Members present:

Mr Berry
Rev Robert Coulter (Acting Chairperson)
Mr J Kelly
Ms McWilliams
Ms Ramsey
Mrs I Robinson

Witnesses:

Mr P Deazley )
Mr M Hendra ) Department of Health,
Ms J Hill ) Social Services and Public Safety
Ms J Thompson )

The Acting Chairperson: We are glad that officials from the Department have come to meet the Committee. I would like to welcome Mr Peter Deazley, Mr Mike Hendra, Ms Judith Hill and Ms Jennifer Thompson. We look forward to hearing your comments on the Bill, and then we will have questions for you.

Mr Deazley: Clause 1 amends the Health and Personal Social Services (Northern Ireland) Order 1972, removing any charge for nursing care from residents of either statutory or independent residential nursing homes. Paragraph 4A gives the following definition of nursing care:

Ms Ramsey: I would like it to be on the record that the Committee has raised concerns about separating nursing and personal care. I do not want to sound negative, because this is a positive step, but people have concerns. You have heard from individuals, Age Concern and the Belfast Carers’ Centre. We must raise concerns with you from the outset, but we must also note the Department’s constraints, particularly financial ones. We have heard that the interdepartmental working group is looking at personal care. When does it hope to report?

Mr Hendra: The interdepartmental working group will report to the Executive by the end of June.

Ms Ramsey: Is that definite?

Mr Hendra: Yes.

Ms Ramsey: Will the Committee see the report?

Mr Hendra: That will be for the interdepartmental group and the Executive to decide.

Ms Ramsey: Chairperson, should the Committee not receive that report? I do not know what the procedure is, but the Committee is examining the Bill, and the report is going to the Executive. Should the Committee not have some input into the report or see what it says?

The Acting Chairperson: Are there any further comments or questions?

Ms McWilliams: The Committee must receive the report. If it is to scrutinise the legislation, it must have all the evidence, including that report. Will that report contain the assessment tool?

Mr Hendra: No. The group has been asked to examine the cost and implications of personal care.

Ms McWilliams: OK. As I understand it, the other report relates to the ongoing pilot scheme.

Mr Deazley: That document is almost complete. It will be going to consultation, and we hope to send it to the Minister in a few days. As promised before, we will send a copy to the Committee also. That report will contain the assessment tool, the guidance for its use and all the necessary information.

Ms McWilliams: That makes scrutinising the legislation difficult for the Committee. There are two key issues: the scheme was introduced in England with tiered payment levels, but nursing care was paid for at a flat rate in Wales; and the Committee is unsure about the Department’s intentions. Should nursing care be described as free, when only some people will have all their costs covered?

Does the Department intend to make it clear in the explanatory memorandum and any publicity material that not all nursing care is free? "Free nursing care" is a misnomer, because not everyone will get free care, and a memorandum that describes it as such is confusing.

Mr Deazley: Nursing care will be free according to the definition in the Bill. We intend to send proposals to the Minister within the next 10 days. They will say whether payment will be tiered or in a single band along the same lines as the Welsh system. We will publicise the method that is adopted.

Ms McWilliams: You must accept that it is difficult for the Committee, if the decision has not been made. If the payment is tiered, some people will have to top up the amount from their incomes.

Mr Deazley: The English system attempts to grade the level of nursing care required into low, medium or high categories. A pro rata contribution is made towards the costs according to that.

The Acting Chairperson: Therefore, the nursing care is not free.

Ms McWilliams: No. It is not free according to that system.

Mr Deazley: It is free according to the definition in the legislation, which provides for the element of care required in the nursing home that is provided directly by a nurse or for

Ms Hill: Nurses who have used the tool on the pilot schemes found it useful. It has enabled them to identify the needs of patients and users of the service. Although it has been used to establish nursing care needs in nursing homes, they see the tool that we have been developing and testing as something that could be used to meet nursing needs more widely. They see it as defining the input that is required from nurses to care for the groups of people that they have been assessing.

I accept that the situation in England is giving cause for concern. The approach there will influence how we think and enable us to make recommendations. We want to avoid those difficulties. The scale that we operate on here enables us to be closer to the staff involved and ensure that they have the appropriate training and support to carry out the assessments. Evidence from the pilot schemes shows that nurses are confident about using the tool. It is to be hoped that a training programme can be developed that will allow us to use it more widely.

Mrs Courtney: I have similar concerns. There is no definition of the meaning of the assessment tool. Even the Chief Nursing Officer has spoken about the need to develop the assessment process and the training that will be required. That seems to imply that the tool has not been properly tested. Will we be able to see how that assessment tool is being used before it is put into practice?

