzheimer's disease require a considerable amount of care and help with dressing, feeding, bathing, mobility and orientation. Yet Alzheimer's sufferers have to pay for that care. Cancer patients do not. That type of diagnosis-related rationale is unfair.

I also believe that free nursing care would introduce a perverse incentive into the system, in that nursing homes may be subsidised. Nursing homes by definition must have registered nurses on their staff, whereas residential homes do not. That may mean that nursing homes will be cheaper than residential homes and, inevitably, that will lead to a tendency for those who are paying the bills to ask people to go into nursing homes. The principle of long-term care is that people are cared for in the least-dependent environment - at home if possible. If care cannot be provided at home, it should be provided in the least-dependent institution. We are trying to promote as much independence as possible. If the nursing home sector - the most-dependent sector - becomes cheaper, that situation has the potential to reverse the whole policy.

I ask the Assembly and the Executive to re-examine the matter, and to consider the possibility of introducing free personal care for elderly people, as was recommended in the Royal Commission report and as is being introduced in Scotland. The strange situation has arisen that Scotland is a more favourable and fairer place than England for those elderly people who are unfortunate enough to need long-term care. It is to be hoped that Scotland does not end up being a fairer place than Northern Ireland.

Thank you for your clear submission, Prof Stout. Members may now ask questions.

In relation to personal care being funded, what would be the estimated cost to the public purse? Would that cost rise steeply as the elderly population continues to grow? Are there better ways of using resources to help the elderly?

I do not know the cost for Northern Ireland. The figure for the UK in 1995 was £1 billion. That is the total cost, not the net cost. There are savings to be made from existing systems that will affect that figure.

The Royal Commission on Long Term Care for the Elderly considered carefully the question of a rise in the cost of personal care as the number of elderly people is predicted to increase. The commission was asked to predict what was likely to happen over the next 50 years, which is a long time during which all sorts of things can happen. The number of elderly people is set to increase, because everybody who is alive today will be elderly in 50 years' time. Two factors are unknown, one of which is the future health of elderly people. Will the need for long-term care decrease as the health of elderly people improves over that period of time? The trend so far suggests that that would be the case. There will not be more elderly disabled people. What seems to be happening as the population grows older is that the onset of disability is postponed, although that trend is not quite confirmed.

The other unknown factor is the extent of informal care given by unpaid relatives and friends who have no professional training. A huge amount of that informal care is currently given. There are changes in society that will militate against that situation, such as both partners in a marriage being out at work, marriages breaking down and factors of mobility and so on. All these factors seem to be putting pressure on the provision of informal care. However, we do not know what will happen in the future. The effect of these pressures has been felt over the past few decades, yet informal care is a strong element in the care of elderly people. The Royal Commission estimated that if the Government had to take over the cost of informal care, it would amount to £30 billion. Those are unknown factors. However, if we assume that present trends will continue, the cost of providing long-term care as a proportion of gross domestic product will not change over the next 50 years. The Chancellor estimates that the economy will grow at a rate of 2·25% each year - about the same rate as the increase in the number of elderly people. Although it is said that £1·5 billion will increase to £6 billion in so many years' time, that is purely inflationary, and as a proportion of the economy of the country does not seem to be changing.

The third question concerned how money could be put to better use. It is a matter of opinion as to what is best use. There is no doubt that many other areas require money, but it is a question of where priorities are placed.

Alan Milburn's explanation for funding only nursing care and not personal care is that additional money was used for other services, which are known as "intermediate" care in England. Intermediate care is a requirement in England, because in the past couple of decades rehabilitation services for elderly people have been virtually removed from hospitals. Fortunately, that has not happened in Northern Ireland, so there is less need for intermediate care here.

One argument is that much money would be spent for the same care that exists at present. My answer to that is that correcting an injustice is a good use of money.

Thank you for your excellent analysis, with which I agree. Could you elaborate on the experience in England, which I am sure you are familiar with, and on the point that this scheme might prove unworkable? It will help us to anticipate problems, should this legislation proceed.

How can nursing care be tested separately from personal care? The Committee received evidence last week from departmental officials, who informed us that they have a tool that does the testing, and which is being piloted at the moment. It will be put out for consultation at a later stage. Have you been involved in the development of this tool to test nursing care, and what is your analysis of it?

I have not been involved. I was invited by the chief nursing officer to be part of a working group that was planning to develop a tool, but I informed her that, in principle, I was not enthusiastic about that plan. So I have not been involved and I am not familiar with the tool. However, I would be interested to see the results of the pilot studies. If the tool works, I would be delighted, but I believe - and that belief is shared by the Royal College of Nursing - that it would be extremely difficult to decide what is nursing care and what is not nursing care.

There used to be an old debate - you may be familiar with it - about what a social bath is and what a health bath is. We might be asking the same type of question when trying to work out what is nursing care and what is not nursing care. Hospital nurses, for example, give total care. It is a highly technical type of care, but it is also personal care. The Royal Commission defined personal care as care that involves touching people - intimate care. However, much of that can be done by staff who are not registered nurses. It would also depend on whether a nurse is available.

