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posted 12 Sep 2000 in Volume 5 Issue 6
Reforms to the National Health Service
and Long-Term Care
By Caroline Bielanska
On the 27th July the
Government announced their plan for investment and reform of the National Health
Service.(1) Contained within the NHS Plan is the Government’s response to the
Royal Commission’s report on Long Term Care. This article gives a brief review
of the main proposals and how it will affect practitioners advising the older
client.
The
impact of the proposed reforms on people aged 65 and over will be immense as
older people use two-thirds of general and acute hospital beds and represent 40%
of all emergency admissions. The Government has accepted all too often older
people are treated in inappropriate acute hospital settings because there is
nowhere else for them to go and as a result many patients spend more time than
is absolutely necessary in an NHS bed. This situation is commonly referred to as
“bed blocking”.
The NHS Plan identifies some of the reasons for bed blocking as:
-
1. The delay in
receiving appropriate home care and/or aids and adaptations to the patient’s
home.
2. Patients not wanting to move into residential or nursing care
because of the fear of having to sell their home.
3. Insufficient information
being available to patients for them to be able to make an informed choice on
their future care.
4. Inadequate rehabilitation, which can as a result means
that patients are unable to return to their own home and have to wait for a
suitable available bed in a residential or nursing home.
5. Problems between
the Local Authority and the NHS in determining who should be commissioning the
care of the patient.
Much of the NHS Plan consolidates what has already been recommended and
contained in various White Papers, Audit Commission reports and press releases
sent out by the Department of Health (2), which builds on legislation, that has
already been passed.(3)
The Plan for Long Term Care
1. The Government announced
investment rising to £900 million a year by 2003/04 for intermediate care and
related services, such as community equipment. In addition £360 million a year
is to be targeted to tackle the inequality of the present funding system for
long term care.
2. The National Care Standards Commission, the independent standards
watchdog, which is enshrined in the Care Standards Act 2000, is to start work in
2002.
Part of
the Commission’s role will be to monitor, represent the consumer, provide
national benchmarks and encourage the development of better domiciliary,
residential and nursing care services. There will be a new National Standards
Framework on standards of services for older people following the consultation
document, “Fit for the Future? – National Required Standards for residential and
Nursing Homes for Older People”, which will be released in autumn of this year
and implemented in 2001. It will contain the outline of an improved cultural
awareness in services offered to black and ethnic minor elders.
3. The Government
intends to improve intermediate care and associate services to enable older
people to be independent and to provide care closer to their home.
The Government has
tackled the problem of health and social care for the older person from two
sides; preventing admission to hospital and post admission. The Government has
introduced financial incentives for Health and Local Authorities to work in
partnership and put in place the following: -
1.
(i)The prevention of unnecessary hospital admissions by establishing
rapid response teams to provide emergency care and help as appropriate.
(ii)Older people should receive a one-stop service for social and
health care at general practice or social work level, possibly by social
workers being based at GP’s surgeries or establishing a single key or link
worker to a unified multidisciplinary team comprising of GP’s, social workers,
nurses, occupational therapists and physiotherapists to deal with whatever
health or social care need the patient has.
2.Older people should not be left in a hospital bed when they could be
discharged with rehabilitation and support or left to try and find there own way
round the health and social care system alone. This should be achieved in a
number of ways: -
- (i)Integrated home care teams will coordinate and arrange
appropriate home care for patients upon discharge from hospital to assist them
to live independently at home.
The Government intends by April 2002, to introduce a single assessment
process for both health and social care with protocols, which will be agreed
locally between Health and Social Services. Initially it is intended that they
will be targeted at older people who are most vulnerable, for example those who
live alone, or those who have been recently bereaved or discharged from hospital
or about to enter residential or nursing care. Each vulnerable person and where
appropriate their carer will be involved in agreeing their personal care plan
which will contain the following details: -
- (ii) Intensive rehabilitation services: these will normally be
situated in hospitals to help older patients regain their health and
independence after major illness or surgery.
(iii) Recuperation facilities: short term care either in a nursing home or other special accommodation will be provided for those patients who do not need hospital care but are not fit enough to return to their own home.
4. The value of the resident’s home is to be disregarded from the means test from April 2001 for the first three months from admission to residential care.
The Government is of the view that this will ensure a reasonable length of time passes between a resident entering a home and any question of selling the family home, which will give him or her time to think about their future and if possible to return home.
