October should see the introduction of free nursing care for
some older people in residential care homes. But campaigners are
worried about the tight criteria, the tool used to make the
assessment and the amount of money earmarked for free services.
Jonathan Pearce reports.
(It may be advisable to print this document as it is
Small print reveals limits to free nursing
There may be no such thing as a free lunch but the Department of
Health has, at least in theory, fulfilled the government’s
promise of free nursing care for all.
“We are determined to make the system fairer by providing free
NHS nursing care for the first time in nursing homes from 1 October
2001,” said health minister Jacqui Smith earlier this month,
announcing a four-week consultation on guidance to implement the
proposals. “This will eliminate the anomaly of people having to pay
for care that is provided free in other settings.”
But, of course, it is not that simple. Look at the guidance and
it is clear that what the large print gives the small print takes
away. Nurses, nursing homes and older people’s campaigners
say proposals for free nursing care have been watered down.
So what is the DoH’s definition of free nursing care?
In last year’s NHS Plan the DoH gave the following
commitment: “From October 2001 … nursing care provided in nursing
homes will be fully funded by the NHS.”
But in a draft circular last week, it refines the promise
contained in the NHS Plan, claiming: “The government gave a
commitment to make care from a registered nurse free for all,
regardless of the setting in which it is delivered.” A subtle
distinction, but effective.
Of course, the Health and Social Care Act 2001 had already
defined nursing care as “any services provided by a registered
nurse and involving (a) the provision of care, or (b) the planning,
supervision or delegation of care, other than any services which…
do not need to be provided by a registered nurse.”
In short, free nursing care has been couched in terms that will
effectively put a limit on the promise and the cost.
As the Royal College of Nursing points out, a broader definition
would clearly include care provided by nursing or care assistants.
Pauline Ford, the RCN gerontological programme director, says: “The
RCN has serious concerns that nursing care provided by health care
assistants under the delegation, supervision and management of
registered nurses is free on the NHS, but for people being cared
for in long-term care it is not. For people receiving long-term
care, once nursing care is delegated to health care assistants, it
will be means-tested.”
Age Concern England director general Gordon Lishman adds the
reality: “Tasks such as dressing ulcers and pressure sores, which
anyone would reasonably regard as nursing tasks, may still have to
be paid for.”
Not as free as you thought then. So what does the small print
From the beginning of October 2001, those people funding their
own nursing home care will no longer have to pay for “registered
nurse care… where the NHS assesses such care as needed”. The
government estimates this will apply to 35,000 self-funders.
From April 2002, this group will be extended to cover other
nursing home residents, previously the responsibility of local
authorities. Also, from next April, another 15,000 nursing home
residents will enter the equation – those who entered residential
accommodation before 1993 and who are currently in receipt of
preserved rights to higher rates of income support to pay for their
Some of the April changes will be budget-shifting exercises.
What free nursing care really refers to is the additional £80
million that will be allocated to health authorities, or primary
care trusts to cover the costs of self-funders’ nursing care.
Next year’s funding has not been finalised.
Three bands of care for self-funded nursing home residents are
proposed – £35 per week (low-level care), £70 (medium)
and £110 (high). The bands are based on an average of £85
per week per self-funding resident, a figure based on the average
difference in fees between a nursing home and a care home,
according to Smith.
Add all this up and it makes £77.4 million of free nursing
care between this October and next April, leaving £2.6 million
for administration and care management, which also comes out of the
The big question behind the figures is whether or not this is
enough money to cover all the nursing care provided. The Registered
Nursing Home Association has made its views clear. RNHA chief
executive Frank Ursell has described the proposals as “a slap with
a cold flannel”.
“It’s all very well for politicians to posture for effect,
but the figures suggest that the government wants something on the
cheap,” adds Ursell. “It claims to want high standards of care to
be delivered, but the proposed £10 a day standard NHS
contribution to a patient’s nursing home costs sends the
opposite signal.” His argument is simply that the cost of a
nurse’s care is higher than the government’s
At the Department of Health, health minister Jacqui
Smith’s response is that the funding is not about the cost of
employing a nurse, but for how much nursing care a nurse provides.
