The truth about `free care`

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

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.


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

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

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

– 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

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

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

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

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

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

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.

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