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The bid to create a fairer system of long-term care for older people involves a lot more than the question of whether personal care should be free, writes health analyst Melanie Henwood.

Two years ago a Royal Commission offered an appealing solution to the challenge of paying for long-term care.¹ The commission's swingeing critique of the present system identified the major shortcomings of complexity, unfairness and confusion. In place of this, the commission urged the establishment of a new model based on the pooling of risks between the individual and the state, with the cost of services underwritten by general taxation and "based on need rather than wealth." The costs of the change was estimated to be between £800m and £1bn in the first year, rising to an additional £2.6bn by 2021, and to a possible £6.4bn by 2051.

The government's full response to the commission was set out as part of the NHS Plan.² Many of the commission's key recommendations were accepted, including the establishment of the National Care Standards Commission. However, the recommendation that personal care should be free was rejected because it would consume most of the extra resources the NHS Plan identified for service development for older people, yet this would not "necessarily improve services", nor would it help the least well off. The arguments around fairness, affordability and the respective responsibilities of the individual and the state, are set to continue - not least because of the decision of the Scottish parliament to go its own way and accept the commission's full recommendations on free personal care. Although how that is to be funded and whether the actual sums allocated for personal and nursing care really offer such a good deal remains to be seen.

While rejecting the full "free personal care" package, the government set out alternative proposals which, it argued, would offer a better prospect of improving standards of care, and generating better health and independence for older people. The key to this is to be significant investment in intermediate care services, prevention and rehabilitation. The primary objective is to restore independence following a crisis or acute episode, and thereby avoid or delay the need for permanent residential care. Such aspirations command widespread support; however their achievement in practice presents a fundamental challenge to the established configuration of care services, and to staffing patterns and skill mix, and necessitates the rapid adoption of evidence-based practices.

Alongside these changes was the announcement on free nursing care. The government accepted the arguments of the Royal Commission that there could be no justification for the continued anomaly of charging people in care homes for the costs of their nursing care. It stated that in future: "The NHS will meet the costs of registered nurse time spent on providing, delegating or supervising care in any setting."³ This will be achieved through the determination of the registered nursing care contribution (RNCC) required by people in nursing homes. The difficulties of what this might mean in practice have been debated in the wake of the NHS Plan, and throughout the passage of the Health and Social Care Act 2001. Particular dissatisfaction has surrounded the way in which nursing care has been defined, with concerns that it excludes the bulk of hands-on nursing care provided by health care assistants.

The facts about the introduction of free nursing care need to be separated from the confusion and alarmism that has characterised recent comment. There has been much concern, for example, about the way in which decisions will be made by nurses, rather than by social workers. This is professional defensiveness gone mad. Social workers - and other care professionals such as occupational therapists and physiotherapists - will be fully involved in the assessment process. Determining registered nursing needs only happens once the single assessment has been completed and the care plan has indicated permanent admission to a nursing home is the best outcome.

A key objective of the new single assessment is to ensure a person-centred approach is adopted within which professionals work together in the best interests of the older person. This is an opportunity to be rid of the multiple, unco-ordinated, and often incompatible layers of assessment that too often bedevil health and social care approaches. Clearly, such collaborative working relations will not be helped by a climate that reinforces rigid demarcation of professional boundaries and sticks to the ludicrous claim that the wrong people are determining registered nursing input. Social workers have many skills; but they do not have a monopoly on professional knowledge, and do not have the knowledge or expertise to evaluate people's nursing needs.

Further misconceptions surround the consequences for individuals. No nursing home resident will be worse off as a result of the changes. The flow of resources will not involve the client. The changes introduced in October will benefit a relatively small group of people - an estimated 42,000 people who are currently paying for their own nursing care (that is self-funders) - by up to £5,000 a year (and £100m is to be transferred to health authorities to fund registered nursing care for self-funders from October to March 2002). This money will not be paid to self-funding residents; it will be transferred to the nursing homes direct, but self-funding people will see their fees reduced accordingly. Seven out of 10 nursing home residents already get some or all of their care costs paid from public funds. The amount this group contributes to their care fees will not change. The only change from April 2003 is that the NHS will fund nursing care costs currently being met by local councils (or through preserved rights to higher rates of income support).