In addition, the top band is not a cap. High dependency residents
will receive free nursing care even if they exceed the upper limit.
The consultation asks for views and evidence of any such
The government appears to be basing its proposals on estimates
from the University of Kent’s centre for health service
studies. The centre has developed an assessment tool suggesting
residents with clinically complex nursing care needs receive an
average of 48 minutes of registered nursing care per day, compared
with 31 minutes for those with standard needs. The difference
between the two is around 55 per cent and explains the difference
between the top two bands.
Before October, health authorities and primary care trusts have
to appoint a nursing home co-ordinator and a lead nurse for free
The co-ordinator will manage the budget and monitor spending,
including liaising with local nursing homes, social services
departments and nurses to identify eligible residents and oversee
the assessment process.
The lead nurse will monitor the quality and consistency of
assessments, provide professional nursing advice and ensure nurses
are trained in the use of the registered nursing care contribution
(RNCC) tool – the mechanism used to determine how much care is
provided by a registered nurse in an individual’s care
The RNCC tool has been developed by the DoH and the guidance
states a draft version will be available by mid-July. It has yet to
appear. Full training will be provided to NHS nurses in September,
adds the guidance.
With final guidance due in September, some people are worried
there is not enough time before implementation in October, while
the lack of an assessment has led some observers to mutter darkly
about carts and horses.
“This whole approach is being hurried through,” says Counsel and
Care chief executive Martin Green. “There are serious issues about
how it is going to be implemented. It’s very complex, and it
is going to lead to a lot of confusion.”
More fundamentally, however, both the RCN and the RNHA have
questioned nurses’ roles as both fund-holder and assessor – a
system that effectively makes nurses the “gatekeepers” to nursing
care. “We are not sure that the profession is willing to accept
this role as it contradicts the basis on which nurses practice,”
adds Ford at the RCN.
At the RNHA, Ursell warns of history repeating itself: “Most
people will know what happened when community care was introduced
with a great fanfare in the early 1990s. Assessments of need were
often not worth the paper they were written on. Rigid budgetary
limits were set and even if individuals were found to be in need of
basic care, they often had to go without.”
The DoH denies the problems – everyone will go onto at least the
basic low-level band of nursing care come October, with the
opportunity to change bands, following an assessment. Nurses are
experienced at both providing care and managing budgets, says
Smith, so fears of “gatekeeping” are unfounded.
But a central issue still remains – what will the nursing home
co-ordinator do when need has been identified, but the cupboard is
bare? Has the DoH done its sums right? The final guidance in
September will answer some questions, but as with all free lunches
someone has to pay, sooner or later. The questions are who, and
Categories of eligible groups for free nursing care from
1 October 2001
– Existing self-funding residents, or those admitted after
October following an assessment, who pay the full cost of their
care, except those with preserved rights to higher rates of income
– Those who, after October, are assessed as needing registered
nursing care and placed by social services departments, where
departments pay the full standard rate: but where the chargeable
income exceeds the cost of the place and the department is an
– Those placed by social services before and after October where
social services pay only a very small part of the cost.
From 1 April 2002.
– Those placed by social services departments which currently
pay the full care costs of those people placed under Mental Health
Act 1983 section 117(2).
– Those in a nursing home with preserved rights to higher rates
of income support whose care management is transferred to local
Lauren Revans talks to Jane
Campbell, chairperson of the Social Care Institute of
Excellence, about her vision for social care and how she wants
service users to be the driving force behind improvements
The challenges ahead
“Scie is going to be the most accessible disseminator of good
practice in the country, if not the world,” Jane Campbell promised
within hours of the government announcing her appointment as
chairperson of the new Social Care Institute for Excellence.
Campbell is widely known and respected for her successful
campaigning efforts for disabled people’s civil rights as
co-director of the National Centre for Independent Living
Her posting to Scie is significant because it could mark a
fundamental shift towards best practice being determined by service
users, rather than researchers and civil servants.