I believe that we should try to keep elderly people in their own homes as much as possible, which would involve domiciliary care packages, most of which could be given by care assistants. Currently a charge is made only in certain local authorities in England, so charges can be made.

There are certain tasks that are clearly defined as nursing care - for example, management of intravenous fluids and naso-gastric tubes, administering injections and so forth. However, there are some tasks that any caring person could do, which are clearly not nursing tasks. There is a large group in the middle that would be difficult to define, and I can see appeals and complaints arising out of attempts to differentiate between them.

I have heard only indirectly what is happening in England. I am aware through the general press and the medical press that when free nursing care became available, nursing homes simply increased their fees, taking the original fees plus the free nursing care.

The Government are trying to come up with legislation to stop that. Perhaps the delegation appearing after me from Age Concern might have more information on what is happening in England, but the general message that I receive from colleagues in England is that the system is proving difficult to work.

Thank you for your lucid presentation. I agree that people born in the welfare state expected that that would last from the cradle to the grave. The sense of betrayal arising from that is potent. Why were you opposed to becoming involved in the pilot scheme?

Having spent an intensive year with the Royal Commission and having discussed all these matters in great detail, I feel strongly that the introduction of a partial system that funds only nursing care and not personal care is not the correct path to take. I wanted to be free to speak openly about that issue.

What is your response to the argument that free personal care for all, regardless of means, would transfer income to the better-off at the expense of the more needy? Is the approach socially equitable?

I have several answers to that question. First, any universal benefit will benefit the well-off and the needy. That applies to healthcare, education and other areas.

Secondly, the current upper limit of the means test is £18,000, which recently increased from £16,000. That covers total assets, including the value of a home. Many people have assets of £18,000 and more. The Royal Commission report contains a table that indicates the levels of income of elderly people who could not be described by any stretch of the imagination as being wealthy. People go over a cliff at £18,000. If they have £17,999, they pay a relatively small amount; however, if they have £18,001, they pay the whole lot - about £400 a week. Although there may be some wealthy people among those, many people who are by no means wealthy will also be included.

Thirdly, the payment of benefits is only one part of the equation, the other part of which is tax. Wealthier people pay more tax. The tax system could be altered in ways that would claw back that amount of money if necessary, so one would not have to rely on a means test with all its inherent problems. Although there is some truth in that assertion, it is not a powerful argument.

Prof Stout has already answered my question in reply to Monica McWilliams's question, when he said that medical evidence from England had given him the impression that nursing homes might inflate their fees and that consequently a resident would be no better off. I was going to ask if that would be a possibility - whether what is happening in England could also happen here?

I suspect that it could. There is no question that the nursing home sector is currently under considerable financial pressure. A serious concern is that nursing homes are closing at a time when the need for them is increasing. We cannot be critical of nursing homes for looking for extra incomes; some of them are in serious financial difficulties. However, that is not what the system was intended to do.

Your presentation has made the Bill easier to understand. As members of the Committee, we carry out inquiries into legislation, and we take evidence from people with an interest so that the Committee can come to a decision whether it supports, rejects or possibly would like to amend the legislation through the Assembly.

I have several concerns, some of which you have outlined. Last week I asked the Department for its definition of nursing and personal care. In my own mind, I could argue that what is seen as personal care is actually nursing care.

The Committee is being told that the Bill is intended to introduce free nursing care, while the working group that you have mentioned is considering the issue of personal care. It is due to report on that in June 2002. In the light of your concerns, would it be right to go ahead with the Bill while waiting for the recommendations of that report? Last week the Department told the Committee that at present 2,000 people pay for their nursing care. Although that appears to be unfair to some, it is also unfair to others.

Although the Bill does not go far enough, would it not be easier to implement it and then build on it? Parties are represented on the Executive. The Assembly can, therefore, build a campaign to ensure that the Executive provide money to introduce free personal care as well as free nursing care. I am concerned that what will be seen as an injustice to some will also affect others. What should the Committee do - cut off its nose to spite its face?

The working group that you have just mentioned, which is examining personal care, is not the one that I referred to earlier. I was referring to the working group that was set up by the chief nursing officer to consider the definition of nursing care. I am aware of the other working group, but I am not a member of it and have no knowledge of its activities.

You have made a valid point. There is no question that the introduction of free nursing care will improve the present situation. At present there is an anomaly: nursing care provided in a hospital is free; nursing care provided in people's homes by community nurses is free; but nursing care provided in nursing homes must be paid for. The Bill will correct that anomaly, and that will be an improvement. To some extent, it is a matter of tactics.

However, I am concerned that if the Bill were passed, pressure might be taken off the Department. It might think that because it has dealt with the problem of long-term care it does not, therefore, have to address it again. It takes some time for legislation to be developed and progressed. There might be higher priorities in legislation. At present, many consultation documents are being circulated within health and social services that will require action. Passing the Bill, and hoping that personal care will be dealt with later, could mean that it is never dealt with. However, the Committee is better able to judge that matter than I am.

That concludes the questions. Thank you for your helpful submission.

17 April 2002 (ii) /Menu / 24 April 2002