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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 long).

Small print reveals limits to free nursing care

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 say?

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 care.

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 budget.

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 estimate.

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 examples.

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 nursing care.

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 package.

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 when?

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 support.

- 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 intermediary.

- 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 councils.

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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 (NCIL).

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 says.

"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 social care.

"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 grasped it.

"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 out of."

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 care.

"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 it.