Ms Hill: That is the consultation process that Mr Deazley referred to. The pilot schemes have been completed and will go out for consultation.

Mrs Courtney: Where will the pilot schemes take place?

Mr Deazley: The pilot schemes have already been completed. They were carried out in every board area.

Ms Hill: The pilot schemes were carried out in the independent sector as well as in the statutory sector.

Mrs Courtney: Having met the independent sector, I doubt that it is content with the assessment tool as it stands.

Ms Hill: The independent sector is represented on our working group, and it has not said that to us. It will be able to raise concerns in the wider consultation, and we will listen to them.

Mrs Courtney: I am still not convinced.

Ms Ramsey: I have a concern about payments. Prof Stout said that the Royal Commission was not advocating payments for bed and breakfast. There is confusion around the definition of personal nursing care.

Mr Deazley: This is only one response to the Royal Commission, not an acceptance of its recommendation, which was for much more than free nursing care. The response is similar to the response in England.

Mrs I Robinson: Do you accept that the "Defining Personal Care" section of the Royal Commission’s report is an all-embracing, itemised account of the meaning of personal care? Should we be working from its definition of what nursing care is and what personal care is?

Mr Deazley: I will ask Mr Hendra to answer that question, as he is involved with the personal care group.

Mr Hendra: I am involved in supporting the interdepartmental group, though I am not on it. It is looking closely at definitions. The Royal Commission is perhaps a starting point. The group has looked at a raft of other definitions running on from the Scottish care development group work — definitions in legislation that provide the legislative background to this. That is then to be translated into an operational definition for personal care. That work is ongoing.

The Acting Chairperson: I want to ask about the £85 that you have drawn up in the formula. Given that Wales has set a flat rate of £100 a week and the highest English band is £110 a week, why is our one so low?

Mr Hendra: The £85 a week was an indicative cost that was established around 18 months to two years ago when the Government first gave their response to the Royal Commission. That was used for resource bids. It does not necessarily reflect the level of banding that will be used, but it provides the overall level of resources that the bandings will reflect.

The Acting Chairperson: Is there any indication of the banding, which is now being looked at after two years?

Mr Hendra: Peter Deazley spoke about the submission that is going to the Minister for a decision on whether we run with several bands or a single price for nursing care.

Mr Deazley: That will address both issues — the banding issue and the payment at individual level.

The Acting Chairperson: When will we get information on that?

Mr Deazley: We aim to have a submission with the Minister within the next two weeks at the latest.

The Acting Chairperson: That will be useful. Can you explain the assessment method that you will be using?

Mr Deazley: Which assessment?

The Acting Chairperson: How people are going to be evaluated to discover what they should, and should not, pay.

Mr Deazley: The nursing needs assessment will be carried out first. If it is decided that a level of nursing care is required, as defined in the legislation, that element will be removed from the means assessment. There will be no further assessment of the contribution towards nursing care. The personal care and accommodation aspects will remain when a person has the means to address those. However, the nursing care element will simply be removed from the assessment.

The Acting Chairperson: Will we be consulted on your assessment methods?

Mr Deazley: I imagine that the current financial assessment process will continue to be applied when people are assessed for care management. There will be no need to change that system.

Mr Hendra: The Health and Personal Social Services (Assessment of Resources) Regulations (Northern Ireland) 1993 apply. The exclusion in clause 1 of the Bill prevents that from being applied to nursing care.

The Acting Chairperson: That will be standard right across the country?

Mr Hendra: Yes.

Ms McWilliams: Given our concerns about the assessment tool, what about the right of appeal? Currently people can make a complaint under the normal complaints procedure about all other areas of health and social services. Is that a fair way of allowing people redress if they have not been assessed accurately, or would a separate appeals system built into the legislation be more appropriate?

Mr Hendra: We have not considered a separate appeals procedure. We have looked at what is done in England, and it relies on the existing local authority and NHS complaints procedures. If someone is dissatisfied with the assessment and that is not resolved by negotiation, he has recourse to local level and then to a higher level of complaint. We propose to do the same at this time.

Ms McWilliams: It may not be appropriate to look at England, as, with our devolved Administration, the structure of health and social services is entirely different there.

Mr Hendra: The health and social services complaints procedure is integrated with social services and health services and is generally the same. The detail of an assessment would be looked at by the appropriate professionals clinicians.