The three bands of registered nursing input (high, medium and low) have been given indicative price tags of £110, £70 and £35 respectively. Some sections of the independent nursing home sector have been alarmed at the inadequacy of these figures to meet the costs of registered nurses. But that is not the intention; those staffing expenses are part of the routine running costs of a nursing home. The figures should reflect the time actually spent by a registered nurse in providing, planning, supervising, and delegating care averaged across a week or so. Concerns have focused especially on the adequacy of the upper band. Should some of these higher cost cases even be considered within this system? The Department of Health has stressed the new requirements for the NHS, to fund nursing care in all settings, are in addition to existing responsibilities for continuing NHS health care. People with health care needs of such complexity, intensity and unpredictability that they are deemed significantly above the upper nursing band, may well be eligible for fully funded NHS continuing care.

How possible it will be to determine people's needs for registered nursing, and to allocate them to a banding to accurately reflect their needs, will only become clear in time. But field-testing of the approach has suggested the model is practical and reliable. A number of considerations should be highlighted:

- The better the quality of assessment records and care plans, the greater the likelihood of being able to accurately determine residents' registered nursing needs. The decision to defer the second stage of implementation (funding local authority supported residents' registered nursing care) by 12 months (to April 2003 rather than 2002), recognises the importance of giving the single assessment process adequate bedding down time, and to allow the development of a smooth transfer of responsibility to the NHS.

- Close co-operation and dialogue between the nurse undertaking the RNCC determination for self-funding residents already in nursing homes, and the nurse most involved with day to day care will be vital to ensure the full picture of people's needs for registered nursing is recognised in the banding.

- The banding needs to be approached not as a snapshot at a fixed time, but as the average needs of the individual over weeks. While there is scope for re-assessment and changing the RNCC banding, this should not need to happen often simply because someone's needs are fluctuating. The bandings should not constrain registered nursing determination, and the fundamental question for designated nurses undertaking the RNCC is "which of these bandings offers the best fit with the nursing needs of this person"?

- The RNCC determination will only be undertaken by skilled NHS registered nurses designated in each area as those responsible.

The free nursing care route selected by the government will continue to be seen by many as inferior to the free personal care being adopted in Scotland. However, the failure to accept the full recommendations of the Royal Commission needs to be balanced against the steps being put in place; the funding should not dominate the entire debate. Any evaluation needs to address the impact across the board, and to consider carefully all the costs and benefits.

Developing intermediate care and other services to promote independence, together with the individual determination of registered nursing input required for each person permanently resident in a nursing home, offers enormous potential to improve the quality of care and generate better outcomes. Whether such benefits do result will have major significance for current service users and for generations to come.

References

¹ Sir Stewart Sutherland (chairperson), With Respect to Old Age: Long Term Care - Rights and Responsibilities, Cm 4192-1, 1999, The Stationery Office

² Secretary of state for health, The NHS Plan: The Government's Response to the Royal Commission on Long Term Care, Cm 4818-11, 2000, The Stationery Office

³ Ibid, para 2.9

Answers across the Channel

If NHS patients are to be sent to Europe for operations, why not use European mainland resources to assist the UK's overstretched social care work sector? Social care lecturer Brian Munday reports.

The NHS is now looking to other European countries for relief of its two most pressing problems, namely constantly lengthening waiting times for important operations and a chronic shortage of key staff.

UK health authorities intend to use spare capacity in the German hospital system to reduce waiting lists and recruit both doctors and nurses from European countries over-supplied with staff.

Government clearance will soon be given for the NHS to pay for patients to have their operations in modern German hospitals and costing less for health authorities than is currently paid to private hospitals in the UK. Even better, the German price also includes return travel for both patient and a relative, plus the cost of the relative being accommodated for part of the time in Germany.

