REPORT ON THE HEALTH AND
PERSONAL SOCIAL SERVICES BILL
(NIA BILL 06/01)

SESSION 2001/2002 THIRD REPORT

Ordered by The Committee for Health, Social Services and Public Safety to be printed 10 June 2002
Report: 03/01R (Health, Social Services and Public Safety)

COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
TOGETHER WITH THE MINUTES OF PROCEEDINGS OF THE COMMITTEE
RELATING TO THE REPORT AND THE MINUTES OF EVIDENCE

The Committee for Health, Social Services and Public Safety is a Statutory Departmental Committee established in accordance with paragraphs 8 and 9 of Strand One of the Belfast Agreement and under Standing Order No. 45 of the Northern Ireland Assembly. The Committee has a scrutiny, policy development and consultation role with respect to the Department of Health, Social Services and Public Safety, and has a role in the initiation of legislation.

The Committee has the power to:

• consider and advise on departmental budgets and annual plans in the context of the overall budget allocation;
• approve relevant secondary legislation and take the Committee Stage of relevant primary legislation;
• call for persons and papers;
• initiate inquiries and make reports;
• consider and advise on matters brought to the Committee by the Minister of Health, Social Services and Public Safety.

The Committee was established on 29 November 1999 with eleven members, including a Chairman and Deputy Chairman, and a quorum of five.

The membership of the Committee is as follows:

• Dr Joe Hendron (Chairperson)
• Mr Tommy Gallagher (Deputy Chairperson)
• Ms Pauline Armitage
• Mr Paul Berry
• Rev Robert Coulter (replaced Mrs Joan Carson with effect from 11 September 2000)
• Mrs Annie Courtney (replaced Ms Carmel Hanna with effect from 21 January 2002)
• Mr John Kelly
• Mr Tom Hamilton (replaced Mr Alan McFarland with effect from 11 March 2002)
• Ms Monica McWilliams
• Ms Sue Ramsey
• Mrs Iris Robinson MP

General
Deliberations of the Committee

APPENDIX 1. Minutes of Proceedings of the Committee Relating to the Report
APPENDIX 2. Minutes of Evidence
APPENDIX 3. Written Submissions

1.The Committee for Health, Social Services and Public Safety met on the dates given below to consider the Health and Personal Social Services Bill (NIA 06/01) that was referred to the Committee on 12 March 2002 for consideration under Standing Order 31 (1) of the Northern Ireland Assembly.

2.The Committee had before it the Health and Personal Social Services Bill and the Explanatory and Financial Memorandum to the Bill (NIA 06/01) as introduced.

3.The Minister in charge of the Bill, Ms Bairbre de Brún, Minister of Health, Social Services and Public Safety, made the following statement under Section 9 of the Northern Ireland Act 1998:

4.The Bill covers two areas. First, it provides for free nursing care for people resident in nursing homes. Currently the cost of nursing care is included in the overall cost of a nursing home placement and may be borne by residents whose means are such that they fund, or part-fund, their own care. There is an anomaly in relation to nursing care, in that it is supplied free as a health service to a person in their own home (or indeed to a resident in a residential care home, if supplied externally by a Trust via the community nursing service). From 07 October 2002 it is proposed that the nursing care element of the total cost will be met from public funds, reducing the overall cost to the individual.

Secondly, it is proposed to set up a new local body to support the development of nursing, midwifery and health visiting in the key areas of best practice, ongoing education and continuous professional development and performance. The Northern Ireland Practice and Education Council for Nursing and Midwifery (NIPEC) will be able to provide advice and information to nurses, midwives and health visitors, as well as the public, in relation to careers in these professions and on general nursing issues. It will also be able to carry out work locally, on behalf of the newly established national regulatory body governing the nursing professions, the Nursing and Midwifery Council, in relation to the quality assurance of pre-registration and a defined range of post registration courses.

5.The Committee proposed the following motion seeking an extension to the Committee Stage of the Bill. The Assembly agreed the motion on 29 April 2002.

[in the name of the Deputy Chairperson, Committee for Health, Social Services and Public Safety].

6.The Committee met to consider the Bill on the following dates:

• 10 April 2002: consideration of the Bill, when Departmental Officials were questioned;
• 17 April 2002: oral evidence from Prof. Robert Stout, Age Concern, and Belfast Carers Centre;
• 24 April 2002: oral evidence from the Royal College of Midwives (NI) and the Northern Ireland Practice and Education Council for Nursing and Midwifery;
• 01 May 2002: consideration of the Bill;
• 08 May 2002: clause-by-clause scrutiny of the Bill, Departmental Officials in attendance;
• 14 May 2002: clause-by-clause scrutiny of the Bill, Departmental Officials in attendance;
• 22 May 2002: clause-by-clause scrutiny of the Bill, Departmental Officials in attendance;
• 29 May 2002: clause-by-clause scrutiny of the Bill, Departmental Officials in attendance;
• 10 June 2002: consideration of Draft Report.

7.Extracts of the Minutes of Proceedings are given in Appendix 1.

8.The Minutes of Evidence for each of the meetings when the Bill was considered formally are given in Appendix 2.

9.On the subject of free nursing care, the Committee wrote to 48 interested bodies and individuals on 11 March 2002 to seek their comments on the Bill. The seven respondents were generally supportive of the aims of the Bill. A list of the seven substantive responses received and a copy of their written submissions are given at Appendix 3. The Report does not include those replies that welcome the Bill but did not make substantive comment; however, the Clerk can provide a copy on request.

10.The Committee strongly welcomes the introduction of the Health and Personal Social Services Bill as it removes the anomaly that only those in nursing homes are expected to pay for their own care or make a contribution towards what is a free health service in all other settings. Those 2,000-odd nursing home residents in Northern Ireland who are currently paying the full cost, or most of the cost, of nursing home care should no longer be disadvantaged but treated in the same way as those who are cared for at home. The Committee places on record its concern at the late introduction of the legislation, which meant that the nursing home residents concerned did not benefit from the new provisions as soon as they should have. The £3.3m that was set aside from the Budget of September 2001 to allow the introduction of free nursing care from April 2002 had to be surrendered as there was a delay by the Executive in bringing forward the Bill.

11.The Bill addresses the specific issue of financial assistance towards nursing care but is only a partial response to the Royal Commission on Long Term Care. The Royal Commission recommended that personal care should also be provided free of charge and paid for from central taxation on the basis of assessment of need. Many witnesses called for the approach taken by Scotland on personal care to be adopted here. Several submissions argued that the decision to separate nursing from personal care discriminates against those with long-term illnesses such as Alzheimer's and arthritis, who may need considerable levels of personal care but not necessarily the skills of a registered nurse.

12.The Committee would like to see free nursing and personal care, if the necessary resources were available. However, it is equally aware of the ever-increasing demands on a limited health service budget across a wide range of priorities. Increased expenditure on one aspect of health care inevitably means taking away funds from another deserving area. The Committee is aware that a recommendation for free personal care now would necessitate a reallocation from the Block Grant at a time when pressures on funding for key health, education, transport and regional development priorities are already preventing many other urgently needed projects from being funded.

13.The Executive has established an interdepartmental group to examine the costs and implications of introducing free personal care here, drawing on the findings of the Scottish care development group. That group is expected to report its findings in June 2002 but the Committee understands that the estimates of providing free personal care are likely to be well in excess of £25m per annum. In this context, the Committee took the pragmatic view that to recommend adoption of the Clause should be a first, necessary step towards meeting basic equity of provision. The Assembly and the Committee can return to consideration of free personal care and the conclusions of the Royal Commission into Long Term Care of the Elderly in the future. Members will then be in a better position to gauge its affordability and benefits in light of the Scottish experience and the findings of the Executive's examination of free personal care.

14.The Committee was advised that there had been widespread consultation on the nursing care assessment tool, which has been piloted in seven sites across Northern Ireland, across the four HSS (Health and Social Services) Board areas. This involved nurses from HSS Trusts and the independent sector working in partnership. The Department's Chief Nursing Officer advised the Committee that evidence from the pilot schemes showed that nurses were confident about using the tool. The tool has been developed from experiences learnt elsewhere and is due to go out for consultation among its users. The Committee has received an assurance that the Department will set out the assessment and review process in detail for its scrutiny following the consultation process. The Committee agrees with the Sperrin Lakeland HSS Trust that the nursing care assessment should be open, transparent and set against clear criteria.

15.The Committee questioned whether or not the assessment tool would cover those with Alzheimer's disease or dementia. The Chief Nursing Officer explained to members that the assessment tool had been designed to consider all of the needs of people in care as well as those of their carers. This would cover their physical, mental and social needs, including those of people with Alzheimer's disease or dementia, and the tool had been tested by these clients. This is important because evidence from Arthritis Care and the Alzheimer's Society suggested that it would be very difficult to distinguish between people with long-term illnesses on which aspects of their care are nursing and which are personal. The Committee welcomed the assurance given by the Chief Nursing Officer but would await the outcome of the consultation on the document "Assessment For Free Nursing Care" issued by the Department on 23 May 2002 before considering and commenting on the effectiveness of the assessment process.

16.Members were concerned at reports that private care homeowners in England were using the opportunity of free nursing care to increase residents' fees, in order to meet the costs of nursing home places. This meant that a resident receiving assistance was no better off as a result of "free nursing care". It is important that the Department learns from the action being taken in England to prevent the benefit of nursing care payment to the resident being negated. The Committee acknowledges the concerns that nursing homes here have been underfunded and welcomes the additional £3.5m for the sector in this year's Budget.

17.The Committee welcomes the proposal by the Department to introduce a single payment rate system for nursing care, although the actual amount has not yet been settled. There had been concern that we would pursue the sliding scale system adopted in England, which has proved bureaucratic and complex. It has led to a backlog of appeals against assessments that placed an individual in either of the lower two of the three bands of nursing need. A single tier system for Northern Ireland will avoid costly administration and should reduce the number of review requests.

18.The Committee considered that the Department should be cautious in using the phrase "free nursing care" as it is unlikely that everyone will get free care. The Department has not yet determined the level of payment, however, the Committee understands that a minimum contribution of £85 will be made towards nursing care. This may not cover the full costs of an individual's care. If the contribution falls short of what the home is spending on a resident's care, then the resident will still have to make up the difference. The Department should therefore make it clear in any publicity material that it will be providing financial support for nursing care as opposed to free nursing care - unless the rate is set high enough to cover all the defined nursing costs.

19.The Committee had been concerned to ensure that all nursing home residents are made fully aware of their rights under the legislation. It is satisfied with the assurance given by the Department that it will issue directions on the actions required by HSS Boards and Trusts to commence payments for nursing care from October 2002. All nursing home residents who are funding their own care, or their families or carers, will be identified by the relevant HSS Trust and informed of their right to an assessment for nursing care. Such an assessment will require the consent of the individual, or their family or carer.

20.The Committee sought and received an assurance that there would be a simple, fast track appeal mechanism that could resolve a problem quickly and smoothly. Members felt this was particularly important given their experience of the health and personal social services complaint procedure, which can be time-consuming and complex, particularly for older people. It was therefore satisfied with the Department's proposal to issue a direction to HSS Boards and Trusts that will incorporate the guidance and review process. These will be set out in detail, widely disseminated and be publicly available on the Internet, so that those in receipt of nursing care are made fully and immediately aware of their right of appeal.

21.The Committee was satisfied with the assurance from the Department that the entire review process would take a maximum of three weeks from first complaint to the completion of the second stage review. If not satisfied with an initial nursing care assessment, the individual concerned could request a review, which would be carried out by a different nurse/assessor within one week. If that did not prove satisfactory, a review panel would be set up to hear the case within a further two weeks.

22.The Committee called on the Department to ensure that sufficient resources are made available to allow a smooth transition to the new nursing care arrangements and the appeals/review system. The Department must also consider how the system is to be monitored to ensure its proper implementation.

23.The Committee welcomes the proposed creation of the new body in order to develop consistently high standards in best practice, education and performance in nursing and midwifery in Northern Ireland. Members were satisfied that this would not involve additional costs, as transferring the existing budget for the old National Board to the new body will cover the expenditure, which would be subject to rigorous audit. The new Council will work in partnership with the nursing profession to provide guidance and advice, and develop services through a managed approach. The Committee considered that it is important to have a local body to validate the programmes of education and ensure that clinical training placements meet the highest standards.

24.The Committee advocates that the proposals be considered in conjunction with those published for consultation in the document 'Best Practice - Best Care.' The new Council can be expected to play an important role in working closely with the new Local Health and Social Care Groups to examine the role of nurses and explore ways in which to develop their specialist skills. The spreading of good practice across the nursing profession will ultimately benefit all service users by developing consistently high standards of health care.

Minutes of Proceedings

Present:Mr T Gallagher (Deputy Chairman)
Mr P Berry
Mrs A Courtney
Mr T Hamilton
Mr J Kelly
Ms M McWilliams
Ms S Ramsey

Apologies:Dr J Hendron (Chairman)
Mrs P Armitage
Rev R Coulter
Mrs I Robinson

In Attendance:Mr P Hughes (Committee Clerk)
Mr D Harkin (Assistant Clerk
Mr D Gordon (Executive Support)
Mr B Greene (Administrative Support)
Ms L Dempster (Administrative Support)

Departmental Officials:Ms Judith Hill, Chief Nursing Officer
Mr Peter Deazley
Ms Jennifer Thompson
Mr Mike Hendra

Mr Deazley gave a brief presentation on the background to, and rationale for, the Health and Personal Social Services Bill, which was followed by a question-and-answer session. The entire proceedings are recorded separately in verbatim minutes of evidence.

The Officials explained that some 2,000 people who fund their own care in nursing homes in Northern Ireland would benefit from the introduction of free nursing care. A detailed survey will be carried out over the next few weeks to establish the precise numbers involved and the level of that funding. Just over £9m per year has been set aside from the Budget to cover the costs of free nursing care.

Mr Deazley advised that the Department is aware of the publicity surrounding the issue of nursing homes in England increasing their charges with the advent of free nursing care there, and that it would consider ways to avoid that happening in Northern Ireland. However, he admitted that this was an extremely difficult issue.

The Department is currently piloting a detailed assessment tool in relation to the definition of "nursing care". The tool, which will take into account all the physical, mental and social needs of people, will be going out to consultation soon. A training programme will be developed to roll out the use of the tool. Appropriate arrangements will be made to monitor and evaluate its effectiveness. The Department undertook to provide the Committee with a copy of the assessment tool when it is published.

In terms of training, the Department will provide the resources, so the main issue will be the costs involved in the release of nursing home staff. Nursing assessment will come under the arrangements that Trusts operate for care management.

Members expressed some concern that it would be particularly difficult to distinguish between people with long-term illnesses, in terms of which aspects of their care are nursing and which are personal.

The normal health and social services formal complaint procedure will apply, with the necessary support available to the nursing home resident or their advocate.

In relation to a point raised by Ms McWilliams that Northern Ireland's proportionately higher number of nursing homes than GB may have financial implications for Budget resources, the Department undertook to provide a written response.

Clause 2 establishes a Northern Ireland Practice and Education Council for Nursing and Midwifery, in line with a major review of nursing regulation Orders across the UK. The new Council will focus on practice development, the establishment of new knowledge and technologies, developing the educational process and examining the performance of nursing and midwifery services. The estimated £1m budget for the new body will be financed from the resources available for the national board, which is being stood down from 31 March 2002.

The Chief Nursing Officer undertook to respond in writing with regard to the position of health visitors vis-à-vis their satisfaction with the title of the Bill.