Ms McWilliams: Members of this Committee are fairly familiar with the complaints procedure. It is long, drawn-out, time-consuming and difficult. It is also tiered: as a complaint gets bigger, it goes up a level. It is hard for some people to understand, and it is mainly elderly people who are involved. Some people are disorientated and unfamiliar with the process. A built-in appeals procedure might help those who felt that they had been wrongly assessed in the first place. It might also help us.

Mr Hendra: You are focusing on a fast track, local level complaints procedure that could resolve an issue quickly and would be more formalised than the existing one.

Ms McWilliams: Yes. Some people could be dead by the time we had a complaint resolved. I have been involved in the procedure, and I know how long it can take. The one I am involved in now has taken nearly two years. Elderly people getting nursing care need an urgent assessment, and if they felt that it was not done accurately, they would want to be able to appeal it.

I discovered recently that the nursing assessments some people had were assessments of the care they needed when they went into hospital not of what they needed when they came out. If someone was treated like that, he would want to appeal. Complaining in the standard way can take a long time — between six to 18 months, and not many take less than six months.

Mr Hendra: We will see if we can formalise a fast track in the system. Ultimately a patient would have recourse to the normal complaints procedure, the health ombudsman, et cetera.

Ms McWilliams: How would that be done?

Mr Hendra: It would be part of the guidance document on the implementation paper for free nursing care.

Ms McWilliams: Would it go into the Statutory Regulations?

Mr Hendra: It may be regulated on.

Mr Deazley: It would be more likely to go into directions from the Department to the trusts.

Ms McWilliams: If we vote this legislation through on the Floor of the Assembly, would we know from you that that guarantee was in place or would we be taking your word on a wing and a prayer?

Mr Deazley: There would have to be a process, and the boards would have to monitor it. There would be a registration process of the complaints and tight monitoring to make sure that they were fast-tracked. We would have to ensure that the directions we gave to the trusts were implemented.

Ms McWilliams: You will have a look at that and then come back to us.

Mrs I Robinson: I support what has been said. Many people may feel aggrieved when the Bill is enforced, and they could flood the process by wanting to be reassessed. The ordinary system may not be able to cope. It is logical that each board should be responsible for dealing with its area.

Mr Deazley: Part of the experience in England has been heavily related to its tiering system.

The Acting Chairperson: Concerns have been raised that conditions such as Alzheimer’s disease may be excluded from the definition of nursing care. We accept that the Chief Nursing Officer has said that the assessment tool will cover assessment of the physical, mental and social needs of people in care. Can you confirm that nursing care for sufferers of Alzheimer’s and those with other mental health needs will be covered? How will providers ensure that such people are identified and assessed?

Ms Hill: We took that into account when piloting the assessment tool. A range of service users has been assessed, and those with mental ill health and dementia will be included in assessment for nursing care. This was raised by the Alzheimer’s Society and discussed with it by colleagues. The society awaits wider consultation but appears satisfied that its needs and concerns have been considered.

Ms Ramsey: Much faith has been put in the pilot projects. Can we see the results?

Ms Hill: We must report on them as part of the working group activity. We will check on the feedback and consider what can be made available.

Mr Deazley: The second part of the question Ms Hill was asked dealt with identifying and assessing people with Alzheimer’s disease or dementia. The boards will soon be asked to identify all self-funders in independent nursing homes, regardless of their reasons for being there. All those people will be told of their right to free nursing care and offered an assessment of their nursing care needs.

The Acting Chairperson: How will the assessment work with someone in a nursing home who is reasonably healthy but becomes ill, needs nursing care and then returns to reasonable health?

Mr Deazley: Did the person remain in the nursing home throughout?

The Acting Chairperson: Yes.

Mr Deazley: That will depend on the decision regarding single-band or tiered payments. Tiered payments provide an opportunity for review to increase the level of nursing care.

The Acting Chairperson: Who will institute the review?

Mr Deazley: In those circumstances it is highly likely that the nursing home proprietor and manager would do it. The resident — or, if he were unable, his family — could ask for it. The request could come from several areas.

Ms Hill: I understand that there is in any case an annual review which could identify situations.

The Committee Clerk: The Department wishes to respond to members’ concerns. Perhaps we might return to clause 1 after it has done so next week.

The Acting Chairperson: Are members content?

Mrs Courtney: If health visitors are no longer included in the title, how are they included in the clause?

Ms Hill: A health visitor must first be a registered nurse, so they are included in the title.

Mrs Courtney: They are simply not named explicitly.

Ms Hill: That is right; it follows decisions made at Westminster about the new Nursing and Midwifery Council (NMC), which is operating across all four countries of the United Kingdom.