Although it may assist a greater number of people overall, the current Regulations contained within the Charges for Residential Accommodation Guide are far wider.(4) The home should be disregarded where:-
a) The resident intends to return to occupy that dwelling and the dwelling is still available to him; or
b) He is taking reasonable steps to dispose of the property in order to acquire another more suitable home to which he will return.(5)
This period of temporary residency can last for any period up to 52 weeks or, in exceptional circumstances longer (6).
5. From October 2001 Local Authorities will be given an additional special ring fenced grant to increase their opportunity to place legal charges on homes and recoup their costs at a later stage once the home is sold.(7)
6. There will be free NHS nursing care from October 2001 wherever the patient resides.
This plan will require primary legislation, which will need to be introduced within the forthcoming session of Parliament if it is to be implemented within the time scale proposed. The NHS will meet the costs of registered nurse time spent on providing, delegating or supervising care in any setting. Individuals who can afford to do so, will still have to make a contribution towards their personal care and accommodation costs while in nursing care. The definition of personal care will need to be clarified as traditionally nurses have performed as part of their responsibilities personal care such as washing a patient.
It is anticipated that this change will benefit around 35,000 people at any one time and could save up to around £5,000 each year of nursing home care. Up to the 31st March 1999, there were a total of 196,000 registered beds in 6,100 nursing care homes and private hospitals and clinic.(8) Each one of these patients will need a separate assessment of the level of nursing care they require, which could change on a frequent basis as the patient improves or deteriorates. It is hard to see how any assessment can reasonably be done unless it is based on clear and detailed national guidelines for without them there must surely be further uncertainty. Practitioners should alert both nursing home proprietors and their clients of the anticipated changes.
It would appear that any patient who currently fulfills the Health Authority’s criteria for continuing health care needs, for funding of the cost of their nursing care, personal care and accommodation charges will, after legislation has been passed, only be entitled to have paid their nursing care. The likes of Pamela Coughlan (9) may very well be means tested to contribute towards the cost of their accommodation and personal care.
7. The prescribed limits for Local Authority residential care funding was set in 1996. From April 2001 the upper capital limit is to be changed from £16,000 to more than £18,000.
There is no mention within the NHS plan of the increased figure for the lower level. It would appear that it also will be increased upwards to current values but unlike the upper level no figure has been specified. The effect of this is that Local Authorities will ignore for the purpose of means testing, capital assets up to the prescribed lower level. Thereafter for every £250 of capital held the resident will be treated as having £1 income per week. With an increase of £2,000 on the upper level it will therefore make a difference of £8 per week. The net result is that the resident will use up their capital at a slightly slower rate than at present.
8. The resources which underpin the residential allowance of Income Support, in respect of new cases, will be transferred to Local Authorities from April 2002.
Since 1993, residents of independent or voluntary sector residential care or nursing homes may be entitled to the residential allowance component of Income Support. Residents in homes owned by the Local Authority are not so entitled and get a lower rate of Income Support.
The individual does not benefit from this as the Local Authority simply recoups the payment through the means test towards the cost of placement. It leaves the resident with the same personal expenses as those in a Local Authority owned home.
The effect is that the residential allowance subsidises part of the Local Authority’s cost in purchasing residential accommodation in the independent sector and so encourages them to do this for financial reasons. Furthermore, it can sway Local Authorities in deciding to place an individual in residential care rather than caring for them at home.
9. The “preserved rights” payments of Income Support will be brought into the community care funding system from April 2002..
Residents in care on the 31st March 1993 have currently a preserved right to receive an enhanced level of Income Support in order to purchase their care. The purpose was to reassure residents in care at the time that they could remain in their chosen home and avoid Local Authorities assuming financial responsibility for a million residents at the same time. Currently 65,000 people in England are in receipt of preserved rights Income Support. Of which 40,000 are over pension age and 25,000 are young disabled people.
There is commonly a shortfall between fees charged by care homes and the weekly benefit received by such residents. Commonly, such residents have no income of their own, loose all their capital or become dependent on family or charity to pay the shortfall. In extreme circumstances, individuals have been evicted from their care home, although many homes cover the deficit themselves to avoid such action being taken. As a result of this, the Government is determined to wind up the preserved rights scheme as from April 2002 when the Local Authority will be responsible for the assessment and care management of everyone with preserved rights. The Government will issue transitional guidance.
10. The partnerships between health and social care will be strengthened in particular with the ability to pool budgets and lead commissioning of care services.
Since April, as a result of the introduction of the Health Act 1999, it has now been legally possible for Health and Local Authorities to pool their budgets to fund care services. New “Care Trusts” will bring together Health and Social Services into one organisation. This new single multipurpose legal body will be able to commission and be responsible for the delivery of all local health and social care which should put an end to the current confusing system.