Present:Mr T Gallagher (Deputy Chairman)
Mrs P Armitage
Mr P Berry
Mrs A Courtney
Rev R Coulter
Mr J Kelly
Ms M McWilliams
Ms S Ramsey

Apologies:Dr J Hendron (Chairman)
Mr T Hamilton
Mrs Iris Robinson

In Attendance:Mr P Hughes (Committee Clerk)
Mr D Harkin (Assistant Clerk
Mr D Gordon (Executive Support)
Mr B Greene (Administrative Support)
Ms L Dempster (Administrative Support)

Dr Janice Thompson presented a Research Services paper on the HPSS Bill, in relation to the provision of free nursing care.

Witnesses: Prof Robert Stout, Prof. Geriatric Medicine, QUB
Mr Tom Cairns, Age Concern
Mr David McConnell, Age Concern
Ms Caryl Williamson, Age Concern
Mr Ricky Devlin, Belfast Carers Centre

Prof. Stout, the representatives from Age Concern, and Mr Devlin made separate presentations on the free nursing care provision of the Bill. The entire proceedings are recorded separately in verbatim minutes of evidence. The witnesses concerns are summarized as follows:

While not opposed in principle to the provision of free nursing care, Prof Stout felt that it would be unworkable and unfair. This was because it would be very difficult to devise a mechanism that differentiated clearly between nursing care and non-nursing personal care. He also opposed the funding of free nursing care rather than personal care, as this amounted to diagnosis-related rationing, which was unfair. For example, a cancer patient needing Health Service treatment would qualify for free nursing care, but an elderly Alzheimer's patient would not, even though they may need considerable care and help with dressing, feeding, bathing and mobility.

Prof Stout voiced concern that the Bill may introduce a perverse incentive into the system, in that nursing homes would be subsidised, as they are required to have registered nurses on their staff. Residential homes do not. If the nursing home sector becomes cheaper than residential care homes, this could undermine the policy of promoting independence by providing long-term care in the least dependent environment.

Age Concern agreed that the proposed system would be discriminatory and create a two-tier service. They highlighted the considerable confusion that exists among the public, and elderly people in particular, about the system. Many do not make a distinction between nursing and personal care. The representatives raised concern that the interdepartmental working group on the introduction of free nursing care was not taking any submissions from groups such as Age Concern.

Early evidence from the implementation of the new system in England suggests that the nursing assessments are complex to administer. Also, a recent survey found that three out of five health authorities and primary care trusts have clear evidence of nursing homes increasing charges so that they fortuitously match the amount that people have been awarded through free nursing care. There is real confusion in England about to whom appeals should be directed. There does not seem to be a clear and simple appeal procedure.

Mr Devlin reiterated the view that the definition of what constitutes nursing care could prove problematic. Ambiguous boundaries could leave too much room for interpretation and prove distressing for the residents and their families. There is a danger that those who are the strongest advocates will win out and the most vulnerable will suffer the most.

That, in accordance with Standing Order 31(5), the period referred to in Standing Order 31 (3) be extended to 07 June 2002 in relation to the Committee Stage of the Health and Personal Social Services Bill (NIA 6/01).

Present:Mr T Gallagher (Deputy Chairman)
Ms P Armitage
Mr P Berry
Rev R Coulter
Mr T Hamilton
Ms S Ramsey

Apologies:Dr J Hendron (Chairman)
Mrs A Courtney
Mr J Kelly
Ms M McWilliams
Mrs I Robinson

In Attendance:Mr P Hughes (Committee Clerk)
Mr D Harkin (Assistant Clerk
Mr D Gordon (Executive Support)
Mr B Greene (Administrative Support)
Ms L Dempster (Administrative Support)

Royal College of Midwives: Ms Breedagh Hughes

Shadow NIPEC: Ms Paddy Blaney, Acting Chief Executive

The Committee took oral evidence from the above sets of witnesses in relation to the provisions for the establishment of the NI Practice and Education Council for Nurses and Midwives. The entire proceedings are recorded in separate verbatim minutes of evidence.

Present:Mr T Gallagher (Deputy Chairman)
Mr P Berry
Mrs A Courtney
Rev R Coulter
Mr T Hamilton
Mr J Kelly
Ms M McWilliams
Mrs I Robinson

Apologies:Dr J Hendron (Chairman)
Mrs P Armitage
Ms S Ramsey

In Attendance: Mr P Hughes (Committee Clerk)
Mr D Harkin (Assistant Clerk)
Mr D Gordon (Executive Support)
Ms L Dempster (Administrative Support)
Mr B Greene (Administrative Support)

The Committee considered a paper from the Clerk highlighting the main provisions in the Bill and key concerns raised by witnesses, particularly in relation to the separation of nursing and personal care, and the recourse to appeal and complaint mechanisms. Members agreed to return to the matter at next week's meeting, when the formal Clause-by-Clause consideration would begin. The Clerk will arrange for the attendance of Departmental Officials to facilitate the discussions. The Committee's deliberations are recorded separately in verbatim minutes of evidence.

Present:Mr P Berry
Rev R Coulter
Mrs A Courtney
Ms M McWilliams
Ms S Ramsey
Mrs I Robinson

Apologies:Mrs P Armitage
Mr T Gallagher (Deputy Chairman)
Dr J Hendron (Chairman)
Mr J Kelly

In Attendance:Mr P Hughes (Committee Clerk)
Mr D Harkin (Assistant Clerk
Mr D Gordon (Executive Support)
Mr B Greene (Administrative Support)
Ms L Dempster (Administrative Support)

Departmental Officials:Mr Mike Hendra
Mr Peter Deazley
Ms Judith Hill
Ms Jennifer Thompson

The Committee commenced its clause-by-clause scrutiny of the HPSS Bill, taking evidence from the above-named Officials. The entire proceedings are recorded separately in verbatim minutes of evidence.

The Officials gave a number of undertakings in relation to Clause 1 and the Schedule to the Bill, as listed below:

The Department reiterated its commitment to provide the Committee with a copy of the Interdepartmental Group's consultation document on the assessment tool for free nursing care and the guidance for its use, which is due to be sent to the Minister in the next few days.

The Department will check on what feedback can be made available to the Committee on the work of the pilots on the assessment tool.

The Department will give consideration to making provision for a fast-track appeals/complaints procedure on nursing care needs through the Statutory Regulations. The Department will consider how such a complaints process could be monitored to ensure that Trusts implement its directions.

Question, That the Committee is content with Clause 2, put and agreed to.

Question put and agreed to:

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

"Nursing and Midwifery Order 2002"

and insert

"Nursing and Midwifery Order 2001 Statutory Instrument 2002 No.253".

Question, That the Committee is content with the Schedule, subject to the Committee's proposed amendment, put and agreed to.

The Committee suspended further clause-by-clause scrutiny of the Bill until at next week's meeting, when Departmental Officials will be re-invited to attend.

Present:Dr J Hendron (Chairman)
Rev R Coulter
Mrs A Courtney
Mr T Gallagher (Deputy Chairman)
Mr T Hamilton
Mr J Kelly
Ms M McWilliams
Mrs I Robinson

Apologies:Mrs P Armitage
Mr P Berry
Ms S Ramsey

In Attendance:Mr P Hughes (Committee Clerk)
Mr D Harkin (Assistant Clerk
Mr D Gordon (Executive Support)
Mr B Greene (Administrative Support)
Ms L Dempster (Administrative Support)

Departmental Officials:Mr Peter Deazley
Mr John McKeown

The Committee resumed its clause-by-clause consideration of the HPSS Bill, and the entire proceedings are recorded separately in verbatim minutes of evidence.

Mr Deazley explained that the Department was examining how an existing model review system within the Department could be adapted and developed to take account of the nursing care assessment process. This system requires the assessment to be reviewed within one week to the satisfaction of the service user, the carer or other interested parties. Where it is not satisfactorily resolved, a panel must be constituted and a further review completed within two weeks.

Mr Deazley advised that the Department proposes to issue a statutory direction to the Boards and Trusts that will incorporate the guidance and the review process. He assured the Committee that the Department would widely disseminate the directions and guidance in relation to the nursing care assessment. A nurse would carry out the initial assessment, but a different nurse assessor would undertake the first review.

Mr Deazley advised that the Department should be in a position to provide the Committee with details of the assessment tool, the recommendation on the payment mechanism, and the evaluation from the pilot studies by next week.

The Committee suspended further clause-by-clause scrutiny of the Bill until next week's meeting, when Departmental Officials will be re-invited to attend.

Present:Dr J Hendron (Chairman)
Mr P Berry
Rev R CoulterMr J Kelly
Ms M McWilliams
Ms S Ramsey
Mrs I Robinson

Apologies:Mrs P Armitage
Mrs A Courtney
Mr T Gallagher (Deputy Chairman)
Mr T Hamilton

In Attendance:Mr P Hughes (Committee Clerk)
Mr D Harkin (Assistant Clerk)
Mr D Gordon (Executive Support)
Ms L Dempster (Administrative Support)
Mr B Greene (Administrative Support)

Departmental Official: Mr Peter Deazley

Mr Deazley advised that the report on the professional assessment tool and the proposed payment system had been passed to the Minister for approval. He explained that the document on the assessment tool, which had been taken forward by professionals and had only recently been received by the Department, was substantial and would take time to digest.

Members expressed deep concern that, even at such a late stage in the Committee's consideration of the Bill, such major pieces of information were still not available. The Committee underlined its expectation that all the relevant material should have been made available in parallel with the legislation, to facilitate the Committee Stage of the Bill within the set timescale.

Agreed: The Committee agreed to defer further consideration of the Bill until a later date, when the Department would endeavour to make the outstanding information available. The Clerk will consult members with regard to the possible scheduling of an additional meeting, in order to meet the deadline of 07 June for the Committee Stage of the Bill.

The entire proceedings are recorded separately in verbatim minutes of evidence.

Present:Dr J Hendron (Chairman)
Mr P Berry
Rev R Coulter
Mrs A Courtney
Mr T Gallagher (Deputy Chairman)
Mr T Hamilton
Mr J Kelly

Apologies:Mrs P Armitage
Ms M McWilliams
Ms S Ramsey
Mrs I Robinson

In Attendance:Mr P Hughes (Committee Clerk)
Mr D Harkin (Assistant Clerk)
Mr D Gordon (Executive Support)
Ms L Dempster (Administrative Support)
Mr B Greene (Administrative Support)

Departmental Officials:Mr Peter Deazley
Ms Janice Smyth
Mr John McKeown

Mr Deazley spoke to a briefing paper in relation to the consultation on the nursing needs assessment tool, the fast track review mechanism, and the payment system. He outlined the main points from the paper, which are summarized as follows:

The terms of reference for the development of a nursing needs assessment were to review what was available in GB, as well as in Northern Ireland, and then to measure those tools against the National Service Frameworks. The information would then be used to develop a tool responsive to the nursing needs of people in Northern Ireland. The nursing needs assessment tool was piloted in seven sites across Northern Ireland, encompassing the four Board areas. Nurses from the Trusts and independent sector worked in partnership. The tool is now ready for stakeholder consultation.

The Minister has decided on a single rate payment system for nursing care, although the actual amount has not yet been settled. A survey is being carried out of the Trusts to determine how many fully or partly self-fund their nursing care, so that proposals can be put to the Minister on the weekly contribution towards nursing care. The payment will not be less than £85 per week.

The Department proposes to provide directions that will give statutory guidance on actions required by Boards/HSS Trusts to commence payments for nursing care in registered nursing homes from 07 October 2002. Trusts will be required to identify all nursing home residents who are funding their own care in nursing homes, and to inform those individuals, their families, carers or appointees of their right to an assessment for nursing care. Such an assessment will require the consent of the individual or their family or carer.

The assessment and review process will be set out in detail. If not satisfied with an initial nursing care assessment, the individual concerned can request a review assessment, which will be carried out by a different nurse within one week. If that does not prove satisfactory, a review panel must be set up to hear the case within a further two weeks. In England, almost all appeals to date have been against assessments that placed an individual in either of the lower of the three tiers of nursing need. A single tier system for Northern Ireland should therefore reduce the number of review requests.

The Chairman acknowledged the importance of the Bill, in terms of correcting an anomaly faced by some 2,000 self-funding residents of nursing homes who have been put at a distinct disadvantage in comparison with those receiving free nursing care as a health service in their own home. Adopting the provisions of Clause 1 would be a necessary first step in ensuring basic equity of provision and ensure that Northern Ireland can provide similar benefits to those in England and Wales.

The Chairman placed on record the Committee's ultimate desire for free nursing and personal care, if the resources are available. The Committee awaits the report of the Working Group on Personal Care in June 2002 but notes that the costs are anticipated to be well in excess of £25m. The Assembly and Committee's future consideration of free personal care will be informed by the Executive's examination of the financial implications and the experiences of Scotland, where it has already been introduced.

The entire proceedings are recorded separately in verbatim transcripts of evidence.

Question put and agreed to:

That the Committee is content with the Clause.

[Clause 2 and the Schedule to the Bill were previously agreed to.]

Question put and agreed to:

That the Committee is content with the Clause.

Question put and agreed to:

That the Committee is content with the Clause.

That the Committee is content with the Short Title.

Question put and agreed to:

That the Committee is content with the Long Title.

The Clerk advised that a draft report on the Bill would be prepared for consideration at next week's meeting.

Monday, 10 June 2002 at 12.00 pm
IN ROOM 152, PARLIAMENT BUILDINGS

Present:Dr J Hendron (Chairman)
Mr P Berry
Rev R Coulter
Mrs A Courtney
Mr T Gallagher (Deputy Chairman)
Mr J Kelly
Ms M McWilliams
Ms S Ramsey
Mrs I Robinson

Apologies:Mrs P Armitage

In Attendance: Mr P Hughes (Committee Clerk)
Mr D Harkin (Assistant Clerk)
Mr D Gordon (Executive Support)
Ms L Dempster (Administrative Support)
Mr B Greene (Administrative Support)

The Committee deliberated.

Draft Report on The Health and Personal Social Services Bill (NIA 06/01), proposed by the Chairman, brought up and read.

Ordered: That the Draft Report be read a second time, paragraph by paragraph.

Paragraphs 1 to 24 read and agreed to.

Resolved: That the Report be the Third Report of the Committee to the Assembly.

That the Report should include written and oral evidence from the following witnesses:

Age Concern (Oral Evidence)
Belfast Carers Centre
Down Lisburn Health and Social Services Trust (Written Evidence)
Eastern Health and Social Services Board (Written Evidence)
National Board for Nursing, Midwifery and Health Visiting (Northern Ireland)
(Written Evidence)
Prof Robert Stout, School of Medicine, Geriatric Medicine, Queen's University Belfast
Registered Nursing Home Association (Written Evidence)
Royal College of Midwives (Northern Ireland) (Oral Evidence)
Sperrin Lakeland Health and Social Care Trust (Written Evidence)
The Department of Health, Social Services and Public Safety (Oral Evidence)
The (Shadow) Northern Ireland Practice and Education Council for Nursing and Midwifery (Oral Evidence).

Resolved: That the Report be printed.

Wednesday 10 April 2002

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

Mr Peter Deazley
Mr Mike Hendra) Departmental Officials
Ms Judith Hill
Ms Jennifer Thompson

1.

The Deputy Chairperson: 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.

2.

Mr Deazley: 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.

3.

The Deputy Chairperson: What is the background to the Bill?

4.

Mr Deazley: 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.

5.

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 it 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.

6.

The Deputy Chairperson: What is the position in England, Scotland and Wales?

7.

Mr Deazley: 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.

8.

The Deputy Chairperson: They are obviously taking different approaches to the issue.

9.

Mr Deazley: 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.

10.

The Deputy Chairperson: How many people in residential care would benefit?

11.

Mr Deazley: 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.

12.

Ms Ramsey: 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".

13.

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.

14.

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.

15.

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".

16.

Mr Deazley: 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.

17.

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

18.

Mr Deazley: 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.

19.

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.

20.

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

21.

