Will intermediate care be the undoing of the NHS?
BMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7258.393 (Published 12 August 2000) Cite this as: BMJ 2000;321:393
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The government's response to the Royal Commission on Long Term Care¹
asks NHS intermediate nursing home services to somehow distinguish between
'nursing' and 'personal' care.
This should then help the proposed new care trusts determine
responsibilities for both provision and funding.
The recent editorial by Allyson Pollock² draws attention to the
concerns being felt by those responsible for providing intermediate
nursing care for older people.
However, she makes no specific mention on the potential impact for
psychiatric intermediate nursing care.
The majority of patients referred to psychiatric intermediate care
have clinical needs as a direct result of dementia.
They appear at greatest risk of facing the double penalty in the level of
psychiatric nursing input provided for them and in paying directly for
specific services that have now been labelled 'personal' rather than
'nursing.'
The distinction between 'nursing' and 'personal' care can seem
particularly arbitrary when applied to this patient group³.
How will clinicians be able to claim that, for instance, 'wandering' or
'shouting' behaviour constitutes primarily a nursing and not social need?
Pollock has not commented on the contradictions between the government
policy and the outcome of the Coughlan case 4 and it is easy to foresee
challenges made against decisions by assessment panels who decide
intermediate care should be provided in settings with minimal input from
the NHS psychiatric nursing service.
When, there is an assumption that a client's condition is 'medically
untreatable', it may prove tempting to claim that intermediate care will
not require much 'nursing treatment' and judge that the costs of the care
package result from the personal care element (implying charging the
client).
This involves widening our understanding of what constitutes 'nursing
treatment' for patients with dementia.
The inherent nature of the intermediate care service is one of treatment
but this is largely through social and behavioural interventions. Delaying
or alleviating symptoms of a disorder should also be seen as treatment,
even when no 'medical' improvement is likely.
Pollock makes reference to three possible funding mechanisms for
providers of intermediate nursing home care.
One suggested model already employed in the United States and Australia is
reimbursement based on levels of disability. The dependency levels in
older people within United Kingdom psychiatric nursing homes vary greatly
across different regions5.
If such a funding mechanism were to be applied to psychiatric intermediate
care, it can only deliver chaos, as any scale that measures dependency
based on any existing scale will hardly equate with the psychiatric
nursing input required.
It must also be pointed out, that the intermediate care service in
psychiatric nursing homes can not be put in the same bracket as the
intermediate care service in general nursing homes.
Many health-care trusts do not provide this service at all. Where it is
provided, it may be used as an alternative to rather than a continuation
of an acute hospital admission. The advantages are, firstly that it offers
a longer time period for this assessment than can usually be offered on an
acute hospital ward. Secondly, the client mix may be more similar,
creating a less disruptive environment for the patient. Thirdly, the
staff skill mix may be more appropriate for assessing and managing the
problems of the client group.
Therefore, charging clients for a service they might reasonably
expect, free, if they lived in an alternative part of the country, where
the intermediate psychiatric nursing care does not exist and an acute
hospital admission would be offered instead (incurring no personal charge)
is clearly at odds with the 'universal' claim of the NHS.
REFERENCES
(1) Secretary of state for Health. The NHS plan: the government response
to the Royal commission Report on Long Term Care. London: stationery
office, 2000 (CM 4818-II)
(2) Pollock A M 'Will intermediate care be the undoing of the NHS?'
BMJ 2000;321:393-394
(3) Wistow, Pearson N (1995) 'The Boundary Between Health Care and
Social Care'. BMJ. Vol 311: P 208 - 209.
(4) Department of Health Ex. Parte Coughlan: Follow up Action: London
DOH (HSC 1999/180: LAC (99)(30).
(5) ' A National Audit of Nursing Home Care' (1998). Discussion
document. St. George's Medical School, London
Competing interests: No competing interests
Dr Pollock is to be commended for her response to the new NHS Plan
illuminates the effect of the government's proposed policies in terms of
care funding.
My concern is that I have not heard anyone speak of the long-term
agenda to decrease government spending on all care.
The pooling of social and healthcare budgets raises two major issues.
The way the Department of Health may separately fund the social services
and health aspects of care to a pooled budget is a practical one. The
effect on the vulnerable population relying upon the National Health
Service and Social Service departments (both within the DoH remit)is the
issue few people within the government will openly address.
A committee of medical, nursing, and long-term carers would present
the best universal definition of people meeting criteria for the place
personal and nursing care to meet.
Consider the person of any age, with special attire including an
indwelling supra-pubic catheter and special dressings for a long-standing
pressure sore requiring a special mattress and much time in bed. This
person also fails to recognise and is unable to respond to personal
danger. The personal and nursing care providers also employ the use of a
hoist to assist in the move from bed to chair to bath. Would such a person
be entitled to total NHS funded care (with or without pooled budgets?)(in
any setting?)
The undercurrent of spending less will ultimately result in
disappointment to those in need of long-term care. Currently, individual
bodies closely guard their own budgets. Current policy provides the
potential for greater expenditure when there is no "team looking after one
budget". The new NHS Plan will result in many guardians looking after one.
I would appreciate evidence that the pooling of budgets with no clear
delineation of roles or priorities; and that amounts spent on individual
needs will not diminish the level of care provided to those with complex
care needs.
Though Mr Milburn professes to have developed this plan with the
elderly in mind, the elderly have the most complex care needs. There is no
evidence that the new NHS Plan will meet the needs of people with complex
and long-term care needs.
Competing interests: No competing interests
Placing professionals in the middle
Intermediate care can refer to the place of care between hospital and
other settings. Intermediate care can also refer to treatment that falls
between the medical, nursing, and supporting healthcare professionals.
I am personally very concerned about the issues Professor Pollack and
Dr Beirne raise as the spouse of a
person whose condition is not considered psychiatric or dementia, but his
cognition and behaviours are similar to those classifications.
There is no clear guidance to Directors of Social Services and people
in
health care trusts about the delineation of responsibilities or when
personal care becomes nursing care. It is my perception that the plan to
is
take the "treatment" aspect of nursing (catherisation, medication,
managing
IVs, suctioning, TPN, etc) as the definition of nursing.
What frightens me is the reality of having a spouse with complex
needs being
care for by unskilled staff that will fail to recognise symptoms or care
needs while feeding, bathing and dressing their "charges".
Recently, my father was recovering from Congestive Heart Failure and
was
also very confused and agitated.
During a visit, his nurse queried how my father had hurt his back and
how
long he had back pain. Confused by this apparently unrelated enquiry, I
asked my father about his complaint.
Not being male, it took a few questions to realise the pain was far
lower
anatomically and was due to pressure on his testicles as a result of his
position in bed. Dad said he was having pain and needed help. The staff
assumed that he really had back pain and had dispensed pain medicine.
The nurse then could not understand why the pain medication was not
relieving the "pain".
This is the tip of the iceberg in terms of non-physicians ordering
medication and providing diagnosis and treatment. The lack of training for
staff working in care homes inhabited by "confused or forgetful" residents
exacerbates gaps in the national plan of care.
The New NHS Plan can work with clear and concise structure,
accountability
and accreditation.
Intermediate and long-term care will clearly require new
accreditation and
regulation for professionals assuming roles that were not an essential and
critically evaluated part of their qualification.
Competing interests: No competing interests