Care Trusts will only be established where there is a joint agreement at local level between Local and Health Authorities. Where effective joint partnerships have failed to be established or where after inspection or joint review it has been shown that services are failing, the Government will have powers to set up an integrated arrangement through the Care Trust. It is anticipated the first wave of Care Trusts will be in place in 2001.
11. New proposals for patient advocacy services in the NHS.
The NHS will be establishing a scheme called “Care Direct” similar to the established “NHS Direct” telephone service but it will extend to drop in centres, online and outreach services. Advice and support will be given on health and social care, housing, pensions and benefits. The service aims to give, for example help to people wishing to complete forms, assist with applications and take follow up action. An army of older volunteers will be attached to each Care Direct help desk to “befriend” older clients. Their role will be to offer support, possibly by visiting them in their own home, acting as intermediaries to find out information and accompanying them to appointments. Unfortunately, this will not be an independent service as it will be based at each Local Authority area and so is not strictly speaking a true advocacy service.
12. Powers contained in the Care Standards Act 2000 will enable statutory guidelines to cover fairer charging arrangements for services provided at home.
There is current inconsistency in the discretionary charging scheme for services provided at home (10). At present, every Local Authority has it’s own rules for assessing income and as a result inconsistencies arise. The report by The Audit Commission, “Charging with Care” published in May of this year has shown the full extent of variations in policies between Local Authorities: -
Within the new Care Standards Act there is a power for the Secretary of State to issue statutory guidance (11) on discretionary charges for non -residential social services, which is proposed to be exercised in early 2001.
Provision of equipment by the NHS is already free of charge. However many Local Authorities have the right to charge for disability equipment and although the Government does not go so far as to say they should not, they do say they should consider carefully the cost effectiveness of doing so within the new integrated community equipment service, which should be fully established by 2004.
13. Additional resources facilitate better services for carers will be provided in the Spending Review.
In April 1999, a new Carers’ Special Grant was launched by the Government to enable Local Authorities to facilitate a break from caring for carers. The Carers and Disabled Children Act 2000, which should come into force sometime next year contains for the first time a Carers’ assessment which is not tied to an assessment of the person for whom they care.(12) Many Carers were unable to have a break from caring where it was not the wishes of the service user. Within the Act there is provision for Regulations to be introduced for the issue of vouchers which can be used for to give the carer a break from caring. This will enable the carer to determine when they are to receive the break; when it is convenient and of most use to them.
The very nature of caring often precludes carers receiving information that may be of assistance to them; such as advise on welfare benefits and groups that can offer support. To this end the Government launched a carers’ website (13) in February, providing access to Government information, links to relevant organisations and their websites.
Will these proposals be a solution to the problem of bed blocking? To an extent the answer has to be yes. Certainly the delays that can occur whilst waiting for adequate home care may be reduced with increased funding for aids and adaptations and with the intermediate care plans there will be a definite policy to actively rehabilitate patients and allow time for recuperation. The system will however be more complex and wider than at present, giving individuals more information and options for their long-term care. Given that many Social Services departments have difficulties fulfilling their current obligations to vulnerable and disabled people through insufficient training, high staff turnover and staff shortages, even with more money channelled to long term care the writer is cynical that the NHS Plan will be the total solution that it is made out to be.
Caroline Bielanska Associate Solicitor with Longmores, Hertford
1 The National Plan for the New NHS- www.nhs.uk/nhsplan
2 10th May 2000- Minister outlines plans to address variations in home care charges; 19th May- Health Minister acts to end the lottery of home care charges; 9th June- New report points way to better services for Older People; 20th June – response to Audit Commissions report “The way to go home”- Rehabilitation and Remedial Services for Older People, and Charging with Care; The White Papers; The New NHS and Modernising Social Services.
3 Health Act1999; Care Standards Act 2000 and the Carers and Disabled Children Act 2000.
4 LAC (2000) 11 par. 3.008
5 Schedule 4 Par. 1 National Assistance (Assessment of Resources) Regulations 1992
6 2(1) Regulations 1992
7 Section 22& 24 Health and Social Services and Social Security Adjudications Act 1983
8 Community Care Statistics 1999 Residential Personal Social Services for Adults, England DoH. May 2000
9 R v North and east Devon Health Authority ex. parte Coughlan July 1999.
10 White Paper, Modernising Social Services 1999.
11 Under Section 7 of the Local Authority Social Services Act 1970
12 Section 7 Carers and Disabled Children Act 2000
13 www.carers.gov.uk