Ms Hill: 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.

22.

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.

23.

Ms McWilliams: 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.

24.

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?

25.

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.

26.

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?

27.

Mr Deazley: 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.

28.

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.

29.

Ms McWilliams: 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 an historical legacy or do more ill people here require nursing care rather than residential care?

30.

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

31.

Mr Hendra: 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.

32.

Ms McWilliams: Is that an appropriate direction?

33.

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

34.

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

35.

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

36.

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

37.

Mr Deazley: 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.

38.

Ms McWilliams: 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.

39.

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.

40.

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

41.

Ms McWilliams: 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 to England, Wales and Scotland.

42.

Mr Deazley: 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.

43.

Ms Hill: 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.

44.

Ms McWilliams: May the Committee have a copy of the assessment tool when it is published.

45.

Ms Hill: Absolutely.

46.

Mr Kelly: 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.

47.

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?

48.

Mr Deazley: 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.

49.

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.

50.

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

51.

Mr Deazley: 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.

52.

Mrs Courtney: 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.

53.

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?

54.

Mr Deazley: 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.

55.

Mrs Courtney: When will the consultation start?

56.

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

57.

Ms Ramsey: 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?

58.

Mr Deazley: 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.

59.

Ms Ramsey: 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.

60.

Mr Deazley: 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.

61.

Ms McWilliams: 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.

62.

Mr Deazley: They should not.

63.

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

64.

Ms Hill: 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.

65.

Ms McWilliams: 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?

66.

Ms Hill: 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.

67.

Ms McWilliams: They have raised that point with me.

68.

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

69.

The Deputy Chairperson: How does one appeal against an assessment of nursing care?

70.

Mr Hendra: 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.

71.

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

72.

Mr Deazley: 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.

73.

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

74.

The Deputy Chairperson: Let us now consider clause 2 and the schedule of the Bill.

75.

Ms Hill: 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.

76.

The Conservative Government started the review before devolution.

77.

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 practice.

78.

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.

79.

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.

80.

Ms Thompson: 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.

81.

Ms McWilliams: 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.

82.

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 -

83.

Ms Hill: That is why the men do not like the word 'matron'.

84.

Ms McWilliams: 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?

85.

Ms Hill: 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.

86.

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.

87.

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.

88.

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.

89.

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

90.

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

91.

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.

92.

Ms Thompson: We have not had any comeback or opposition.

93.

Mrs Courtney: 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?

94.

Ms Hill: 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.

95.

Mrs Courtney: 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.

96.

Ms Hill: We will look into that.

97.

The Deputy Chairperson: What are the costs?

98.

Ms Thompson: 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.

99.

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

Wednesday 17 April 2002

Mr Gallagher (Deputy Chairperson)

Ms Armitage

Mr Berry

Rev Robert Coulter

Mrs Courtney

Mr J Kelly

Ms McWilliams

Ms Ramsey

Mr Tom Cairns)

Mr David McConnell) Age Concern

Ms Caryl Williamson)

100.

The Deputy Chairperson: You are very welcome.

101.

Mr Cairns: Thank you. Age Concern is delighted to meet with the Committee. I hope that our submission will be as clear as Prof Stout's. Age Concern wholeheartedly agrees with all the points that Prof Stout made and was delighted to speak to him earlier.

102.

Age Concern welcomes the revised draft Budget and the provision of free nursing care from 7 October 2002. It was devastated that the first Budget did not even mention nursing care. However, on 27 February 2001 the following motion was passed: "That this Assembly notes the decision of the Scottish Parliament to provide the elderly with free nursing and personal care and calls on the Executive Committee to make similar provision for the elderly in Northern Ireland and to promote the greater well-being of the elderly in this part of the United Kingdom."

103.

Age Concern agrees wholeheartedly with that motion and the implementation of the recommendations of the Royal Commission on Long Term Care for the Elderly that nursing and personal care should be free, based on an assessment of need. A distinction between nursing and personal care is artificial, unworkable and unfair. The charges for those services will cause confusion, anxiety and bitterness. I will repeat some of Prof Stout's points, because the people with whom we deal feel strongly about the matter.

104.

If the Scottish Parliament goes ahead with its proposals a two-tier system will be created. The divide between nursing and personal care is false. The Scottish proposals would also create a divide across borders that would disadvantage Northern Ireland citizens.

105.

Personal care should be paid for by the state, as people have already paid tax and National Insurance. Even with the introduction of free nursing care, many will still be forced to use up their savings and sell their homes. All the organisations with which we are involved are united on the issue. The system discriminates against people with chronic illnesses, such as Alzheimer's disease or arthritis. It penalises people for their ill health. We must think again about means testing, and deliver on the promise of equity in healthcare. As Prof Stout said, the system creates diagnostic inequity. Patients in hospital have access to free personal care, but those receiving residential and nursing care must pay. That is humiliating for older people and turns them into third-class citizens. It is contrary to the spirit of section 75 of the Northern Ireland Act 1998 because it seems that older people are the only group that must pay for treatment as determined by a medical practitioner.

106.

We are running away from older people's issues, and that is the most central issue. The longer we run away, the bigger the mess there will be. I believe that the Northern Ireland Assembly will not abdicate its responsibilities for the most vulnerable citizens. Again, as Prof Stout said, the debate never took place in the community. There is great resentment and anger about that, because people thought that the Health Service would look after them when they needed it to. There are glaring anomalies and inconsistencies in the system. What is the definition of nursing care? Must people sell their homes in order to receive care? People simply cannot understand that situation.

107.

The case for free nursing and personal care was made most powerfully by the Royal Commission on Long Term Care for the Elderly. Universal free personal and nursing care are hallmarks of a society that understands the limits of individual responsibility. Prof Stout outlined what that means as regards how we prepare for what may happen to us as we age. We are asking the Assembly to deal with only one of the many health and social care issues that older people face.

108.

Age Concern raised all those points with the Minister, and when we met her, we outlined the enormous confusion among MLAs and the public. She agreed to write to MLAs and to clear up some of the public's confusion. People do not understand the system. As Age Concern lobbied the Assembly, it became clear that many MLAs do not understand the distinction between nursing care and personal care.

109.

Many people are not aware that an interdepartmental working group is investigating the financial and other implications of introducing free personal care in Northern Ireland. The group will report in June 2002. The latest figure for the cost of introducing free personal care is £24 million. The group is not taking any submissions from groups such as Age Concern, although it has now formed a working group that includes NGOs (non-governmental organisations). That approach does not represent open government on a central issue that affects older people.

110.

Some questions related to our information from England. Our colleagues there say that nursing assessments are complex and difficult to administer. There are extensive waiting lists for assessment, and nursing homes are increasing fees. Those who were supposed to benefit from nursing assessments are not doing so. That is therefore not a good way to legislate. I refer back to Prof Stout's answer to Ms Ramsey: we want the legislation, but it must be appropriate.

111.

I will hand over to my colleague Caryl Williamson, Age Concern's regional co-ordinator for advice and information. Through the service that she provides, the organisation receives thousands of calls from old people and their families. She will present some of the information that we are gleaning from England.

112.

Ms Williamson: I run Age Concern's busy advice line, which receives about 5,000 queries a year. More than one in 10 queries relates to residential nursing care. When we try to explain the situation to people, they become concerned about the current and projected charging procedures. People at all levels display fundamental and worrying ignorance about what is happening. Many believe that Northern Ireland has adopted either the Scottish or the English model. They imagine that nursing care is free, and they do not distinguish it from personal care. People are astonished to hear that Alzheimer's disease and dementia may not be covered in the current provisions, because they imagine that those conditions have specific nursing care needs.

113.

The feedback from Age Concern England about the English scheme has been interesting. The scheme there has been running for only six months, but Age Concern England raised concerns about the problems as early as January. One unexpected bonus of the assessment procedure in England is that it exposed poor practice and inappropriate or inadequate equipment for individuals, which might not have come to light otherwise. Unfortunately, the process is incredibly slow. Even in January there were severe concerns that care homes were using the situation as an excuse to raise prices. Another problem was that if people had difficulties with the assessment - even if they were capable of complaining - they did not know who to complain to, or where the buck stopped.

114.

In February, Age Concern England said that the system was an "absolute shambles." It called for an inquiry by the Health Select Committee. The document says that only those

"lucky enough to live in a home which is making sure that it passes the relevant NHS supplement . likely to see the benefits of 'free' nursing care."

115.

In March 2002, Paul Burstow, the Liberal Democrat Shadow Minister for Older People, conducted a survey and condemned the English system as "a cruel hoax". I have listed some of the relevant findings: three out of five health authorities and primary care trusts have definite evidence of homes not passing on payments - some of that evidence is widespread; one in five people are still waiting for a decision on their assessment, even though all assessments should have been completed by December 2001. We must not forget that the system has been in operation for only six months, and already the backlogs are building up. Those who have been assessed are owed £11.9 million in outstanding payments. Thirteen per cent of people did not have the face-to-face assessment that they were promised but were assessed by telephone. Glaring anomalies are still emerging despite the fact that twice the original number of nurses were employed to carry out the assessments. It is clear that the system is just not working.

116.

Although there is only one banding in Wales, compared to the three that operate in England, officials experience the same problems. Nursing homes increase their charges so that, fortuitously, they match the amount that people have been awarded. The award is nominal; often, it has no effect on people's income.

117.

The Deputy Chairperson: I apologise, Mr McConnell, but could you keep your comments brief? We must leave time to hear the submission and to ask questions.

118.

Mr McConnell: Mr Cairns mentioned that an estimated £24 million would be needed to pay for personal care. We do not know the costs of administering the nursing assessment tool, for example. Two thousand people pay for personal care, and more may become caught in the net because of the policy of selling homes to sitting tenants. People who in the past would not have owned their own home will do so now. As those people age, they may be affected by that situation.

119.

The interdepartmental committee to consider personal care is not accepting any submissions or evidence. There may be consultation on the outcomes of the committee's inquiries, but that contradicts the thrust of open government and consultation. Consultation should take place at a formative stage. Therefore, in response to Ms Ramsey's point, Age Concern is concerned about the focus of that interdepartmental committee, its considerations and the potential outcomes. Although a working group with some NGO representation, which is attached to the interdepartmental committee, has been formed, there is no formal NGO representation on it.

120.

Today I attended a meeting of the age sector reference group, an umbrella organisation of 17 old people's organisations, including Help the Aged, the Northern Ireland Pensioners Convention and all the local forums and consortia. Those organisations speak with one voice. They do not ask for free personal care - they demand it as a right.

121.

Rev Robert Coulter: I have received letters from people who are concerned because nursing homes have increased their prices. Such a price increase left one old lady with only 10p per week with which to buy personal items such as soap. What should the Department do to ensure that that does not occur?

122.

Mr Cairns: Such situations are exceptionally difficult to avoid, and officials in England are trying to deal with that. A major nursing home provider in England stated that providers are "driving a coach and horse" through the attempt to legislate for that. In England, officials are trying to insist that nursing home providers give a detailed breakdown of their costings; for example, hotel costs and nursing care. It would be a desperate situation if people did not have what is laughingly described as "pocket money" to cover the expenses of daily living. I can only suggest that the Department consider the attempts being made in England to legislate for that. However, those steps appear to be unsuccessful.

123.

Mr Berry: What steps is Age Concern taking to inform the elderly and their families about the Bill and its implications? Age Concern receives 5,000 queries a year, which is tremendous. What proportion of callers raised concerns about the Bill? There is a perception that the Bill provides for both free nursing care and personal care. Do many of those who make queries believe that the Bill covers both? How many calls have you received about the Bill?

124.

Mr Cairns: I will answer the first part of your question. The issue is so important that Age Concern does not deal with it alone. It is involved with the Right to Care group, which includes UNISON and the organisations of the age sector reference group. Through those bodies we attempt to get a better public understanding of the Bill. Age Concern has its own network of organisations throughout Northern Ireland, through which it provides information on the issue, but it is such an important matter that we need to operate as a strong sector in order to lobby.

125.

Ms Williamson will deal with the types of queries that Age Concern has received.

126.

Ms Williamson: One in ten queries concern residential and nursing care. However, many people receive too little information too late. First-time homeowners often feel especially at risk in Northern Ireland. Many people still feel that their home is safe because they have made a will to bequeath their property to their family. That perception exists across the board; there is widespread ignorance. Many people have no idea that this Bill is coming through.

127.

Many believe that "nursing care" includes personal care therefore they assume that they are entitled to free provision. They do not query why they must pay for their care until a bill arrives. If people knew what was really happening, there would be blood on the streets, for different reasons, because they would be extremely disappointed and unhappy.

128.

Mr McConnell: The Assembly has a cross-party group on ageing, of which Rev Robert Coulter is a member. In tandem with the debate, we are preparing a briefing on the issue for all Members. We are also preparing material for the media to diminish people's confusion about the matter.

129.

Ms McWilliams: The word "free" is very cosy. The care will not be free; there are bands. Your study said that in 13% of cases people did not receive a face-to-face assessment; therefore, the outcome might have been inappropriate. The lack of assessors is an enormous concern. To date, £11·9 million is still outstanding in relation to that 13%. Your survey suggested that as a result of those assessments some people might have put in the wrong band. If those people want a second opinion, is there a right of appeal whereby they can be reassessed?

130.

Ms Williamson: The real confusion is deciding to whom someone should appeal. Should an appeal be made to the nurse, the home, the trust or the board? There does not seem to be a clear procedure. A person may not even realise that his or her assessment was done improperly. Someone in a home who is in very poor health will not even realise that the assessment has been made. There are questions about advocacy and buried costs. In England, there seem to be fantastic amounts of buried costs in an inept scheme that is being poorly applied. Officials are now trying to put the brakes on too late.

131.

Ms McWilliams: Prof Stout spoke about rationing by diagnosis and rationing in the system. Here we have rationing within the bands, with no right of appeal. That leads to enormous concerns, given that a right to appeal exists in respect of other legislation. Prof Stout said that Age Concern might answer my question about the English experience, which you outlined. One of the concerns that the Committee expressed earlier was that the English authorities, instead of responding to concerns that nursing homes are retaining money, decided to change the care homes regulations so that homes cannot deduct money from the residents' fees. Similar care homes regulations exist in Northern Ireland. I anticipate that, if the Bill were passed, the same problems would arise here. The Committee is concerned that there would be an attempt to change our care homes regulations, rather than address the core of the problem in the first place.

132.

Mr Cairns: Absolutely.

133.

Ms McWilliams: Is that happening in England?

134.

Mr Cairns: Yes. As I said in my response to Rev Coulter, the care homes are confident that you could "drive a coach and horses" through any attempt to legislate on the matter.

135.

Ms McWilliams: I want it on the record that those regulations exist in Northern Ireland, and that we would have to do something similar.

136.

Mr Cairns: I am not sure about that.

137.

Ms Williamson: Part of the problem in England is that the money is not paid to the individual. Sometimes people are pre-assessed, and after that there is a holding brief until the assessment is carried out. It could be down to the framing of that in Northern Ireland.

138.

Ms McWilliams: I appreciate your concern that Assembly Members are confused. For the record, Members were further confused when they thought that the legislation had not come forward due to insufficient funds. However, the legislation was not in place, and the public was not made aware of that. That is why we are discussing the matter so late. Because the legislation is late, Northern Ireland might be able to benefit from the experiences of others and improve on the other systems. What would you say to that?

139.

Mr Cairns: I could not agree more. You raised that issue in the press recently. Northern Ireland is legislating on the matter a year late. Legislation was introduced on 1 October 2001 in England and Wales. Surely there is an opportunity to examine those matters.

140.

Mr McConnell: Given the timescales, is it possible that evidence from the pilot schemes in Northern Ireland would come forward too late for their consideration in the debate on the Bill?

141.

