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Consultation on supplementary guidance on NHS funded nursing care

Summary of Outcome

Consultation on Supplementary Guidance on NHS Funded Nursing Care

1. Responsibility for funding the nursing care of around 42,000 self-funders fell to the NHS from 1 October 2001. The funding of the nursing care of around 88,000 residents of care homes providing nursing care who are receiving care from a registered nurse will transfer from local authorities to the NHS from 1 April 2003. The supplementary guidance was intended to be read in conjunction with that contained in HSC2001/17: LAC(2001)26 issued on 25 September 2001. That circular set out the framework for implementing the scheme, and outlined the roles of lead nurses and care home (nursing home) co-ordinators.

2. A consultation draft was issued on 20 December 2002, for comments by 31 January2003. The Department received a total of 78 responses: 31 from the NHS, 20 from carehome providers, 17 from local authorities, and 10 from voluntary organisations and others.

Results of the Consultation

3. Most respondents confined themselves to the detail of the draft guidance, and made some helpful drafting suggestions. Providers and their representative organisations were particularly concerned that there should be no disruption to payments as a result of the changes in funding responsibility. The majority of voluntary organisations continued to oppose the scheme on principal, preferring some form of free personal care as has been introduced in Scotland, though they all generally welcomed the clarification evident in certain aspects of the guidance, in particular on determining the needs of those with dementia, on the link with fully funded continuing NHS healthcare and clarity around admission to hospital.

4. The main points made by care home providers and their representative bodies were:

- gross fees payable currently in respect of council supported residents in independent care homes should not be reduced. Other concerns involved the administrative burden on homes, potential problems surrounding cash flow, and the amount of the proposed banding.

- believe that care homes should be reimbursed for the administrative costs of these proposals;

- cash flow problems could be eased by ensuring that resources are properly allocated by April 2003 to allow assessments to be carried out on a timely basis, and entry to a care home not delayed, resulting in people remaining in hospital unnecessarily.

- steps should also be taken, and this made clear in the guidance, that the total funding and cash flow to care homes will not be affected due to unforeseen budget pressures in PCTs.

- strongly believe that the proposed funding for the low, medium and high nursing bands from April 2003 does not represent the true cost of registered nursing care and the guidance gives no indication as to whether or how they will be increased in future years. There should be a commitment to review the bands annually.

- the funding allocated to the NHS is clearly insufficient to meet nursing care costs in independent homes.

- consider that the guidance does not make explicit how gaps in funding are covered if the nurse banding levels proposed do not adequately cover the costs of the registered nurse input necessary to meet the regulatory requirements and the actual needs of individual residents.

- believes there has been a lack of consultation on the extension of NHS funded nursing care, as there was with its initial introduction. Although the Department has consulted with the ADSS, LGA and NHS Confederation, thinks that the involvement of providers in this final stage consultation is too late in a process which will require significant goodwill on the part of providers if the initiative is to be introduced smoothly.

5. The main points made by local government were:

- continues to have some reservations about placements made out of area.

- concerns about the arrangements for intermediate care not being clear. Although they understand that the intention is that intermediate care should be provided free, the removal of a charge for the "residential" component is still to be enacted. Concerned that if such episodes of care are provided in a care home providing nursing, it is assumed that the relevant PCT will be responsible for the costs associated with nursing.

- concern about the responsibility to provide equipment should be specified rather than what they believe currently reads as a rather "hit and miss" arrangement where responsibilities and expectations are unclear. Believes the provision of equipment to meet specific needs will be essential to effective achievement of the care plan and should form part of the contractual arrangement to ensure compliance.

- has found it helpful to have confirmation that the NHS will be responsible for the provision of continence products in all care home settings.

- preference for Model A for "in area" placements, but is unclear about the arrangements for "out of area" placements and believes they may be unduly burdensome for host authorities. Concerned that Model B indicates that a council's only role will be the payment of fees and administrative costs, with no obligations to the council from the PCT or care home provider. It was felt that restrictions on councils levying an administrative charge or recouping costs from PCTs was unlikely to effectively oil the wheels.

6. The main points made by the NHS were:

- concerns about funding responsibilities based on GP registration. This will create an extremely complex process, particularly for large, urban areas where there are significant levels of cross boundary flow, and will require hours of administration.

- the "preferred" partnership arrangements should be prescribed and introduced uniformly across the country.

- the guidance should provide a precise indication of where the scope of NHS funded nursing care should stop and NHS fully funded continuing healthcare should start.

- concerns about proposals for out of county placements (that the LA should enter into a partnership arrangement with their local PCTs to contract with the care home on behalf of the placing LA). This will place a very heavy administrative burden on host LAs.

- involvement of families and relatives can, in many cases, be a difficult and protracted process, particularly when there are several family members who all want to be involved but cannot be there at the same time. Nurse assessors do not have the capacity to arrange separate meetings. There needs to be more funding available to pay for assessments.

- concerns that the allocations will not meet the financial pressures, particularly in relation to current council placed residents who have higher dependency and tend to be high band, with additional continence needs.

- PCTs have experienced difficulties in engaging in discussions with the National Care Standards Commission (NCSC), who do not appear to be informed of their responsibilities in respect of contract monitoring and often appear to have little understanding of clinical governance issues.

7. Of the voluntary organisations, Age Concern felt that, for simplicity, the new guidance should be integrated with the previous guidance and new guidance issued to avoid any confusion. The main recommendation was that the opportunity should be used to clarify the difference between the highest band of nursing care and the criteria for fully funded NHS continuing care. Have reiterated its concerns about fee levels rising in line with the NHS payments and their recommendation that people who happen to have capital above the capital limits should still be able to access social services contracting with the home. New NHS continuing care guidance should be issued incorporating paragraphs 17 & 18 of the draft guidance, and that the review date for continuing care guidance be brought forward.

Help the Aged recommended that the guidance should encourage PCTs and local councils to proactively ensure that people are aware of their right to an assessment, and understand the importance of being assessed. They welcomed clarification that self-funding residents who wish to receive either NHS funded registered nursing care, or the 12-week property disregard, must agree to a joint assessment of their needs. They provided examples of cases where the implementation of the 12-week property disregard has been inconsistent across the country. Believes the relationship between this and NHS funded nursing care must be made explicitly clear to local authorities, to residents and their families.

Concerns about the impact of the arrangements from April 2003, in relation to the possibility that the process of using the RNCC determination on LA supported residents may identify individuals who have no need for nursing care under the definition. Seeks assurances that continuity of care will take precedence over administrative convenience in such circumstances.

Outcome

8. Ministers were content to note the responses to the consultation, and the views of key stakeholders, and to approve the issue of guidance on NHS funded nursing care to the NHS and local government incorporating comments received during the consultation. The guidance was issued as HSC 2003/006: LAC(2003)7 on 12 March 2003.

61 responses were received to this consultation. Ministers were content to note the responses to the consultation, and the views of key stakeholders, and to approve the issue of guidance on NHS funded nursing care to the NHS and local government incorporating comments received during the consultation. The guidance was issued as HSC 2003/006: LAC(2003)7 on 12 March 2003.

• Draft supplementary guidance on NHS funded nursing care consultation