Are there similar possibilities for UK social services? So far under-staffed social services departments have recruited social workers from countries such as Spain and Germany where more staff have been trained than can easily find work in their own countries. We already import some good practice in social services from participation in multi-national projects, staff visits and exchanges, and initiatives such as the Isabel Schwarz Fellowships jointly sponsored by Community Care and the European Institute of Social Services.

If UK social services wish to follow the NHS lead, certain criteria should be met:

- There has to be a serious shortage of a service in the UK.

- There should be cost advantages.

- There must be advantages to the service user and they must agree to the placement.

- Practicalities must be manageable.

- Ideally, there should be advantages to both countries in the transaction.

- There are ethical considerations to be met when recruiting trained staff from abroad.

At first sight the opportunities for social services appear to be far less than those of the NHS, with the exception of staff recruitment. But UK social services face two increasingly pressing and related problems: the declining availability of residential care beds for older people; and the costs of buying beds in the private sector. Can social services realistically look to Europe for both short-term care such as respite care and longer term residential care?

There may well be spare capacity in some other European countries and almost certainly there would be cost advantages to UK social services. But even for short-term placements for older people in France or Spain, there are issues concerning stressful journeys, communication problems with care home staff, separation from any family members and friends, and with diet.

Yet large numbers of UK older people regularly spend part of the winter enjoying low-cost, highly sociable stays in Spanish hotels. Hard evidence may be lacking but arguably there are important preventive health and social care benefits from this flourishing phenomenon, with associated benefits for the Spanish hotel industry.

There are also real possibilities for under-staffed social services in the UK to recruit social workers from elsewhere in Europe. Membership of a common European market offers more feasible staffing opportunities for UK social services. Many social workers trained in other European Union member states speak English and have qualifications recognised in the UK.

The extent of over-supply of staff elsewhere is unquantified, but Germany in particular has previously trained more social workers than it needed. In Spain, the school of social work in the University of Barcelona has 800 students in training and not all of them will find it easy to obtain posts in modestly staffed Spanish social services.

Approaches should be carefully planned. Departments may also be tempted to look beyond the European Union to recruit poorly paid qualified social workers from former communist countries, but these countries desperately need to retain these staff to develop their own services. It is one thing to accept unsolicited applications from staff in these countries, but deliberate recruitment campaigns in such countries are ethically very dubious.

The European Institute of Social Services at the University of Kent has considerable knowledge of social services across Europe and is able to advise organisations interested in exploring possibilities for making careful use of services in other countries and recruiting staff.

Making progress

In reply to recent articles in Community Care about social exclusion, Cabinet Office minister Barbara Roche outlines the government's achievements and its future aims.

You're 10, you've run away from home. You don't know who to turn to. Now someone is approaching you on the street. It's hard to imagine the fear that compels a young person to run away. What it highlights is just how wrong things can get for some of our most vulnerable young people.

The social exclusion unit's work on young runaways is drawing on the expertise and experience of professionals, voluntary agencies and young people themselves to devise new policies aimed at tackling the problems that lead to running away. It aims to make sure those young people who do run are safe, as well as finding long-term solutions for them.

This is just one example of how serious we are as a government about working with professionals and communities to help the most vulnerable people in society.

Community Care's series of articles on social exclusion was critical of government policy, giving the impression that we don't care about those most at risk of social exclusion. I disagree. But the articles were right to highlight the extent of the problem, and certainly right to highlight the need for us to do even more to drive down rates of social exclusion for all vulnerable groups in society.

It is worth remembering the sheer scale of the problem we are faced with, and setting out the approach we are adopting to tackle the most intractable social problems in a more strategic and focused way. The levels of social exclusion cannot be underestimated. Analysis by the social exclusion unit shows that by the mid-1990s Britain was far adrift from its European counterparts on many scores.

It topped the European league on teenage pregnancy; the number of 18-year-olds in learning was well below the EU average; around 2,000 people slept rough on London's streets every night in the early 1990s; and the proportion of children living below the poverty line more than doubled from the early 1980s to the mid-1990s.