The Deputy Chairperson: We are not sure. It is likely that it will come too late. That is a good point, Mr McConnell.

142.

Ms Ramsey: I want to clarify that I was not suggesting earlier that personal care should not be introduced - I wanted to introduce the reality that the Health Service has been underfunded by £190 million over the past 10 years. There are competing issues, and I was asking whether we should build upon that point. I am concerned that the interdepartmental working group has not taken submissions. It should take submissions from people who are interested and knowledgeable about the matter.

143.

I wish to return to a question that Ms McWilliams asked. During our inquiry into the last Bill, we pointed out to the Department that trusts do not always make people aware of their rights. Officials were asked about that last week. During last week's Committee discussion, officials said:

"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."

On the effectiveness of the tool they said:

"we will put in place appropriate supervision arrangements to ensure feedback and monitoring of the effectiveness of this tool."

144.

We questioned the officials about the matter, and Ms Mc Williams asked for a copy of the details, to ensure that the tool is effective. I support the provision of free care, and I am not convinced that the definition of "nursing care" is appropriate. I agree that the separation of the two types of care is discriminatory. If the Committee rejected the Bill, it would not be passed by the Assembly. However, we would be disenfranchising 2,000 people, who would continue to suffer because they would have to sell their homes to pay for their care. Is it not right to build on the present Bill?

145.

Mr Cairns: I could not agree more, and I discussed the matter with MLAs earlier. I thought that the Assembly would be responsible for examining the possibility of providing both types of care much earlier. Age Concern would be delighted to see a fully costed proposal for the measure, the options within the existing Budget, and an examination of the proposals for obtaining additional resources.

146.

I am not familiar with the process whereby politicians go to Westminster and agree an adequate level of funding for this reasonable request. As this devolved Administration have no tax-raising powers, we need to examine the options within existing budgets. As Prof Stout pointed out, the Royal Commission on Long Term Care for the Elderly believe that that is eminently affordable.

147.

Only the care element should be covered, with a means test remaining for the hotel costs. Therefore, what we are proposing is not totally free. The Scottish Parliament took that on board, much to the extreme dismay of politicians in Westminster. The Scottish Parliament flexed its muscles effectively on the issue.

148.

Ms Armitage: We have been told that nursing homes are closing because they are no longer viable, and that accounts for the increase in their fees.

149.

There seems to be a difference in the provision for those with Alzheimer's disease. Some are accepted into a nursing home, but others have to go into a specialised unit, which normally provides free care. You said that many people believe that their house is safe because it has been bequeathed in a will. Is a house safe if it has been given to the family as a gift? There are many homes for the elderly in my area, so that information would be useful.

150.

Ms Williamson: Many people who have bequeathed property to their family do not realise that they have to die first for the will to take effect. That demonstrates many older people's basic lack of knowledge about how the world works. A person's house is not safe simply because he or she has signed a will.

151.

Ms Armitage: What is the situation if a person has given their house as a gift to his or her family?

152.

Ms Williamson: That is tricky territory, because it involves the intentional deprivation of assets. There is an excellent fact sheet on that subject. The house would still be regarded as an asset.

153.

Ms Armitage: People with Alzheimer's disease appear to be treated differently.

154.

Ms Williamson: That depends on how progressed the disease is. Those who suffer from Alzheimer's disease and dementia need a good deal of care and attention, which is not being defined as a nursing need - that is the problem. The disease can progress to the extent that a sufferer develops additional health conditions that require nursing attention, perhaps in a secure environment. That illustrates the real problems. People who are patently unwell, who are not themselves, and who need care and attention, possibly nursing care, may still fall outside the ambit of this scheme for a long time.

155.

Ms Armitage: Is it not correct that a person with Alzheimer's disease who is admitted to a special unit receives free care? It seems a bit unfair.

156.

Ms Williamson: There is a crossover. Someone with the early stages of dementia who needs only to be watched over so that he or she does not wander will not qualify for nursing. He or she may qualify later, but that could take years. It could take 20 years for someone with an early onset of dementia to reach that stage.

157.

Mr J Kelly: Further to Ms Armitage's point, yesterday I was involved in a case where someone with Alzheimer's disease was refused re-entry into a nursing home. What is the situation regarding that?

158.

Ms Williamson: It would depend on the grounds on which they were refused readmission. It would also depend on the type of home. Many people do not realise that there is a difference.

159.

Mr J Kelly: It was a nursing home.

160.

Mr Cairns: A private nursing home has a private contract with an individual; it is different from a residential home. The state has never provided nursing homes.

161.

The Deputy Chairperson: Thank you for your submission and for giving the perspective of the sector that would be most affected by the changes.

Wednesday 17 April 2002

Mr Gallagher (Deputy Chairperson)

Ms Armitage

Mr Berry

Mrs Courtney

Mr J Kelly

Ms McWilliams

Ms Ramsey

Mr R Devlin) Belfast Carers Centre

162.

The Deputy Chairperson: I welcome Mr Ricky Devlin from the Belfast Carers Centre.

163.

Mr Devlin: Thank you for your invitation. I will try to keep my presentation as short as possible, because I run the risk of sounding like a cracked record. I am about to repeat much of what has already been said.

164.

Generally speaking, the Belfast Carers' Centre welcomes the introduction of the legislation. However, there are several short points that I would like to make. My chief concern is the definition of what constitutes nursing care. I see little distinction between personal care and nursing care. That could be an invitation for endless arguments and discord in relation to the legislation. I see it is deemed as being nursing care by a registered nurse, or nursing care carried out under the direction of a registered nurse. There is much ambiguity in that definition. Other staff routinely carry out many duties that were once the preserve of a qualified nurse. The boundaries in the legislation are somewhat hazy. Therefore, I would be fearful of potential disruptive debates as parties seek to challenge or present existing or potential interpretations of the Bill's wording.

165.

Would I be presumptive in saying that if a cost has been formulated for this, should some thought not have been given to what actually constitutes nursing and personal care? I have possibly more questions than answers. Would it not be appropriate to include some such detail in the Bill?

166.

There is also a question of infrastructure in relation to free nursing care. This issue has already been touched upon, especially in an appeals process. Whom do I appeal to if I am the carer of my wife or my father in a nursing home, and I am unhappy with what has been presented to me? Do I appeal to the nursing manager, the officer in charge or to this Committee? Whom do I appeal to? Such a question is one reason that the issue should be considered carefully.

167.

A patient may be in a nursing home but may still be cared for by a wife, husband, daughter or son. I would be fearful of endless distress and argument over what constitutes what. If there is a review, the argument may arise that one person may feel that the case requires nursing care, whereas in someone else's opinion it is not nursing care. That would create much difficulty and distress. There is too much room for interpretation. Those who are the strongest advocates will win the argument; therefore, it is the most vulnerable and the least able to represent their views who will suffer the most. There is a danger that residents in one home may have different levies charged. The situation is a hornet's nest. There are too many grey areas and not enough black- and-white areas. The nettle should be grasped. There is a false distinction between personal care and nursing care: I cannot unpick that problem and have yet to see any other interpretation that would not leave room for argument.

168.

Ms McWilliams: You may not be in a position to answer this query, but given that you are from the Belfast Carers Centre, there is some evidence to suggest that with the transfer of reserved rights from the social security budget to the health budget that the problem is not only current funding. One of the trusts makes the point that in future these people may not be found places in homes, but may have to find places elsewhere because that funding runs over the years and those places start to decrease. Do you anticipate that carers in homes will take on that responsibility, because the Bill will have implications for those who are being nursed in their own homes?

169.

Mr Devlin: Yes, that would be the case. The situation with regard to nursing or residential home care and support for the cared-for in their own homes is a time bomb. There is concern that more pressure will be put on carers to continue to care within the marital or family home, because provision will not be available, or the quality of that provision will be questionable. I do not know if it is anecdotal evidence, but the quality of the care currently provided in nursing and residential homes is a regular concern of carers coming to the centre. Unless that situation is addressed fully, the concerns I have heard expressed, and from my own experience with my family, are that carers will be taking on a greater burden. That could be the case for carers even if the cared-for person is in a nursing home. That could add to, rather than alleviate, their distress. Some of the carers' financial concerns and burdens may be addressed, but frequently it is the families and the carers of the cared-for - as we would arbitrarily describe them - who pick up the tab.

170.

Ms McWilliams: Ms Armitage and John Kelly raised the point that there seems to be variation in the rates. The situation where people are transferred out was also raised. John Kelly mentioned the case where someone had not been readmitted to a home.

171.

We may all be aware of cases where people have not been accepted. That seems to make an even stronger case that rates should be agreed regionally, and that variation is avoided.

172.

Mr Devlin: That is very important.

173.

Ms McWilliams: Does the group that you represent see that? Are you getting phone calls about people being shifted here, there and everywhere?

174.

Mr Devlin: Less so. However, I am aware of the variations. The problem of readmittance is quite common. One has to ask why that is happening, and sometimes the answer is that a person's care or nursing needs change. We may not be qualified or equipped to maintain that person safely within the unit. Personal development is another matter. What sort of provision of care is there for that individual? Those variations do exist.

175.

Ms McWilliams: We could probably understand that, based on assessment of need, but our concern, if the Bill is passed, is that there might be assessment based on bands.

176.

Mr Devlin: That could happen, but I would not be -

177.

Ms McWilliams: We would increase the disorientation of many older people by shifting them around the system.

178.

Mr Devlin: That is a valid point, which applies to both patients and their carers. There is evidence of that happening already between one nursing home and another. I take people round nursing homes to show them the type of provision available, tell them what each home is charging and what they will be expected to pay. That causes much confusion and upset at a time when people are looking for suitable nursing care for their loved ones. All that does is pour fuel on the fire, causing more confusion, upset and disorientation. A false distinction is being made between personal care and nursing care.

179.

Mr J Kelly: The centre has highlighted that an infrastructure needs to be in place. Is the infrastructure there? If not, what changes must be made?

180.

Mr Devlin: The basic problem is the argument about what constitutes nursing care. I do not think that the infrastructure is there at the moment, because nobody has a ready answer. People ask me to define nursing care and personal care, and I cannot give an answer. I reply that it is in the legislation, and I am told that it is not. Is it anywhere else? I cannot see it. I am simply an outside agent and an advocate for carers. If I have a statutory responsibility, whom do I go to? That is not clear. If I go to body A and it does not know, that indicates a lack of infrastructure and a lack of clarity. That will create more difficulties than it will resolve.

181.

Mr J Kelly: Are you saying that the provision of that infrastructure will reconcile the differences?

182.

Mr Devlin: The way to reconcile the difference is to acknowledge that there is no difference. If a difference were to be made, then make it, because I cannot see it. We need a structure that allows a quick and clean method of reviewing the matter. Private day nursing care needs to change.

183.

The Deputy Chairperson: Thank you, Mr Devlin.

Wednesday 17 April 2002

Mr Gallagher (Deputy Chairperson)

Ms Armitage

Mr Berry

Rev Robert Coulter

Mrs Courtney

Mr J Kelly

Ms McWilliams

Ms Ramsey

Prof R Stout

184.

The Deputy Chairperson: I welcome Prof Robert Stout from the School of Medicine, Geriatric Medicine, at Queen's University Belfast.

185.

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

186.

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 the proposals come from its recommendations.

187.

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.

188.

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.

189.

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.

190.

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.

191.

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.

192.

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.

193.

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.

194.

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.

195.

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.

196.

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 for. 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.

197.

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.

198.

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.

199.

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.

200.

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.

201.

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.

202.

The Deputy Chairperson: Thank you for your clear submission, Prof Stout. Members may now ask questions.

203.

Rev Robert Coulter: 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?

204.

Prof Stout: 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.

205.

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.

206.

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.

207.

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.

208.

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. Intermediary 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.

209.

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.

210.

Ms McWilliams: 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.

211.

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?

212.

Prof Stout: 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.

213.

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.

214.

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.

215.

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.

216.

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.

217.

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.

218.

Mr J Kelly: 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?

219.

Prof Stout: 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.

220.

Mr J Kelly: 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?

221.

Prof Stout: 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.

222.

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.

223.

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.

224.

Mrs Courtney: 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?

225.

Prof Stout: 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.

226.

Ms Ramsey: 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.

227.

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.

228.

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.

229.

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?

230.

Prof Stout: 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.

231.

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.

232.

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.

233.

The Deputy Chairperson: That concludes the questions. Thank you for your helpful submission.

Wednesday 24 April 2002

Mr Gallagher (Deputy Chairperson)
Ms Armitage
Mr Berry
Ms Ramsey
Mr Hamilton

Ms Paddie Blaney)Northern Ireland Practice and
Education Council (NIPEC)
Ms Maureen Griffiths)

234.

The Deputy Chairperson: I should like to welcome Ms Paddie Blaney and Ms Maureen Griffiths from the Northern Ireland Practice and Education Council (NIPEC). Perhaps you might start with a short presentation, after which we shall proceed to questions.

235.

Ms Griffiths: The main role and function of NIPEC is to support nurses, midwives and health visitors in their education and practice. Its ultimate aim is to provide better patient care. Through supporting the profession it provides better care for patients, families and communities. Appointments to the council were made through an open selection process. I applied and was appointed as chairperson. Afterwards there was an open selection process to appoint members of the council. While we did not state in our advertisements that we wished to have a midwife or health visitor, we took care to satisfy ourselves that each sector of practice was represented in some way. We were looking for a mix - 60% professional and 40% lay - and we have been able to achieve that balance in the applications which we have received. We are happy to have a strong council. Our approach has been to retain one or two places so that we can identify any gaps which need filling in NIPEC's early months.

236.

Ms Blaney: Thank you for the opportunity to speak to the Committee. I have a foot in both camps, as I am still a nursing officer in the Department, and next week I become chief executive designate of the shadow NIPEC, which has the status of an advisory body.

237.

The role and aim of NIPEC have come together through three main factors. The first factor was that, about four and a half years ago, we reviewed legislation regulating nurses, midwives and health visitors across the UK. I know about it because it was largely part of my remit; it achieved final fruition on 1 April 2002. We have established a UK-wide regulatory body for nurses and midwives which registers them and ensures that good conduct is maintained. The legislation meant that we lost the national board for Northern Ireland - which was largely an education quality-assurance body - and it was replaced by the Nursing and Midwifery Council (NMC).

238.

The second main factor was devolution. It was happening in Wales, Scotland and Northern Ireland, and all those countries were examining their devolved health and education systems to find out what they required to support the professions. Each country has gone for a similar body, though ours is slightly broader functionally.

239.

The third area of dynamism at the time was clinical and social care governance, concerned with quality, better partnerships, more accountability and the importance of professionals remaining up to date and safe to practise. Along with the development of the An Bord Altranais, our sister regulatory body and national council in the Republic, that gave us an opportunity to examine what we need in Northern Ireland to support the development of nursing and midwifery. We must support that because of the huge changes in roles.

240.

Nurses work in criminal courts, schools and industry. They also work with clients in clinics and on the streets. It was recognised that a body could be established to support the development of nurses and midwives in a more local fashion. That has been the historical background and rationale to the establishment of NIPEC. I am delighted to have been given the role of chief executive designate, but I have yet to take it up full time. When I take up that role, the focus of our work will be on education, practice development and performance.

241.

The difference in our body lies in its broader functions. It is not simply concerned with education; there is much more lay involvement. As Ms Griffiths said, 40% of the council's representatives are lay people, and that will bring a wonderful dynamic to NIPEC. That is a broad interpretation of our role, and I am happy to take more detailed questions.

242.

Mr Hamilton: Thank you for your presentation. Ms Griffiths said that each sector should be represented in some way. How are midwives represented?

243.