Mrs Courtney: Is that simply a matter of standardisation?

Ms Hill: Yes.

Ms McWilliams: You may not be able to answer this question. Recently some non-departmental public bodies (NDPBs) have been stood down and brought back under the auspices of the Department, yet we are establishing a new one. Are the provisions for establishing this NDPB the same as for the others?

Ms Hill: They are similar. Ms Thompson has been working on the shaping of the Bill, which reflects the establishment of certain other organisations.

Ms McWilliams: Are there any differences?

Ms Thompson: We have received advice on how the legislation is formulated with regard to the establishment of the body, so I am not aware of any differences. It will be a standard NDPB like the others. It will have the same powers, establishment, functions and accountability to Departments as other NDPBs. It will also be accountable to the Minister for its budget, annual reports and so on.

Ms McWilliams: It is difficult to understand how these bodies operate. On one hand they are independent, and on the other they are public.

Ms Thompson: It can be more rightly described as an "arm’s length" body, as it is not fully independent. An NDPB is funded by the Government and accountable to the Department. The NMC is more independent, since it is funded by registrants, meaning it is slightly more removed from the Government.

Ms McWilliams: Will this NDPB replace the NMC?

Ms Thompson: NIPEC is not replacing the NMC. The NMC is replacing the four national boards and the UK Central Council for Nursing, Midwifery and Health Visiting. It was clear that we could not set the body up to be funded by registrants, as they would then have to pay two registrant’s fees — one to the NMC and one to the new body. That would not have been acceptable, so it had to be funded by the Government.

Ms McWilliams: Do the registration fees go to a separate body?

Ms Thompson: They go to the NMC as the registration body.

Ms McWilliams: So there will be two bodies involved in management, but only one in registration.

Ms Hill: Strictly speaking, it is not management but providing guidance, advice and an opportunity to develop services in a managed approach. It is not management in the way a regulatory body would function; it is very much in partnership with nurses and midwives in the service. The idea is that the development of the profession will come from the service into the body. It will then be tested and shaped, giving us the opportunity to spread good practice which might have been developed in one area across the rest of the service. We shall be able to build on that good practice to the benefit of all service-users.

Ms McWilliams: So it is more policy-oriented.

Ms Hill: Yes. It would be standard-setting and development by agreement with the profession, as opposed to their being imposed by an outside arrangement.

Ms McWilliams: As I am not familiar with how nursing is organised, I am trying to find out what differences there are between the registration body and this body, so that I might be able to explain it to someone. It appears that this body is setting standards, but you would be struck off by the other body if you did not meet them. I am trying to establish the relationship. If this body changes its standards, the other body would need to have a close relationship to know. Am I thinking along the right lines?

Ms Hill: Yes. In essence, the NMC is operating at a four-country level, setting high standards for the operation of the profession. People initially qualifying as nurses must meet those standards. They must also meet ongoing registration standards. We recognise that people could be competent when they qualify initially, but as things change they must continue to demonstrate competence. The function of that central body is to help people gain an initial licence to practise and then maintain it. If they fail in some way, it must remove them from practice.

This body will work much more closely with local health and social services, looking at the roles we desire for nurses within the broad standard framework which the central body is developing. If we seek specialist skills, we can agree locally how we want that to occur, and we can make it happen within the framework of general and local legislation. That is the relationship.

Ms McWilliams: You have a great deal of international experience. Is this how it works everywhere, or do some countries combine the functions of the two bodies into one?

Ms Hill: Yes, some do. Interestingly, the Republic of Ireland has gone for two bodies. It has gone for An Bord Altranais, which is its registering body, and a National Council for Professional Development. They recognise that, in developing roles beyond initial registration, there must be a different, more developmental and participative approach as opposed to the bureaucratic tendencies one finds in the regulatory functions.

Others have tended to look to professional organisations to lead on some of these issues. The Royal College of Nursing or the Royal College of Midwives might have that sort of function in some other countries. Professional organisations would set standards for specialised roles as part of activity in employment and industrial relations. We have tended to keep that separate here.

Mr Berry: Paragraph 17 of the schedule states that the council will be subject to investigation by the Commissioner for Complaints. How will the arrangement work, and what opportunity will nurses, midwives and health visitors have to redress complaints or appeal against decisions?

Ms Thompson: The clause is a standard inclusion in the establishment of an NDPB. It does not refer to complaints against an individual nurse, since the body will not be concerned with the registration or conduct of individual nurses. The clause is included in the legislation so that the body must adhere to a complaints procedure if, for example, a member of staff made a complaint against it. A change to the legislation was required.