Tackling problems that have often been decades in the making - the experience of many of our most deprived neighbourhoods for example - is a big challenge. But there has been a genuine change in the focus, energy and investment that government is devoting to solving these complex problems, as well as a radical shift in our approach to making social policy.

Ten years ago, the discussion about social exclusion was confined to academic circles. Looking at social exclusion as a series of interconnected problems - rather than trying to address individual social issues in isolation - has been in recent years one of the most fundamental shifts in thinking on the part of policy-makers, professionals and politicians.

But it's about more than just semantics and debate. It's about a move away from the culture of blame where victims of social exclusion were labelled and held responsible for their circumstances. Increasingly society understands that a teenage mother, young offender or 50-year-old rough sleeper face problems that are not simple and straightforward. Government, too, has recognised that it needs to take a more strategic and co-ordinated approach to achieve real improvements.

Our approach is based on three fundamental principles.

First, we want to prevent people from becoming socially excluded in the first place - especially those at risk. This preventive approach is familiar to those involved in social work practice and is now absolutely central to government policy. We know care leavers, ex-prisoners and people leaving the armed forces are more likely to end up sleeping rough on the streets, for example. Two of the SEU's current projects are looking at raising the educational attainment of children in care and reducing reoffending among ex-prisoners. It's a question of getting to the root causes - not sticking a plaster over the symptoms.

Second, we are driving forward policies to make sure that public services deliver basic minimum standards for everyone - especially the vulnerable who need them most. This is backed up by a dramatic increase in spending on public services - an extra £43 billion over the next three years. Investment in children's services, for example, has been boosted by the £885 million Quality Protects programme.

Additional resources are combined with a major shift in how departments spend their money. For the first time ever, departments are being measured on the areas where they are doing worst, not on the average. That may sound like a technicality but the reality is a guarantee of a decent standard in public services for everyone.

The third plank of our approach is to make sure that we help those who have slipped through the net to get back on their feet. Many people who end up sleeping rough, for example, need much more than just a roof over their heads - they have multiple needs that span housing, employment, benefits, drugs, alcohol, physical and mental health. A lynchpin of the our strategy on rough sleeping is rebuilding people's lives away from the street by providing the right support and helping people to access training, education or employment.

This focus on prevention, mainstream services and reintegration is backed up by a more open approach to policy-making, involving and listening to the views of practitioners and people affected by social exclusion as well as by extra resources. We are already seeing positive early results. Rough sleeping has fallen by almost two-thirds; rates of pregnancy among under-16s have fallen to their lowest rates since 1983 bar one; and permanent exclusions from school were a third lower last year than in 1996.

Behind these statistics are individual lives. Lives which government policy and the efforts of dedicated professionals like social workers are changing for the better.

Community Care's survey and analysis of the views of social workers suggested the government had ignored social workers in its social exclusion strategy. Yet the links are clear between what we're trying to achieve in policy and what social workers are trying to achieve on the ground - preventing social exclusion, reintegrating people who have become socially excluded, and ensuring decent standards in mainstream services for everyone.

Social workers can be the main source of support for the young person in care, help teenage mums to make the right decisions about their future, or lend support, say, on mental health issues, to help a rough sleeper settle into a new home. And they have been a useful source of expertise during consultations on our new policies to combat social exclusion.

A fortnight ago health secretary Alan Milburn launched the government's first ever national recruitment campaign to bring more social workers into the profession. Why? Because we recognise what an invaluable role social workers play both in picking up the pieces when things do go wrong, in preventing problems from arising in the first place or from escalating and that we need more people in the profession.

Social exclusion poses huge challenges for government on a national policy level; for professionals like social workers on the ground; and most importantly for the people themselves who are affected by social exclusion.

While we don't claim to have tackled every problem of social exclusion, we have made good progress and galvanised more support and funds for tackling these problems than for many years.

Making sure that delivery happens on the ground, that we hear all the voices in the debate and that we continue to learn from what works and what doesn't is crucial. There's no room for complacency - but equally no room for defeatism. The challenge now is to make sure our existing policies are on track and that we keep looking at areas of policy that we have not yet tackled, working in partnership with all those who can make change happen.