Ms Griffiths: We have appointed a midwife as an educationalist. I am also a midwife, albeit non-practising. Ms Blaney made a point about practising midwives. There is a midwifery focus, and the opportunity existed for practising midwives to apply in open competition. While that did not happen on this occasion, I stress that there is no bar to such applications. The same applied to health visitors, among whose number I count myself. There are ways of bringing those perspectives to the work of the council.

244.

Mr Hamilton: Since you wish to see each sector represented, would automatic places for practising midwives and others rather than nominations from the Department not be the best way to achieve that?

245.

Ms Griffiths: A great deal of thought went into the matter. What do you mean by nominations from the Department?

246.

Mr Hamilton: The midwives said:

"We are concerned, however, that it is proposed that all nominations to the board should be made by the Department of Health, Social Services and Public Safety."

247.

Would you not feel more content that everyone was properly represented if midwives had a right to a place?

248.

Ms Griffiths: As I have explained, appointments were not made through a nomination process but through open competition. The Nolan principles were applied. Since we wished a balance of 60% professionals and 40% lay people on a council of between 10 and 16 members, we could have representatives from mental health, learning disability and all the different specialisations.

249.

On reflection, we did not consider it the best route to take; we felt it would be better to have an open competition and get the best candidates. Thereafter there would be other ways of working through expert panels, so that, if the council had to discuss a midwifery issue, I could have midwifery input. The remit of my other position also covers midwifery. I commission midwifery services, so there will be no ignorance of such issues. The council will have an educationalist with a strong midwifery background, and we shall also be able to draw on experts from the sector. The same will apply to health visiting and learning disability if they are not represented.

250.

Mr Hamilton: Are you saying that the Royal College of Midwives (RCM) was incorrect when it said:

"We are concerned, however, that it is proposed that all nominations to the board should be made by the Department of Health, Social Services and Public Safety."?

251.

Ms Blaney: That is incorrectly expressed. There were no direct appointments; there were an open competition and interviews to decide the composition.

252.

Mr Hamilton: That would suggest that we are talking not about what has happened, but what is proposed.

253.

Ms Blaney: They are incorrect, as I shall try to explain. I believe that the RCM is concerned about nominations at this stage. It is incorrect, since we did not nominate, and neither did the Department. The Department advertised under the Nolan principles and conducted interviews to determine the body's composition.

254.

Mr Hamilton: You are telling us what happened to put you and the rest there.

255.

Ms Griffiths: No, it was to put the council in place.

256.

Mr Hamilton: Put the council in place?

257.

Ms Blaney: Council members have been interviewed and have only just received letters of appointment. A press release will be made later this week or next. There is a hiatus there to explain this properly. The Minister has already given her approval for the composition of the panel drawn from the nominations. That is probably where the misunderstanding arose.

258.

Mr Hamilton: So there is no proposal that future nominations be made by the Department?

259.

Ms Blaney: Not to the best of my knowledge. Any future council would be recruited under the normal procedures for appointing non-departmental public bodies - open advertisement under the Nolan principles and competition decided on that basis.

260.

Mr Hamilton: The document appears to discuss what will happen in future.

261.

Ms Blaney: We are not aware of that.

262.

Mr Hamilton: I merely wish to be clear about the matter.

263.

The Deputy Chairperson: We can return to it when we go into detail on the clauses with the Department.

264.

Ms Blaney: I am certainly sympathetic to any sector of nursing which feels that NIPEC should represent it. As chief executive I am conscious that it is equally important that women with children feel NIPEC has something to offer them. It has been a delicate balance, and we shall "suck it and see". We shall have some latitude on numbers when NIPEC is established and sets to work. If we see any gap, we can certainly work to fill it.

265.

Ms Armitage: If we are concerned, should this be removed?

266.

Ms Blaney: I am not sure of the status of the paper to which you refer.

267.

The Deputy Chairperson: It is merely a submission on behalf of the RCM. At this stage it is a submission, and we shall go back to the departmental officials. At present we are taking submissions from other interested parties in preparation for the final stages of the Bill.

268.

Ms Blaney: We can correct that and give you a fuller picture.

269.

Ms Ramsey: I am not claiming to speak for the RCM, but, while the advertisement is to be open, the college's concern is with the criteria put in place by the Department, which appoints people to the board. It might be open, and 100,000 people might apply for it, but criteria are in place, and it is a departmental appointment. My concern is to clarify that. While it is open and accountable, it is still the Department's selection.

270.

Ms Blaney: I cannot talk about the specific process, as I was not involved. However, I can assure you that the criteria were set to find those who would contribute the most personally, as opposed to narrower criteria which would have disadvantaged midwives.

271.

Ms Ramsey: I understand that, but my concern is whether the proper criteria are in place. I take on board the point you made that 40% of the council are lay members; that is commendable. We do not want to set up another quango made up of the great and good. I should like to see a copy of the criteria in place by the time the Minister makes appointments. It is not a question of whether people are applying, but of whether they get the job.

272.

Ms Griffiths: [Inaudible owing to mobile phone interference.]

273.

Ms Ramsey: I mean in general. As a layperson I can [Inaudible owing to mobile phone interference.] anybody who is appointed to the council..

274.

Ms Blaney: The application criteria in the advertisement were very open.

275.

The Deputy Chairperson: We can find out more about the matter from the Department.

276.

Ms Ramsey: Few people have any problem with the Bill generally. In your presentation you said that, given the council's work, there may be a need to co-opt others who do not currently sit on it. I sit on several groups which allow the co-opting of those working in the mental health field. Can your organisation solve that problem? Can free places be set aside to co-opt a nominated representative?

277.

Ms Blaney: Places on the council itself can be set aside. We also propose allowing secondments for particular pieces of work. There will be project work which midwives could, where relevant, feed into. We hope to establish expert panels for education and practice development which will offer different levels of opportunity for active involvement from any practitioner, nurse, midwife or health visitor.

278.

Ms Griffiths: The arrangements are flexible and should be more dynamic rather than static.

279.

Mr Berry: Will the Bill's provisions meet all the council's needs? Do you feel that there might be a time when you have to revisit it?

280.

I asked Breedagh Hughes of the RCN about the database, and you will be aware of my concerns on the question. We have been told that it is proposed that NIPEC retain a database on qualifications and training.

281.

Ms Blaney: As a nursing officer, my current remit covers areas related to the Bill. The project director the Department appointed is here today. We hope that the structure will enable NIPEC to support the development of nurses proactively to improve care. I cannot see any major loopholes in the Bill; it is enabling legislation, and I am sufficiently comfortable that we shall be able to deal with it.

282.

There are two issues to be clarified about the database. The NMC, which is now the UK-wide regulatory body, will continue to maintain a register. A person must appear on that register to practise as a nurse and midwife. That will continue and will be simplified. Nothing will change. Every nurse, midwife, health visitor, mental health nurse, learning disability nurse and children's nurse in Northern Ireland must be on that register to practise. It is a public safety and regulatory issue.

283.

There is some confusion about the NIPEC database. Previously, the national board held an indexing database, whereby any student entering training was indexed and tracked through it. At the end of three years' training, the national board told the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) that the student could be entered on the register. The NMC has put new arrangements in place to do that electronically together with all the universities in England, Scotland, Wales and Northern Ireland, so an indexing database is no longer required here to register people.

284.

NIPEC will need to develop databases which support its work, for example, databases of practice development work. There has been the old syndrome of brilliant work being done in one area without the sister in the next ward or trust knowing about it. There will certainly be information needs and database developments. They will not be at an individual level but will be maintained by the NMC. That is also a public safety issue.

285.

Ms Griffiths: NIPEC's database is functional.

286.

The Deputy Chairperson: Thank you very much for your submission. It has been very helpful.

Wednesday 24 April 2002

Mr Gallagher (Deputy Chairperson)

Ms Armitage

Mr Berry

Mr Hamilton

Ms Ramsey

Breedagh Hughes) Royal College of Midwives

287.

Ms Hughes: Thank you for the opportunity to appear before the Committee.

288.

The United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) was disestablished at the end of March 2002 and replaced by the Nursing and Midwifery Council (NMC) on a UK basis. Separate local bodies were to be established for each of the four countries, and the Royal College of Midwives (RCM) in Northern Ireland welcomed that. It had been proposed that everything would be dealt with from London - a suggestion with which RCM members in Northern Ireland were unhappy. Therefore, we are glad to have a replacement local body in Northern Ireland. I wish to put on record our thanks to the previous staff of the National Board for Nurses, Midwives and Health Visiting in Northern Ireland (NBNI). We look forward to working with the new body - the Northern Ireland Practice and Education Council (NIPEC).

289.

The RCM welcomes NIPEC's establishment as a non-departmental public body. It feels strongly that the new body must be a step removed from the Department of Health, Social Services and Public Safety (DHSSPS). When the format of the new body was in consultation, three options were proposed: that it be a completely independent statutory body; that it would be a unit in the Department; or that it would be established as a non-departmental public body.

290.

The RCM's preference was for it to be an independent statutory body. However, the costs would have had to be borne by the registrants. Bearing in mind that the cost of the NMC on a UK basis is also borne by the registrants, the RCM felt that that would be an unfair financial penalty. Therefore, the second best option was the establishment of a non-departmental public body. The RCM did not consider it appropriate that the new body should be established as a unit of the DHSSPS.

291.

The RCM welcomes the fact that the staff of the NBNI have transferred to the new body, which is operating in shadow form, and that they have full protection of their existing terms and conditions of employment in accordance with the Transfer of Undertakings (Protection of Employment) (TUPE) regulations. It also welcomes the new body's continued recognition for trade unions and professional organisations such as the RCM.

292.

The RCM has some concerns about the composition of the new council. While it is satisfied that the proposed spilt between practicing nurses, midwives and health visitors, of whom there will be 60%, and lay members, of whom there will be 40%, is a healthy balance, it is concerned by the proposal that all nominations to the board should be made by DHSSPS. There should be an opportunity for organisations such as the RCM or those that represent consumers to have scope for nomination. Obviously, that would be in accordance with the public appointments system and the Nolan principles. The RCM believes that a senior practicing midwife should be a member of the board.

293.

Section 2(4)(a) of the draft Bill states that the new council shall act

"in accordance with any directions given to it by the Department".

294.

That proposal initially caused the RCM some concern.

295.

We agree with the provisions of section 2(4)b that the council should act under the general guidance of the Department, but we would like clarification as to what working "in accordance with any directions" means. The concept of a non-departmental public body infers a degree of autonomy and independence, and that may be compromised by a requirement to work under the direction of the Department.

296.

We received a letter from the Minister's office dated 8 March - the Committee may have received a copy - that deals with nursing, midwifery and health visiting and the approval of education programmes in Northern Ireland, and sets out what NIPEC's functions will be. It states that one of the functions of the new body will be to maintain a database relating to the qualifications and training undertaken by midwives. We will seek clarification of the details to be held on that database, as it is not clear what will be included. Will it be details of people undergoing pre-registration education leading to the qualification of a nurse or midwife, or will it hold qualifications and details of every practising nurse, midwife and health visitor in Northern Ireland?

297.

The letter also states that the recognition of qualifications will be reciprocal: a course undertaken in Northern Ireland will be recognised in England, Scotland and Wales. We have an agreement where qualifications are recognised in the Republic of Ireland and elsewhere in Europe. That is important and we welcome it.

298.

We feel that NIPEC will contribute to the development of clinical and social care governance by setting standards and monitoring the quality of education and practice of nurses, midwives and health visitors. We are pleased that we will have a local body and that we will not be left with a system of visitors from London, which is what will be happening in England. It would not be appropriate to have someone from London assess the standard of training here.

299.

NIPEC must work closely with the human resources directorate of the Department of Health, Social Services and Public Safety regarding workforce planning. Over the last few years the Minister has announced several increases in the number of nurse training places, and we understand that there will be a significant increase in midwifery training places from September. However, the Minister's decision to increase training places must be carried through by NIPEC. It will have to validate the programmes of education, and ensure that the clinical placements will meet the proper standard.

300.

We hope to see the introduction of direct-entry midwifery training. That system allows any individual who knows from the outset that he or she wants to be a midwife rather than a nurse to undertake a three-year training programme and to qualify as a midwife without necessarily having to qualify as a nurse first. We hope that NIPEC will consider that urgently.

301.

We welcome the careers' advisory function to be undertaken by NIPEC. Nursing and midwifery were transferred to higher education in Northern Ireland in the last few years, and everyone seemed to have abdicated from the responsibility to provide careers advice to young people who are considering nursing or midwifery as a career. As the national board was not providing education any more, it did not think that it had a duty to advise young people. Queen's University did not think that it was its duty either; it provided details of the courses it provided, but not on what it meant to be a nurse, midwife or health visitor. The careers' advisory role fell into a black hole, and we are delighted that NIPEC has undertaken to retrieve it.

302.

Healthcare support workers should be regulated. There has been discussion recently in the professional press about whether the Nursing and Midwifery Council might eventually take that on. At present we have an anomalous situation where, if a nurse is found guilty of misconduct by the regulatory body, that nurse can be struck off the register. However, there is no legislation to prevent a person being re-employed in the same place as a healthcare assistant and perhaps repeating what he or she had previously done. Healthcare support workers should be regulated, and we are pleased that the Northern Ireland Practice and Education Council for Nursing and Midwifery (NIPEC) is going to develop the role of healthcare support workers. This is a possible first step in the process of preparing them for future regulation.

303.

We welcome the establishment of the new local body. It has great potential, but we have some concerns. Since 1902, midwives have worked under a system of statutory supervision. At present, the four boards in Northern Ireland act as the local supervising authority for midwives. That role was previously co-ordinated by the National Board for Nursing, Midwifery and Health Visiting. The Nursing and Midwifery Council has decided that it will take the duty back, but we are unclear about the future supervision arrangements for midwives in Northern Ireland. By top-slicing each of the four boards, we could establish one local supervising authority for the whole of Northern Ireland. We contend that that authority should be overseen by a senior practising midwife. We hope that NIPEC will consider that option once it is up and running.

304.

Mr Berry: It is proposed that NIPEC maintain a database relating to the qualifications and training undertaken by midwives. Do you back that proposal?

305.

Ms Hughes: We are not sure what the database will consist of. The Nursing and Midwifery Council already has the details of every nurse, midwife and health visitor who practices in the United Kingdom. The proposed database may simply separate the Northern Ireland section from that. It may contain the details of nurses and midwives in training who have not yet qualified, or of those who have qualified and are undergoing some type of post-registration education or training. That would be helpful. However, we do not know what the proposal involves, and we would like that to be clarified.

306.

Mr Berry: Have you already asked for that clarification?

307.

Ms Hughes: No. The letter arrived only two weeks ago, and the chief executive of the new body will not take up her post until next week. We will ask for clarification, however.

308.

Mr Berry: I am sure that you agree that the direct-entry qualification would attract more people to your profession.

309.

Ms Hughes: It would have two effects. First, it would attract older women - particularly those with families - who cannot see the point of training as a nurse for three years and then having to wait for a place on a midwifery programme, as that means it can take up to six years to qualify as a midwife. If the training could be completed within three years, it would be a more attractive option for such people. Secondly, because those people would not also be qualified as nurses, the training would keep them in midwifery. They would not be able to seek career progression in nursing because they would not have a nursing qualification. That is a very selfish attitude, but it would keep people in the profession. For older people who have thought long and hard about which direction they wish to take, that is a good thing.

310.

Ms Ramsey: You raised concerns about appointments. NIPEC representatives will come before the Committee after you. You presentation suggested that you do not have many problems with the Bill itself, but you are seeking clarification. I will leave that question for NIPEC, and you can stay to hear their reply.

311.

Ms Hughes: I will, thank you.

312.

The Deputy Chairperson: As regards independence from the Department, you raised the issue of nomination by the Department. I presume that there will be some consultation on that before people are nominated. Do you envisage that your organisation will be consulted?