Ms Thompson: The explanatory memorandum states that there will be between 10 and 16 members — we have left it open. Thirteen members have been appointed to the shadow advisory committee. We did not want to appoint 16, since we wanted the committee to be small but flexible so that, if the committee wants 16 members when the legislation has been passed, it will be able to arrange that.

Mrs I Robinson: I note that 60% of the body will be made up of professionals. How do you intend to identify the 40% that will be made up of lay members?

Ms Thompson: Lay members have been appointed to the shadow advisory committee.

Mrs I Robinson: What are their backgrounds?

Ms Hill: The members are: a mother who has done a great deal of work in the voluntary sector; a consultant obstetrician; a retired senior officer from an education and library board; a retired member of Queen’s University who has worked in adult education; and a minister from a cross-community church. The obstetrician and the retired member of Queen’s University are women, so there are three women and two men in the group.

Ms Thompson: Paragraph 5 of the schedule sets out the general rules for appointing the chairperson of the body. The Department may make regulations on the appointment of the chairperson and other members, the tenure and the constitution, functions and procedures of the committee. Some of this detail will be included in the regulations, which we will have to submit to you as part of the subordinate legislation following the Bill.

Ms Ramsey: The royal colleges are concerned that they and similar groups are unable to nominate people for appointment. They are also concerned about the criteria which the Department will use for selecting those who have been nominated. Does the Department have such criteria?

Ms Hill: The criteria were developed for lay people and professionals. The advert was open so that anybody could respond to it. People were shortlisted according to whether they met the criteria. They were then tested against them at interview. The chairperson and I were part of the interview panel, and there was also an outside assessor. People knew the criteria against which they were being assessed.

Ms Thompson: Appointments to an NDPB are made through the public appointment process.

Ms Ramsey: I am concerned that as a group they were not able to nominate someone to represent them.

Ms Hill: It is not a representative body in that sense. Essentially, everyone becomes a member of a corporate body not representing a constituency.

The Acting Chairperson: Are there any questions on paragraph 6 covering remuneration and allowances?

Mrs Courtney: Have separate proposals been made for the chairperson and members?

Ms Thompson: Yes. The remuneration proposed for the chairperson is £9,252. That is in line with, for example, the Northern Ireland Social Care Council (NISCC), which has similar time commitments. The proposal for members is that it should include expenses and payments for substitute carer allowances but no separate remuneration.

Ms McWilliams: What do you mean by "payments for substitute carer allowances"?

Ms Thompson: I have probably not used the right form of words. It means that, if you have to pay for childminding to attend a committee meeting, the costs are covered for you. Likewise, if you need to pay a carer for an elderly relative, those fees are also payable on top of expenses.

Ms McWilliams: That may have been the case for some time. However, it is an interesting innovation considering what used to be considered expenses.

Ms Thompson: The NISCC has also made that provision.

Ms McWilliams: Is it made by other NDPBs?

Ms Thompson: I do not know. When we were considering arrangements for it, we examined the NISCC’s provision. We thought it important and wished to include it.

Ms McWilliams: It is positive in that it may be attractive to younger parents rather than only to retired members of the community — depending on time commitments — and particularly so for lay members.

The Acting Chairperson: Are there any questions on paragraph 7?

Mrs Courtney: Will the chief executive have overall responsibility for the body?

Ms Hill: Yes.

The Acting Chairperson: Are there any questions on paragraphs 8 to 17?

Ms McWilliams: Will the Commissioner for Complaints assume the role of ombudsman? Will the body come under his remit?

Ms Thompson: Yes, and the legislation will require amendment to include NIPEC.

Ms McWilliams: That was not the case under the body which it replaces.

Ms Hill: The national board would have been subject to that legislation.

The Acting Chairperson: We shall now move to paragraphs 18 and 19.

Mrs Courtney: Does NIPEC refer to the extended role of the nurse?

Ms Thompson: It is a standard change to existing legislation, but NIPEC must be included.

The Acting Chairperson: We shall now move to paragraph 20.

Mrs Courtney: I am looking at 20(2) which states:

The Acting Chairperson: I beg to move

That the Committee recommend to the Assembly that paragraph 21(1)(a) be amended as follows: delete

Question put and agreed to.

Ms Thompson: I have not seen a copy of that letter. We shall check the reference. Thank you.

Schedule agreed to subject to the Committee’s proposed amendment.

The Acting Chairperson: We shall leave the remainder of the Bill until the next session. Thank you.