REPORT OF THECHIEF NURSING OFFICER FOR SCOTLAND’S

GROUPON FREE NURSING CARE

THE SCOTTISH EXECUTIVE

CONTENTS

Page No

Introduction 1

Assessment of Need Subgroup 1

Financial Framework Subgroup 2

Assessment Process 3

Resource Allocation 5

Testing & Piloting 7

Training 7

Consultation 8

Payment Rates 10

Management of Allocation of Funding 11

Appeals Process 12

Implementation 12

Conclusion 13

Recommendations 14

Appendix 1 17

Appendix 2 18

Appendix 3 19

Appendix 4 20

Appendix 5 22

Appendix 6 24

Appendix 7 25

Appendix 8 26

Appendix 9 28

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REPORT OF THE CHIEF NURSING OFFICER FOR SCOTLAND'SGROUP ON FREE NURSING CARE

Introduction

1. The Minister for Health and Community Care, as part of her response to the RoyalCommission on Long Term Care in October, set the Chief Nursing Officer the task of takingforward the work on the provision of free nursing care which the response stated: "should beprovided free of charge in all settings". Because this principally affects those in nursinghomes paying for nursing care that is free in NHS hospitals, patients’ own homes andresidential homes, it was decided that the CNO should concentrate on the provision of freenursing care in nursing homes. In response the CNO set up a "Stakeholder Group"representing a wide range of interests (Remit and membership at Appendix 1). This grouphad its first meeting on 27 October, and decided that its task fell into 2 parts:

· assessment of need; and

· the financial framework within which free nursing care should be delivered.

2. Two sub-groups were therefore formed, with membership from the Stakeholders’Group, but also with the ability to bring in people with relevant knowledge and expertise ifrequired. The Assessment of Need (Remit and Membership at Appendix 2) and FinancialFramework Subgroups (Remit and Membership at Appendix 3) each met 4 times, reportingto the Stakeholders’ Group when it met in November and December.

3. This report describes the outcome of those meetings. It discusses the areas coveredby each of the groups; the conclusions reached about how the provision of free nursing careshould be progressed, and makes recommendations on the implementation of the assessmentof need and financial framework.

4. A further point made was that the payment for nursing care in nursing homes shouldnot be seen as perpetuating the system of providing care in institutional settings. While itwas agreed that the first priority for funding should be residents in nursing homes, it wasanticipated that arrangements should be capable of application in other settings, particularlythe person's own home.

5. Limited, but helpful, consultation has also taken place with practitioners, and hasinformed the work of the sub-groups. This consultation, and the information drawn from it,is described under a separate heading.

Assessment of Need subgroup

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6. The Assessment of Need Sub-group met to formulate a way in which the need fornursing care in nursing homes could be assessed, and how that assessment of need could belinked to allocation of resources for the provision of free nursing care.

7. The Group agreed, after considerable discussion that its remit should principallyaddress assessment of need for nursing care in nursing homes, particularly for those whowere currently funding their own nursing care.

8. The group did wish to make clear, however, that its recommendations, though focusedon the provision of nursing care in nursing homes to those who fund their own care, wouldhave wider application to the care of older people and particularly to the population currentlyin nursing homes but not funding their own care. The recommendation of this group is thatthe assessment procedures should be applied to all nursing home residents, and indeed allolder people have a statutory right to a Community Care Assessment of their needs under theNHS and Community Care Act (1990) prior to any decision being made on whether or notthey require residential accommodation. This will have resource implications for agencies,as well as implications for the way in which patients are monitored once they are inresidential accommodation.

9. The group concluded that its role was not to provide a definition of nursing. Rather itassumed that a high level of assessed need and the need for nursing care equate. This meansthat funding could be allocated against dependency characteristics identified from theassessment of need. It also recognised that need might be related to the requirement forrehabilitative input to retain independence. The discussions clarified the fact that nursingcare in this context does not necessarily mean care delivered by a Registered Nurse but thatthere must be appropriate Registered Nurse input.

10. The group took other relevant pieces of work into consideration;

• the recommendations of the Joint Future Group with their emphasis on joint workingbetween health and social services, particularly in the care of older people;

• the move to single care home provision in April 2002, would render the term "nursinghome" obsolete, but it was felt that the term was useful for describing the current system,so it was retained for the purposes of the work in hand;

• other possible impacts of the Regulation of Care Bill were also borne in mind, coupledwith the view that the assessment process being proposed may improve standards withincare homes. The outcome may be the need for a standard governing the frequency withwhich individuals within such homes have their needs reassessed.

Financial Framework subgroup

11. The Financial Framework sub-group considered the issues arising out of its remit, andlimited its considerations to:

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• referring to long term care in nursing homes and therefore excluding stays of less than3 months; and

• covering only the older people (over 65 years of age) in nursing homes.