313.

Ms Hughes: A general advertisement invited people to apply for appointment to the council. The Department of Health, Social Services and Public Safety appointed the council's first chairman in advance of the rest of the council. The Bill provides that, in the future, council members will elect a chairman from within the body. The process is slightly different first time around, which is understandable as the body is so new. It is proposed that there will be between 10 and 16 people on the council. As I said, there will be a balance between professionals and lay people, which we think is healthy.

314.

The difficulty is that we continue to trawl via advertisements in the 'Belfast Telegraph', there applications may not be received from all areas of practice. It would be helpful if professional organisations such as ours, the Royal College of Nursing and the Community Practitioners and Health Visitors Association (CPHVA) had the right to nominate someone from their organisation to the council to ensure that there would always be one nurse, one midwife and one health visitor on the council. If council membership is put out to a general trawl people will apply as they are moved, and there may be areas of practice that are not represented on the council.

315.

Ms Armitage: I am still not sure about the direct-entry rationale, but I must accept that you think that it is a good idea. Is there a different salary scale for nurses and midwives? A nurse obviously has more training than a midwife. Would a midwife not benefit from nursing skills or training?

316.

Ms Hughes: The three-year midwifery-training programme covers all medical illnesses that a pregnant woman is likely to have. The programme encompasses aspects of nursing. It normally takes 18 months to train as a midwife. If the general nursing training - such as work on male surgical wards, which is not relevant to midwifery training - is taken out, there is a combination of 18 months nursing training and 18 months midwifery training. The person is a qualified midwife at the end of the course, but with sufficient nursing skills to care for pregnant women who may be ill.

317.

Ms Armitage: That is what accounts for the different salary scales.

318.

Ms Hughes: The salaries are different. It is accepted that midwives largely work autonomously and a doctor will only be called in where there is a problem. By and large, nurses tend to work as part of a team under the direction of a doctor who prescribes care.

319.

From April 2002, it has been recognised that, in view of the way that midwives work, the minimum grade for a midwife after one year's post-qualification practice will be F. I am conscious that it could take many nurse years to reach that grade. The Royal College of Nursing feels strongly about that. Nurses and midwives are graded on the same system, but midwives tend to be graded higher. Health visitors are graded higher than midwives. The minimum grade for a health visitor is G. The minimum grade for nurses is D. The Royal College of Nursing has taken issue with that.

320.

The Deputy Chairperson: Thank you for your submission. It has been very helpful.

Wednesday 8 May 2002

Mr Berry

Rev Robert Coulter (Acting Chairperson)

Mr J Kelly

Ms McWilliams

Ms Ramsey

Mrs I Robinson

Mr P Deazley)

Mr M Hendra)Department of Health, Social
Services and Public Safety

Ms J Hill)

Ms J Thompson)

321.

The 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.

322.

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:

"(a) the provision of care, or

(b) the planning, supervision or delegation of the provision of care, other than any services which, having regard to their nature and the circumstances in which they are provided, do not need to be provided by a nurse so registered."

323.

The Bill removes the recoverable aspect of any nursing home charges that include an element of nursing care cost. It is a simple Bill.

324.

The Chairperson: Do members wish to make any comments?

325.

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?

326.

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

327.

Ms Ramsey: Is that definite?

328.

Mr Hendra: Yes.

329.

Ms Ramsey: Will the Committee see the report?

330.

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

331.

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?

332.

The Chairperson: Are there any further comments or questions?

333.

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?

334.

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

335.

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

336.

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.

337.

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?

338.

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.

339.

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.

340.

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 own incomes.

341.

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.

342.

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

343.

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

344.

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

"the planning, supervision or delegation of the provision of care"

by a registered nurse. That does not include all the care provided by a nursing home - only the nursing care element.

345.

Mr Berry: The Committee has taken evidence from many witnesses, and we feel that there is no definition of what constitutes care. Professionals in the field have not had an answer, and the boundaries are unclear. The Chief Nursing Officer has explained the assessment process that has been developed and the training that will be required. However, witnesses have told us that similar tools in England have not worked and that the system there as a shambles. Can you explain that?

346.

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.

347.

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.

348.

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?

349.

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

350.

Mrs Courtney: Where will the pilot schemes take place?

351.

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

352.

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

353.

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

354.

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.

355.

Mrs Courtney: I am still not convinced.

356.

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.

357.

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.

358.

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 is nursing care and what is personal care?

359.

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

360.

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.

361.

The 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?

362.

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.

363.

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

364.

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.

365.

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

366.

The Chairperson: When will we get information on that?

367.

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

368.

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

369.

Mr Deazley: Which assessment?

370.

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

371.

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.

372.

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

373.

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.

374.

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.

375.

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

376.

Mr Hendra: Yes.

377.

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?

378.

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.

379.

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.

380.

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.

381.

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.

382.

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.

383.

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.

384.

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.

385.

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.

386.

Ms McWilliams: How would that be done?

387.

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

388.

Ms McWilliams: Would it go into the Statutory Regulations?

389.

Mr Hendra: It may be regulated on.

390.

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

391.

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?

392.

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.

393.

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

394.

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.

395.

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

396.

The 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?

397.

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.

398.

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

399.

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.

400.

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.

401.

The 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?

402.

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

403.

The Chairperson: Yes.

404.

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.

405.

The Chairperson: Who will institute the review?

406.

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.

407.

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

408.

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.

409.

The Chairperson: Are members content?

410.

Ms Hill: Clause 2 refers to the establishment of the Northern Ireland Practice and Education Council for Nursing and Midwifery (NIPEC) and sets out its duties. These include promoting high standards of practice for nurses and midwives and standards for education, training and professional development. Clause 2 also indicates how NIPEC should take these forward through a range of activities providing guidance and information, exercising its functions in close association with the Department.

411.

The Chairperson: Are there any questions?

412.

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

413.

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

414.

Mrs Courtney: They are simply not named explicitly.

415.

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.

416.

Mrs Courtney: Is that simply a matter of standardisation?

417.

Ms Hill: Yes.

418.

Ms McWilliams: You may not be able to answer this question. Recently some 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 non-departmental public body (NDPB) the same as for the others?

419.

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

420.

Ms McWilliams: Are there are any differences?

421.

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.

422.

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

423.

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.

424.

Ms McWilliams: Will this NDPB replace the NMC?

425.

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.

426.

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

427.

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

428.

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

429.

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.

430.

Ms McWilliams: So it is more policy-oriented.

431.

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.

432.

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?

433.

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 a nurse 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.

434.

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.

435.

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?

436.

Ms Hill: Yes, some do. Interestingly, the Republic of Ireland has gone for two bodies. They have gone for An Bord Altranais, which is their 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.

437.

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.

438.

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?

439.

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, as the body will not be registered, it will not deal with 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.

440.

Question, That the Committee is content with the clause, put and agreed to.

441.

Ms Thompson: The schedule sets out some of the general arrangements for the functioning of the organisation. More detail will be included in the regulations, which will be submitted to the Committee at a later stage. The schedule sets out the status of the body, its general powers and duties, membership, appointments and procedure.

442.

Ms McWilliams: How many people will sit on the body?

443.

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 we have been flexible so that, if the committee wants 16 members when the legislation has been passed, it will be able to arrange that.

444.

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?

445.

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

446.

Mrs I Robinson: What are their backgrounds?

447.

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.

448.

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.

449.

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?

450.

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.

451.

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

452.

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

453.

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

454.

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

455.

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

456.

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 substitute payments for carer allowances but no separate remuneration.

457.

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

458.

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.

459.

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

460.

Ms Thompson: The NISCC has also made that provision.

461.

Ms McWilliams: Is it made by other NDPBs?

462.

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.

463.

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

464.

The Chairperson: Are there any questions on paragraph 7?

465.

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

466.

Ms Hill: Yes.

467.

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

468.

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

469.

Ms Thompson: Yes. An NDPB will require a change to that rule.

470.

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

471.

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

472.

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

473.

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

474.

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

475.

The Chairperson: We shall now move to paragraph 20.

476.

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

"This paragraph applies to property, rights and liabilities".

477.

Ms Thompson: That section of the legislation was required because some of the existing staff and assets of the national board are coming over to the new body. However, as NIPEC is currently only an advisory shadow body, it does not have the right to employ staff or hold assets. We therefore had to produce a mechanism for those staff to be transferred. They currently come under the remit of the Central Services Agency. Paragraphs 20 and 21 allow the transfer of staff so their superannuation continues and they have their existing employment. When the legislation is passed, they will be employed by NIPEC. It allows the transfer from the CSA to NIPEC.

478.

Mrs I Robinson: In our file there is a letter dated 25 March 2002 from the National Board for Nursing, Midwifery and Health Visiting for Northern Ireland. It questions sub-paragraph 21(1)(a). However, the reference to the Nursing and Midwifery Order 2002 is incorrect. It should read "the Nursing and Midwifery Order 2001 Statutory Instrument 2002 No. 253," which is the legislation establishing the NMC from 12 February 2002.

479.

The Chairperson: I beg to move

480.

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

"Nursing and Midwifery Order 2002"

And insert

"The Nursing and Midwifery Order 2001 Statutory Instrument 2002 No. 253."

481.

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

482.

Question, That the Committee is content with the schedule, subject to the Committee's proposed amendment, put and agreed to.

483.

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

Tuesday 14 May 2002

Dr Hendron (Chairperson)

Mr Gallagher (Deputy Chairperson)

Mrs Courtney

Mr Hamilton

Rev Robert Coulter

Mr J Kelly

Ms McWilliams

Mrs I Robinson

Mr Peter Deazley)Department of Health, Social Services and Public Safety

Mr John McKeown)

484.

The Chairperson: The Committee welcomes Mr Peter Deazley and Mr John McKeown, who have returned to discuss the Health and Personal Social Services Bill. Matters were raised last week, especially regarding the possible appeals system. If you will update the Committee on what has happened since then, my colleagues will then ask questions.

485.

Mr Deazley: There is a model review process on which the Department has previously consulted. It can easily be developed to take account of the nursing care assessment process. The process is brief and would obviously have to be redrafted to suit nursing care and be put out to professional colleagues and any interested professional bodies, including the Committee.

486.

Essentially, the process requires the assessment to be reviewed within one week to the satisfaction of the service user, the carer, the family or other interested parties. Where it is not satisfactorily sorted out, a panel must be constituted and a further review completed within two weeks. Therefore, the complete process takes three weeks.

487.

The Chairperson: The other point concerned whether the check on feedback can be made available to the Committee.

488.

Ms McWilliams: It would be better to discuss each point one at a time; otherwise, it will be more difficult.

489.

The Department already had that model review for other purposes?

490.

Mr Deazley: Yes. It was used for guidance on continuing healthcare.

491.

Ms McWilliams: Why would you use that model? Because it has been tried and tested, and it works? I am concerned that we are dealing with nursing care, which, in its own right, is a very specific area. A particular assessment tool must be produced.

492.

Mr Deazley: I did not say that that particular process would be used. I said that the model could be adapted and developed for nursing care purposes. The consultation for it was done in 1998, so it is out of date.

493.

Ms McWilliams: That was what I wanted to clarify.

494.

Secondly, we expressed concern last week that the primary legislation as it stands does not have a method of appeal in it. Is the Department going to consider the inclusion of an appeal mechanism?

495.

Mr Deazley: We propose to issue a statutory direction to the boards and trusts that will incorporate the guidance and the review process. That statutory direction comes from article 17(1) of the Health and Personal Social Services (Northern Ireland) Order 1972.

496.

Ms McWilliams: Here is where our learning curve must match yours. That is a statutory regulation that will come after the legislation has received Royal Assent. It is part of the legislative process. Why can it not be included in the primary legislation in the first place?

497.

Mr Deazley: We do not see the need to have it in the primary legislation or to have a separate regulation. Article 17(1) of the 1972 Order gives us the right to issue a direction. There is no legal process to go through. We simply issue the direction to the boards and trusts. That carries the force of regulation under the 1972 Order.

498.

Ms McWilliams: So this legislation amends the 1972 Order?

499.

Mr Deazley: Yes.

500.

Ms McWilliams: Are you saying that an appeal process already exists?

501.

Mr Deazley: A legal process exists by which we can issue direction to the boards and trusts. It comes from article 17(1).

502.

Ms McWilliams: My only concern is that on reading the legislation, as we have, it is not immediately clear that there is a right of appeal.

503.

Mr Deazley: That is true.

504.

Ms McWilliams: I am concerned that those in receipt of nursing care should know about this. I might have a concern either as a relative, or as someone wishing to ensure that a person was correctly assessed. If I accessed this legislation, I would not know about the appeal mechanism. However, if I worked for the board, I would know about it. The people with that knowledge might not always want to grant that right.

505.

Mr Deazley: The directions and the guidance that go along with them will be publicly available. We will not prepare the directions and the guidance and simply issue them to the boards and trusts. They will be available through the same media as the legislation itself. It will be publicly available on the Internet.

506.

Ms McWilliams: If you are going to explain the legislation, will the directions and guidance be included? Are you going to disseminate widely the fact that that right is available?

507.

Mr Deazley: We would not make the right available and not publish the fact that it existed.

508.

Ms McWilliams: Are there other pieces of primary legislation in existence that are similar to this one? Is the right of appeal normally dealt with in the way that you have described? Are there precedents where, by whatever means, you have sought to include it in the legislation?

509.

Mr Deazley: Our research shows us that reviews are normally carried out as a result of departmental direction. On some occasions, where there is professional input through the General Medical Council or nurses' bodies, it is also done by regulation and direction.

510.

Mr Gallagher: If an individual is unhappy with his or her assessment and wishes to appeal, how does that happen?

511.

Mr Deazley: The service user, his or her family, or the carer will simply ask for a review of the decision. It will not be a financial decision. The decision is based around the level of nursing care that the patient needs.

512.

Mr Gallagher: Who carries out the review? Is it done within the trust in question, or is it independent?

513.

Mr Deazley: A nurse will do the initial assessment. A different assessor will undertake the first review - it will be a professional nurse, but not the nurse who carried out the first assessment.

514.

Mr J Kelly: That assessment is done on the individual?

515.

Mr Deazley: Yes, on the individual.

516.

Mr J Kelly: Is it on the individual - whether that is a daughter, son or whatever - and not any circumstances around the individual?

517.

Mr Deazley: All aspects of the individual's physical and mental health are taken into account. I have a copy of the assessment tool with me. It is going to the Minister, and as soon as the Minister has cleared it, we will pass it, the guidance and the consultation letter to the Committee.

518.

Mrs Courtney: I want to pick up on what Ms McWilliams said. We were told that the review would take place within three weeks, hopefully to the satisfaction of the resident or carer, or whoever made the original application for a review. I take it that that includes when the first complaint was made? When a person is on a ward and meets the ward sister, she does the first assessment. The ward sister then has to take that assessment to someone else. Will the whole process take three weeks?

519.

Mr Deazley: Absolutely. It will take three weeks from first complaint to the completion of the second stage.

520.

Rev Robert Coulter: This review on assessment is only for patients. What happens when a nursing home is not happy with the result of an assessment?

521.

Mr Deazley: Nursing homes will have the same right to ask for a review of the assessment.

522.

Rev Robert Coulter: They will have that right as well? It is not just the patient?

523.

Mr Deazley: It is not necessarily aimed at patients. The first people to be assessed under this legislation will be residents in nursing homes who are funding their own care.

524.

Rev Robert Coulter: Will the nursing home have the right of appeal?

525.

Mr Deazley: The nurse manager will have that right.

526.

The Chairperson: You were to check on the feedback that can be made available to the Committee on the work of the pilot projects on the assessment tool.

527.

Mr Deazley: I have copies of the assessment tool, the consultation letter going out with that, and the guidance. I do not have the report on the findings of the pilot study, which has been completed by the University of Ulster. It will accompany all of those documents going to the Minister. It will also be included in the documents coming to the Committee.