“No way is Scie going to become an ivory tower for researchers
to contemplate research and get more PhDs for themselves,” Campbell
“We are obviously going to go to researchers and look at
evidence-based practice, but we are also going to go to places
where I know social care is working best for users.”
Campbell sees Scie as not the single centre of excellence, but
as a uniting partner of many satellite centres of excellence around
the country – centres that are developing their own ideas and with
whom best practice can be shared.
Her number one priority is to gather the grass roots knowledge
that she considers to be the “missing link” in social care. She
cites the user-led campaign for direct payments for disabled
people, in which she played a pivotal role, as an example of what
can be achieved when users are fully involved in the development of
“No other service has been as liberating as direct payments,”
she argues. “That campaign, and the development of the
infrastructure for it has come from users, has been developed by
users and the whole legislation has been implemented by users.
Social services can’t claim that for themselves. Government
can’t claim that for themselves. And nor can the Association
of Directors of Social Services. It was our dream in the 1970s when
we were shut up in institutions or institutionalised within our
homes. And it is the key to independent living.”
Announced in July 2000 as part of the government’s quality
strategy, Scie will be launched this autumn by the Department of
Health and the Welsh assembly. Using £2 million of government
funds, it is charged with helping to modernise social care
throughout the two countries and tackling variations in quality and
standards that exist between local authorities.
Suggestions that Scie will be in any way compromised by its
close links with the government are strongly refuted by Campbell.
She believes that she will be able to turn the relationship to her
advantage and influence funding streams towards the good practice
Scie is putting forward.
“I never, never change my principles wherever I work, but what I
have changed is the method by which I achieve all that,” she
explains. “The NCIL’s main source of funding was the
government and, quite frankly, we were one of the biggest
challenges to government thinking during the past six years.”
If Scie develops as Campbell envisages, its scope will be
enormous. Not only will it be responsible for creating a knowledge
base of what works in social care, it will also produce and
disseminate the good practice guidelines on which future
inspections and Best Value reviews will be based.
To Campbell, understanding the meaning of Best Value is
critical. Yet, in her opinion, not all local authorities have
“Best Value doesn’t mean what’s cheapest, it means
cost-effective,” she explains. “Scie can demonstrate how good
practice doesn’t actually mean more money. It often means a
complete change of delivery and priority.”
She stresses the need for social services departments’
inspection targets to go hand in hand with long-term goals. And she
highlights the fact that no one has yet carried out a cost-benefit
analysis of independent living, looking at the long-term benefits
in terms of people’s physical and mental health.
“You’ve got to look beyond the costs,” she urges.
“It’s just another way of looking at the world. You’ve
got to look at the long-term. Often, what’s cheapest at the
time puts people into crisis, which then costs millions more to get
As part of the modernisation agenda, Scie will work alongside
the profession’s training body TOPSS, the Social Services
Inspectorate, and the incoming regulatory councils and care
standards bodies in England and Wales.
Campbell believes close-working between these institutions will
be vital to success, and she wants to see a policy of co-operation
and cross-fertilisation of ideas.
“We need to make sure we have very, very open and clear paths of
communication with the General Social Care Council, the National
Care Standards Commission, TOPSS and Social Services Inspectorate,”
she says. “We do not want to be working in separate areas.”
But her top priority remains service-users. “In Scie, we can
never underestimate the experience of anyone that calls on the
assistance of the social care sector,” she explains. “A user is not
a stakeholder, he or she is the stakeholder.”
Campbell is aware that her appointment is a gamble for the
government, and is the first to congratulate them for daring to
take on someone who comes from an outspoken campaigning background,
who is a service user herself, and who is street-wise about social
“I haven’t been the quietest of people over the last few
years,” she admits. “I have had many a challenging meeting with
ministers. So it’s good on them that they decided that they
could trust me to work with them.”
Promising to speak the unspeakable, and push others to think the
unthinkable, Campbell is ready to challenge social care as we know