528.

The Chairperson: Is everyone happy with that?

529.

Ms McWilliams: Will that be next week?

530.

Mr Deazley: It will be as soon as it is ready. I cannot say that it will be ready next week. I tried to get the missing document this morning, but could not contact the person who has the material.

531.

Ms McWilliams: We are holding up the process to do that. We would like to have it urgently so that we can clear the legislation. We are almost at the final stage, but we would not want to clear it without having access to the document and its evaluation.

532.

Mr Deazley: I expected to be able to tell the Committee today that it was on the way. I hope that that will be the situation between now and next week.

533.

Mrs Courtney: Will we have all the documentation by next week, including the paper you have today?

534.

Mr Deazley: I will attempt to get everything to you by next week.

535.

The Chairperson: It is important to have everything. If the Committee is not satisfied, it will have difficulty in accepting clause 1. We were talking about appeals and the consideration of a fast-track appeals complaints procedure on nursing needs through the statutory regulations. The Department will consider how such a complaints process could be monitored to ensure that trusts implement its directions.

536.

Those are the main points. Do my colleagues want to raise anything? Would Mr Deazley or Mr McKeown like to raise anything?

537.

Ms McWilliams: We have discussed the right of appeal, and you will provide the Committee with information on the tool and its evaluation. Last week, the Committee asked about the payment mechanism. England and Wales have chosen the flat-tier option. The Committee does not know which option the Department prefers, and it would like guidance on that.

538.

Mr Deazley: The Minister will receive the Department's submission on its recommendations tomorrow.

539.

Ms McWilliams: Therefore, the Committee will leave that until next week.

540.

The Chairperson: Thank you very much. We hoped to conclude clause 1 today, but in view of what has been said, we cannot do so. Therefore, we will wait until next week. Clauses 3, 4 and 5 follow clause 1. Therefore, we will leave them as well.

Wednesday 22 May 2002

Dr Hendron (Chairperson)

Mr Berry

Rev Robert Coulter

Mr J Kelly

Ms McWilliams

Ms Ramsey

Mrs I Robinson

Mr Peter Deazley)Department of Health, Social
Services and Public Safety

541.

The Chairperson: Clause 1 will be considered first, as agreed last week, followed by the remaining clauses. I propose to complete the consideration of the remaining clauses today, if possible.

542.

The Committee welcomes Mr Peter Deazley from the Department of Health, Social Services and Public Safety. The Committee's concerns are centred on the consultation on the professional assessment tool, the fast-track review and the appeal mechanism and the payment system. Last week, you said that you would give the Committee further information today.

543.

Mr Deazley: I had expected to be able to bring the documentation today, but the Minister is still approving the consultation document. Approval is taking so long because it is a large document. I had expected it to be approved in time for today's meeting. For it to be of any use, the Committee would need to go through the document.

544.

The Chairperson: Have you anything to add that was not covered last week?

545.

Mr Deazley: No.

546.

Ms McWilliams: We have known about the report for some time. When was it finalised?

547.

Mr Deazley: The final piece of the report had to be written by Prof Brendan McCormack, who designed and piloted the tool. It was completed two weeks ago.

548.

Ms McWilliams: Knowing that the legislation was going through the Assembly and that the tool went hand in hand with the legislation, I am concerned that the Committee has been delayed in completing consideration of the legislation. With the legislation being considered by the Committee, one would have thought that the Department would have issued a timescale in parallel with the legislation so that everything could have been completed by now.

549.

The Chairperson: That is very disappointing, but we must proceed, as time is passing.

550.

There is an amendment concerning consultation on the professional assessment tool. Mr Deazley has said that he has nothing to add. The Committee was asked to agree to a provision for financial assistance for nursing care costs and to agree the definition of what constitutes nursing care in advance of detailed written information based on the assurances of officials. Members will want to confirm those points with officials, as we discussed last week.

551.

Members may wish to consider whether the Committee should recommend an amendment to the Bill that would require the Department to issue its guidance by means of Statutory Rules. That would ensure that the Assembly and the Committee would have the opportunity to consider and formally agree any guidance or appeal mechanism prior to it being implemented. This would allow the Committee to agree to clause 1 in advance of the details being made available with a greater degree of confidence.

552.

Members should note that the draft amendment is a working proposal that has been drafted without legislative drafting advice and may not be technically competent. Advice is also needed on how and where it should be placed in the Bill in the context of the Health and Personal Social Services (Northern Ireland) Order 1972. Members could discuss and agree the amendment even though it may not be technically correct. That has happened before. That could be done at a later stage via Mr Deazley and the relevant people, but is open to discussion.

553.

Ms Ramsey: This issue has probably arisen in relation to every Bill we have discussed. We are all representatives and know the way boards and trusts work; we all know that those entitled to something are not always aware of the fact. We introduced a clause into the Carers and Direct Payments Bill to the effect that responsibility to inform people of their entitlements should lie with the trust. The proposed amendment does not strike me as being in any way different from what we did with other Bills. I know that the question of placing the onus on the Department, the board or the trust to inform people of their entitlements was raised with the Committee Clerk at the start of deliberations on this Bill. Unless I am reading the issue wrongly, I have no problem with placing responsibility on the trust or relevant authority to ensure that it informs people of their exact entitlements, rather than assuming that it will do so.

554.

The Committee Clerk: The proposed amendment, which takes accounts of members' points, is essentially intended to require the Department to provide for guidance, directions and so on by means of a Statutory Instrument which would have to come through the Assembly and the Committee. The Committee would, therefore, have the opportunity formally to agree whatever guidance or payment arrangements were put into place. It does not specifically identify a requirement on the part of trusts or boards to publicise the information. Based on the evidence given by officials, they are currently arranging for boards to identify all those residents currently entitled. It is therefore not quite the same as the previous amendment that we made, since it is proactive.

555.

Ms Ramsey: But if we ask the Department to bring the guidance to us, we shall at least have another shot at ensuring that the requirement is part of it.

556.

The Committee Clerk: Yes.

557.

The Chairperson: Yes, that is possible. Do we have enough time left?

558.

The Committee Clerk: The Committee must complete the Committee Stage of the Bill by 7 June. We are running late. We need to put the draft report before the Committee for agreement. It must be lodged with the Business Office by 7 June. If we went ahead with an amendment on this basis, it would allow the Committee to consider all the other issues when they come forward from the Department. The Bill is essentially a provision to ensure equity of treatment for nursing home residents. That is in clause 1, and the details will have to follow; the Committee will wish to see them.

559.

The Chairperson: Are members agreed that we should try to amend the Bill? The technicalities of the amendment will, of course, have to be considered further.

560.

Ms McWilliams: Given that the deadline is 7 June, I feel that we have been put in an absolutely ridiculous position. We have neither the tool of assessment nor the payment systems before us for discussion. We are sitting here scrutinising legislation with two massive pieces of information missing, yet the deadline is 7 June. It is absolutely outrageous, and if we continue to act in this manner with other pieces of legislation, we may as well pack up and go home. The amendment is based on the content of two documents that are supposed to come forward to us. We are having an irrelevant discussion about an amendment based on whether what the Department produces is adequate.

561.

The Chairperson: The assessment tool was a key point.

562.

Mr J Kelly: Perhaps I might ask Mr Deazley when he thinks the Statutory Instrument will be introduced.

563.

Mr Deazley: I would rather not make any more promises. In defence of the Department, I should point out that the assessment tool was entirely in the hands of professionals. It was being run entirely by Prof Brendan McCormack. We in the Department could not move on the issue until we had received the documentation. As far as I can remember, we got the report on the pilot about a fortnight ago.

564.

Mr J Kelly: So you are not going to hazard a guess.

565.

Mr Deazley: As I have said, I expected to be able to lay out the consultation document and the submission on the payment system today. It is a big document for the Minister to go through by herself.

566.

The Chairperson: Our choice is to postpone it again - and it seems terrible to do that - or agree that we are content with the clause, subject to the Committee's proposed amendment.

567.

Ms McWilliams: I propose that we postpone it. If we need to have extra meetings before the deadline, then we will do so. We are not in a position to take this forward without two major decisions being made by the Department.

568.

The Chairperson: Do Members agree?

Members indicted assent.

Wednesday 29 May 2002

Dr Hendron (Chairperson)

Mr Gallagher (Deputy Chairperson)

Mr Berry

Rev Robert Coulter

Mrs Courtney

Mr Hamilton

Mr J Kelly

Mr P Deazley)

Mr J McKeown)Department of Health, Social

Ms J Smyth)Services and Public Safety

569.

The Chairperson: For reasons that have been discussed recently, it is important that we agree the Health and Personal Social Services Bill today. On Monday, Members received a folder containing the results of the Minister's consideration of the issues that were before the Committee last week. The Committee must complete its consideration of the remaining clauses today in order to meet the Committee Stage deadline. Our concerns centre on, first, the consultation on the professional assessment tool; secondly, the fast track review and appeal mechanism; and, thirdly, the payment system.

570.

I welcome Mr Peter Deazley, Mr John McKeown and Ms Janice Smyth. The document concerning the assessment tool is lengthy. Some Committee members may have received it on Monday, but not have had time to look at it. Perhaps you could outline its central points, bearing in mind what we requested.

571.

Mr Deazley: Ms Smyth will cover the central points, but there are a couple of issues that I must raise first. Professor McCormack has got back to us to change the title of the assessment tool.

572.

The Chairperson: The long title?

573.

Mr Deazley: The title of the actual assessment tool; it is now simply called the nursing needs assessment tool, as opposed to the older people's nursing assessment tool, because it applies across the board. That is the only change that has been made in that area.

574.

Ms Smyth: Professor Brendan McCormack and his research associate Paul Slater, from the University of Ulster, developed the nursing needs assessment tool. Professor McCormack is well known for his expertise in the development of assessment tools. The tool was commissioned by the working group established by the Minister and chaired by the Chief Nursing Officer, Judith Hill.

575.

The terms of reference were to review what was available in England, Scotland and Wales and to look at what was available in Northern Ireland. Then, those tools were to be measured against the national service frameworks. A tool was to be developed for Northern Ireland to determine the nursing needs of people who need continuing care in a nursing home setting. That was done.

576.

Once the tool was developed, we piloted it in seven sites across Northern Ireland. We asked all the trusts if they wanted to participate. Seven replied positively, and between them those trusts represented all four health board areas. The assessment tool was used to assess the nursing needs of people who require nursing home care.

577.

The Chairperson: Is there much difference between this assessment tool and the original one in England? Have there been many changes made in order to accommodate Northern Ireland?

578.

Ms Smyth: Changes were made to the tool after the pilot exercise. There were originally 22 assessment domains in the tool. The tool is based on professional judgement; it is not a box-ticking exercise. One must take biographical information from the patient, assess their need under each of the domains and determine how the nursing care is going to meet those needs. It then asks whether that nursing care has to be met directly by a registered nurse or through care supervised by a registered nurse, or whether it is directive, where the nurse teaches someone else to do it.

579.

The review amalgamated two of the domains. It also amended the risk assessment, where assessors were asked whether the patient's condition was stable and predictable or unstable and unpredictable. The nurses felt that some of the clients that they assessed fell somewhere in the middle of that; it was not black and white. So, that was amended. Some of the language was also amended because the nurses felt it was not user-friendly and that those who were being assessed, or their carers, would not understand some of the terminology. After the pilot exercise, the review made minimal changes to the structure and content of the tool.

580.

The Chairperson: On other aspects, such as the fast-track review and the payments system, we are going to be using the Welsh system; is that right, Mr Deazley?

581.

Mr Deazley: I must also point out to Committee members that, as stated in the covering letter to the Department's consultation document, the assessment tool is capable of identifying nursing care needs at three separate dependency levels - low, medium and high. That is not a comment on how the nursing care is going to be paid for; it has been decided that there will be one single rate for nursing care.

582.

However, the nursing tool will still be a major help in the care planning process. It will help care planners to decide where nursing care is best delivered. The fact that a person needs nursing care does not mean that it will best be delivered in a nursing home. The detailed output from the tool will go a long way to assisting that care planning process.

583.

The Chairperson: I assume that there was agreement on the part of the various professionals and trusts involved in this exercise?

584.

Ms Smyth: Yes. The pilot exercise was successful and the comments received about the tool and its ability and suitability to assess people's needs were positive.

585.

Mr Deazley: The Minister has decided that we will apply a single rate for each person who is assessed as needing nursing care in a nursing home. The actual amount has not yet been decided. We have written to the trusts today asking them to survey in detail the number of people who fully or partly self-fund their care in nursing homes. We can then put forward proposals to the Minister on the weekly amount that will be paid towards nursing case.

586.

The Chairperson: Will it be at least £85?

587.

Mr Deazley: It will be no less than £85 a week.

588.

The Chairperson: It is certainly not "free nursing care". I appreciate that you are using a particular definition.

589.

Mr Deazley: We have called it "a contribution towards residents' nursing costs in a nursing home".

590.

The Chairperson: The other matter was the appeal mechanism.

591.

Mr Deazley: I am not sure if Members have had time to look at the documents. I have included a very early version of the departmental directions that will issue along with the other guidance.

592.

The first two paragraphs are as they will appear in the final version. They set out the legislation under which we are issuing the directions to the trusts - article 17(1) of the Health and Personal Social Services (Northern Ireland) Order 1972 - and the action required of boards and trusts to commence health and personal social services payments.

593.

I have outlined what will be included in the directions. There will be a brief outline of the legislation under which nursing care is being introduced, detail on implementation, and directions to go out to the trusts identifying every nursing home resident who makes a contribution towards their nursing care and who will, therefore, be entitled to some contribution from the Department of Health, Social Services and Public Safety.

594.

We will require trusts to inform those residents of their right to a nursing care assessment. The trusts will be required to seek the consent of those residents for an assessment to be carried out. Nursing care assessments are entirely voluntary and cannot be imposed on residents.

595.

The directions will describe the assessment and review process, which will be set out in detail. If a resident is not satisfied with the first assessment, he or she is entitled to a review assessment by another nurse within one week. If that is not satisfactory, a review panel must be set up and the case heard within a further two weeks. The process will take three weeks from start to finish.

596.

The experience of the review and appeal procedure in England has almost totally revolved around the three tiers: when people are assessed as being in the lower group, the appeals are to get them into the second group, and when they are in the second group the appeals are to get them into the top group.

597.

In our case, if nursing care need is assessed, people will automatically be entitled to £85, or to whatever contribution they currently make to the cost of their care.

598.

The Chairperson: Are you saying that the fast-track appeal takes three years?

599.

Mr Deazley: No, I am referring to the three tiers. The main volume of appeals in England is due to their three-tiered system. It is not that people have been assessed as not needing nursing care, but rather that the assessment has placed them at the lower level or the intermediate level, and people are inclined to appeal when money is involved.

600.

The Chairperson: Mr Deazley has set out for the Committee the areas to be covered in the departmental directions and guidance, which will be referred to the Committee for consideration. There are different headings, including legislation, implementation and identification. Is the Committee happy with the departmental directions? Has everyone had time to look at them?

601.

Mr Berry: I am concerned about the directions on information. You say that trusts will be required to inform residents. If the matter is left to the trusts, they might inform only the home's owners, not the residents. How can we be sure that all residents and their families or carers will be informed, as well as the home?

602.

Mr Deazley: There are two points. First, the consent of the resident - or their family or carer - to an assessment must be sought. It is a voluntary process. Secondly, it is feasible that someone who is funding their own care will not want social services to be involved. In order to obtain clear consent, the assessments and all other matters are carried out directly with the individual, or, where the individual is incapable of making decisions, with their family, their carer or an appointee. That will be clearly specified in the directions.

603.

The Chairperson: As there are no other queries, I assume that the Committee is happy with the directions. The various headings are detailed. Requiring trusts to identify all nursing home residents who are funding their own care in nursing homes is terribly important.

604.

We have covered information, advocacy and short-term placement. Is the Committee happy, or are there other questions?

605.

Mr Deazley: The identification process has already started. The Department issued the survey request today.

606.

The Chairperson: That goes right across Northern Ireland. Is the Department sending it directly to the trusts, or will it go via the boards?

607.

Mr Deazley: We are dealing directly with the trusts.

608.

The Chairperson: That will be quicker. The Committee wants to clear up clause 1 and the other clauses today. If my Colleagues have nothing further to add, we will move on to that.

609.

The Chairperson: Members will be aware of that we have a potential amendment to clause 1 in the briefing paper, which can be considered in the context of the evidence given by officials. Before concluding consideration of clause 1, the Committee will wish to formally record its views on personal care in the context of the introduction of free nursing care as outlined in the Bill.

610.

Members will be aware of the views expressed by witnesses on the introduction of financial assistance for nursing care for self-funding residents of nursing homes. Many witnesses called for the approach to personal care taken in Scotland to be adopted here. If resources were available now, the Committee would wish to see free care covering the nursing and personal care needs of residents. However, the working group on personal care has not yet reported to the Executive on the outcome of its investigation. A decision is not due to be made until late June 2002, and we do not know what position the Executive will take. However, the estimated cost of free personal care is in excess of £25 million a year, in addition to the £9 million a year cost of free nursing care.

611.

If the Committee were to recommend free personal care now, the money would have to come from the block grant allocation at a time when the pressures on funding for key health, education, transport and regional development priorities are preventing many desperately needed projects from being funded. It would mean making hard decisions on how the health budget should be spent.

612.

However, clause 1 is essentially about equity and correcting an anomaly faced by some 2,000 self-funding residents of nursing homes, who have been put at a distinct disadvantage. In comparison, nursing care is supplied free, as a health service, to a person in his or her own home or to a resident in a residential care home, if it is supplied externally by a trust via the community nursing service. Adopting clause 1 should be seen as a first, necessary step to meeting basic equity of provision. It will ensure that we will be able to provide similar benefits to those already provided in England and Wales. Although it is limited in its intent, the Committee welcomes the aim of the clause.

613.

The Committee and the Assembly may wish to reconsider free personal care and the conclusions of the Royal Commission on Long Term Care for the Elderly in the future. We will then be able to learn from the Executive's examination of personal care and the experiences of the Scottish Parliament. We will be better able to gauge the benefits and costs of introducing free personal care.

614.

Do members have any further comments to make before we vote on clause 1?

615.

Question, That the Committee is content with the clause, put and agreed to.

Belfast Carers Centre77

Down Lisburn Health and Social Services Trust79

Eastern Health and Social Services Board81

National Board for Nursing, Midwifery and Health Visiting (Northern Ireland)83

Prof. Robert Stout, Queen's University Belfast85

Registered Nursing Home Association87

Sperrin Lakeland Health and Social Care Trust89

Written Submissions

In general the Belfast Carers Centre would welcome the introduction of this legislation. However, there are a number of short points that I would like to make in relation to it. In the first place I read with interest the definition of what constitutes nursing care. That element of nursing care that is recognized as such as being eligible for inclusion in this bill is described as services deemed "nursing care by a registered nurse". The additional clarification of this point as embracing nursing care carried out under the direction of a qualified nurse still leaves a little, in my view, ambiguity in relation to what is actually meant by nursing care. Is there a not a potential danger for different interpretations of what constitutes nursing care from other forms of care not deemed nursing care? Many tasks that would once have been the preserve of a registered nurse are now routinely carried out by other staff. From moving and handling through to toileting and other allied duties there are a range of services that I personally would consider core nursing duties that this legislation and the room for interpretation that it would seem to imply might not recognize but then again it might. Essentially, the boundaries that this legislation seeks to describe are to me still a little hazy and therefore I would be fearful of potentially disruptive debate as parties seek to challenge or present existing or potential interpretations of the Bill's wording.

However, given the fact that the Executive have been able to formulate a cost for the introduction of this change would I be presumptive in making the above points? If there is a more detailed formula or more comprehensive definition of nursing care available I would be very happy to receive a copy of it as it would certainly help this Centre and the Carers that it seeks to represent and support if there was such a document that I could direct people to peruse as they seek answers to what free nursing care means to them as they make all of the necessary calculations in arranging appropriate nursing care in the appropriate setting. Would it not be appropriate to include such detail in the Bill itself?

My only other major concern would be that this element of the Bill would appear, from the documentation that I have to hand, constitute only a small part of the Bill. The greater portion of the Bill appears to be taken up by the introduction of the NIPEC. This is a subject that I would not be competent to make any real comment on other than to hope that it functions as well as the legislators would hope it would and that it has a real and beneficial impact on the work that comes into the orbit of its responsibilities.

With reference to the free nursing care component of the Bill. I trust that it will carry with it the type of infrastructure that will allow for a smooth transition. Have the bodies with responsibility been given sufficient resources to absorb the additional work that this move will bring in its train? Is there an appeal system for example? If the resident or patient -what is the appropriate description in this case? - needs the assistance of other persons or organisations in this calculation are there mechanisms to allow for this type of review process to take place? Does it affect all types of unit? Will the nature of "nursing care" be subject to periodic review and will the formula used to calculate the cost of the introduction of this amendment be itself, subject to amendment?

I hope that you receive these comments in good order and that it will be seen as a positive contribution towards this debate. If you would like any further contribution please contact me at the address given.

RICKY DEVLIN
Project Manager

Written Submissions

26th March 2002

Free Nursing Care: The Trust agrees with the principle of treating persons equitably i.e. receiving free nursing care in a home and as if they were in their own home or in a residential home. The result of implementing this proposal should result in a person in a nursing home having their disposable income increased contingent on their financial assessment. The Trust could be concerned that given the concern over fee levels paid to homes, proprietors will take the opportunity to increase their "top up" charges to residents rising from the increases in their disposable income.

Preserved Rights: As with Free Nursing Care the Principle of Preserved Rights clients becoming the responsibility of Trusts is laudable. However there would be a number of concerns:

1.The transfer from DSD to DHSSPS has been poorly handled with Trusts still not in possession of basic information i.e. names and financial assessment details less than three weeks away from the transfer date of 8/4/02. This has resulted in unacceptable pressure on Trust staff and potential financial adverse consequences on Trusts, nursing and residential homes and residents of homes.

2.Given the lack of certainty in respect of numbers of persons to be transferred the funds to be transferred and the infrastructures required the Trust would be concerned that DHSSPS and thereby Trusts may have to bear financial risks/consequences which have not been allowed for.

3.The transferred funds for individuals remain with Trusts only as long as clients remain alive. Down Lisburn would prefer this resource remain with us and infinitum to be reinvested in care, rather than back to DSD.

Nursing and Midwifery Board: The Trust welcomes the development of NIPEC and considers such a body essential in supplying the local development of Nursing, Midwifery & Health Visiting in the areas of Practice, Education, to continue professional development and performance.

The provisions of local and easily accessible advice is also considered necessary and welcome.

MR JOHN COMPTON
Chief Executive

Written Submissions

28 March 2002

I write in reply to letter which was received on 11 March 2002.

I understand that this matter has already by legislated for and that the Personal Social Services (Preserved Rights) Act received Royal Assent on 26-3-2002.

The Board supports this proposal. However, we are concerned that sufficient funds are provided to enable it to be implemented without putting pressure on existing resources. We are also concerned by reports from Great Britain, when those provisions already in place, that are homeowners have raised their fees by amounts equivalent to the additional payments being made to individuals who qualify for free nursing care.

The Board supports this proposal and has made contact with the Shadow N.Ireland Practice and Education Council for Nursing and Midwifery which was established recently, in advance of the proposed legislation.

DR M PAULA J KILBANE
Chief Executive

Written Submissions

25 March 2002

Thank you for your letter of 8 March 2002 in regard to the above and seeking comments on the Department's proposals.

The main issue which the National Board would wish to draw to your attention is with pages 7 and 8 of the Health and Personal Social Services Bill. Reference is made at 20, (2), (a) and 21, (1), (a) to the "Nursing and Midwifery Order 2002". This reference is incorrect. The correct reference should read "The Nursing and Midwifery Order 2001, Statutory Instrument 2002 No 253" which is the legislation establishing the Nursing and Midwifery Council from 12 February 2002.

I hope the above is helpful.

EDMUND N THOM
Director of Finance and Administration

Written Submissions

20 March 2002

Thank you for asking for my comments on the Bill. The Bill has two proposals - free nursing care in nursing homes, and a new Practice and Education Council for Nursing and Midwifery. My comments refer only to the proposal for free nursing care.

I regard the proposals set out in the Bill to be seriously flawed and the background documentation to be misleading. The document refers to the Report of the Royal Commission on Long Term Care, of which I was a member. The Royal Commission considered a wide variety of ways of alleviating the present unsatisfactory situation with regard to funding long term care and concluded that the only satisfactory way forward was for personal care, following assessment, to be funded from taxation. This includes, but goes beyond, free nursing care. The reasons why the Commission concluded that free personal care was the best option were:

1.Introducing free nursing care alone would introduce a new perverse incentive. It would mean that nursing homes would be subsidised, whereas residential homes, which do not have registered nurses on their staff, would have to charge full costs. There would be an incentive, both for the individual and for the Trust, to admit patients to nursing homes even if they did not require that level of care. This is contrary to best practice in providing long term care which is to provide only the level of care needed by the individual.

2.The most important objection is on the grounds of equity. Older people require long term care for a variety of reasons. For some it is because of physical illness such as heart disease or cancer, where care is often given in hospital and is, therefore, free. For older people with continuing disability, whether disability resulting from physical illness, for example, stroke or arthritis, or from Alzheimer's Disease, quite considerable degrees of personal care are often required but not necessarily the skills of a registered nurse. These people would not benefit from the provision of free nursing care and hence would be disadvantaged purely on the grounds of their diagnosis.

The document states that there are no human rights or equality issues in the proposed Bill. As I have pointed out in paragraph two above, there are very serious issues under both these headings.

One of the grounds for objecting to the free personal care proposals is its cost. It should be noted, however, that free nursing care would cost more than half of the cost of personal care and there would be additional savings from the other allowances which such people can currently claim but which would not longer be relevant.

The document also does not mention the fact that Scotland has accepted the Royal Commission recommendations in full. Furthermore, it is becoming clear that the policy of introducing free nursing care in nursing homes, which is being introduced in England, is already proving unworkable.

ROBERT STOUT
Professor of Geriatric Medicine

Written Submissions

27 March 2002

Thank you for giving me the opportunity to comment on this bill before proposed amendments by the Assembly.

1.At present time "Free Nursing Care" in England and Wales is merely a contribution towards this care with rates which in no way reflect the true cost of a nurse's time, experience or supervision. It is to be hoped that Northern Ireland should not follow their lead but adopt a more realistic rate which will adequately reflect true nursing?

2.It is important that the assessment process is correctly applied, how soon will we be informed of how this process will work, and who will carry out the assessment on each patient.

3.Will free nursing care include personal care, and have the assembly defined the term "Nursing Care"?

4.How will this funding be distributed to the individual ie will it be sent to the nursing home manager or directly to the patient/relative?

5.A clear indication must be given on funding towards ancillary aids required within the nursing care ie incontinence products, special mattresses etc.

It is important that the relevant public are correctly and fully informed about this particular funding issue.

1.How will the Chairman and members of council be elected? Will this process be a true reflection of the different specialities of nursing, for example the Independent Sector, which includes its own variety of specialists ie nursing home care.

2.Will the new council work in tandem with the N.M.C. or will major decisions be made at local level?

3.Will N.M.C. continue to have responsibility for registration of nurses and disciplinary matters and locally the council only being responsible for education and compliance in this area within N.M.C. legislation?

ROSEMARY STRANGE
Chairperson
R.N.H.A.

Written Submissions

03 April 2002

Please find below a number of comments in respect of the proposals.

The Trust welcomes the proposal to change the anomalous situation in relation to payment for nursing care in homes but not in hospital or community and to address one of the recommendations of the Royal Commission.

However it is felt that the practicalities of separating our nursing care from personal care may prove very difficult. This places significant responsibility on a professional nursing assessment to be conducted in a manner which is open, transparent and against criteria/assessment tool(s) which will need to be developed in a relatively short timeframe. Work has been ongoing to develop a nursing assessment tool and already differences are emerging as the Scottish system which includes personal care differs from that developed in England and Wales. Such criteria assessment tool(s) should also be based on a body of research which proves its workability and is open to continuous professional scrutiny and evaluation to ensure it remains fair.

There may be potential for home owners to use this opportunity to address issues related to payment rates for care and there is concern that the amount allocated regionally for this purpose is insufficient. It is essential that this assessment tool is robust and fair. It is obviously in the homeowner's interest to place residents in the highest category of need to attract higher rates.

In addition assessments must cover a reasonable time to prevent homeowners requesting free re-assessments with a consequent burden being placed on Trust staff to undertake them more frequently than necessary. It is not apparent from the paper how differences of opinion about whether someone fits into nursing care or the dependency level may be resolved. Does this entail an independent assessment involving more administration and bureaucracy? Any nursing assessment tool should be as simple and straight forward as possible so that it is easy to use, interpret and implement. It would be essential that these proposals do not result in more nursing time being committed to administration when nurses are becoming such a scarce resource.

As indicated above this issue should be completely separate from the general issue of payment rates. Already the practice of third party top-ups is very common throughout Northern Ireland and free nursing care and associated rates could be contaminated by this debate.

One method by which the above difficulty could be avoided would be to consider the introduction of both free nursing and personal care similar to the approach adopted in Scotland. Whilst there would be additional costs associated with same, it will have the following benefits:

i.Removal of the potential for arbitrary and unfair decisions regarding a client's eligibility for nursing care based upon a nursing assessment.

ii.Removing the necessity for developing assessment tools/criteria, which could be held open to interpretation dependent upon the professional conducting the assessment.

iii.Ensuring equality of treatment between the nursing home sector and those people living in their own homes, i.e. personal care is not subject to means testing for domiciliary home care - why should this be the case in a nursing home?

The costs in this Trust area would not be significant as the number of those clients who are self-funding are relatively small.

The Trust agrees that it is appropriate that Preserved Rights cases should be transferred and treated in the same way as care managed clients. As above it is important that homeowners do not see this transfer as a means of addressing general funding issues.

The Trust has already conveyed their concern to the Director of Finance, DHSSPS, about the non-recurring nature of the funding given the fact that these places will have to be replaced in the future and any new admissions will have to be monitored. This could have significant future implications. Homeowners must appreciate that the Care Management process could lead to transfer to other facilities or return to community settings in certain cases.

It seems logical however, to assume that most clients will have become more dependent and it is possible with transfer of Social Security finance who used a lower rate than that used by Health and Social Services Boards, that it will place an additional financial burden on Trusts. This makes it all the more important than regionally agreed rates are used and properly funded.

It seems appropriate to rationalise and restructure the existing bodies and achieve a more cohesive body to regulate and promote training, support and professional development of nurses and midwives.

It is important to have a body to promote and co-ordinate practice, education and training of nurses particularly in the context of nursing homes since there is a serious shortage of qualified nurses at present, which could destabilise this sector. The Trust would urge consideration of these proposals in conjunction with those published for consultation in the document "Best Practice ~ Best Care". This would avoid a disjointed approach.

It is not clear from the information provided as to how these bodies are to be funded.

I trust the above information will be helpful to the Committee. Should you require further information, please contact me to discuss.

HUGH MILLS
Chief Executive