12. The group was unanimous that any financial framework recommended should stressthe following features:

• bureaucracy kept to a minimum;

• financial disincentives to rehabilitation should be excluded;

• recognise NHS Scotland’s responsibility for nursing care;

• not add to the financial uncertainties of nursing home providers; and

• recognise the current system for assessment of community care needs which is carried outby local Authority Social Work departments.

13. Possible future arrangements for the resourcing and management of services for olderpeople recommended in the report “Community Care: A Joint Future” have been consideredwhen developing the financial framework for free nursing care. When considering the likelycost of arrangements proposed, the group recognised demographic trends and the impact theywill have on the nursing home market.

14. The group discussed existing resource allocation systems and how they can beamended to reflect the financial implications of dependency categories, which woulddetermine the need for nursing care.

15. The NHS is accountable for the expenditure on continuing care in nursing homes andthe framework described, which involves administration of the resources jointly with LocalAuthorities, will not undermine that accountability.

Assessment Process

16. The Assessment of Need subgroup reviewed assessment tools which were familiar topractitioners in Scotland, or are being considered for use in England, and reviewed work onassessment tools carried out in England before arriving at its recommendations on assessmenttools and process. (Appendix 4)

17. The Group recommends in line with the recommendation of the Joint Future Group,(which sets a date of October 2001) that a single shared assessment is carried out, preferablyby one person, but involving others if necessary, that the contribution of the multidisciplinaryteam is acknowledged, and that the holistic needs of the person are assessed. Such anassessment is currently required by the NHS and Community Care Act 1990 to determine

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need and the provision of appropriate care. In order to avoid duplication the assessment ofneed for nursing care must be part of this assessment and not additional to it.

18. It is important to note that the single shared assessment process incorporates the useof tools for the assessment of need and for the allocation of resources.

It is recommended that:

1. All older people with identified needs should have a single shared holisticassessment of their care needs carried out by the person/professional mostsuitable to do so.

2. It is vital that the professional undertaking the assessment works inpartnership with the older person, and, if appropriate their carer, and engagesfully with the multidisciplinary team to ensure the needs of the older person havebeen appropriately identified.

19. The tool used for the needs assessment should be CarenapE, or a tool developedlocally, provided that it meets the validation criteria proposed by the Assessment of NeedSubgroup (Appendix 5). The preference of the Stakeholders’ Group was that a singleassessment tool be adopted. There will also be a need for independent audit and validation toensure consistency. Some testing of locally developed tools against validation criteria willtake place where there is evidence of joint working and joint development of assessmenttools. The individual assessment of need will determine or inform where the older person’sneeds can best be met.

Benefits of a single assessment tool

• Provide a consistent approach across Scotland.

• In particular where local authority and health boundaries are not coterminous.

• Should aid joint working between agencies.

• Easier to audit nationally and to compare results.

• Could be linked to IT systems and sharing of information *

• Better consistency in appeals procedures.

• Encourage joint training and management of care.

• Validation and inter- relater reliability.

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• Best implemented following testing and piloting.

• Practitioners are ready for such a move.

Disadvantages of a single assessment tool

• May be seen as centrally imposed.

• Requires significant funding to develop effective national IT systems.

• If not properly validated the tool may not be suitable for the purpose.

• Reaching agreement with all professionals could lead to the lowest common denominator

*Funding has been identified to update CarenapE and D and to technically verify aproposed model, to allow the exchange of core client information between Carenapdatabase, local authority and Gpass systems.

It is recommended that:

3. The tool used for assessment should be CarenapE, or a tool meeting thevalidation criteria established by the Assessment of Need Group.

Resource Allocation

20. In parallel with the needs assessment, a resource utilisation tool, either SCRUGS orIsaacs and Neville's Intervals of Need will be used to determine the patient's requirement forNHS funding for nursing care.

21. The resource allocation tool will determine the resource implication of that placementchoice, and can be carried out by the person undertaking the holistic assessment. It isessential that a single resource allocation tool is used to achieve a consistent approachthroughout Scotland.

22. A quality specification will be developed, against which the resource allocation toolscan be measured as fit for purpose. (Draft, Appendix 6)

23. The final determination of which resource allocation tool will be used will be madefollowing testing and piloting in sites across Scotland. This tool will not determine thepatient's need for nursing home care, only whether they are entitled to payment towards theirnursing care costs.

24. Eligibility Criteria for nursing home care are produced by each Local Authority. Asingle Resource Utilisation Tool to be used across the country which determines a level ofcare to be equated with the need for nursing care will undoubtedly impact on local eligibilitycriteria, and the implications of this must be considered.

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It is recommended that:

4. A single resource utilisation tool, either a variant of SCRUGS(Appendix 7), or Isaacs and Neville's Intervals of Need (Appendix 8), will be usedacross Scotland to determine entitlement to payment for nursing care. ResourceUtilisation Tools proposed will need to be tested; work should be undertakenwith practitioners during January–March 2001 to test the application of the2 tools mentioned above.

The resource utilisation tool will be used in parallel with the tool used forassessment of need.

5. Local eligibility criteria for social care services and criteria forNHS continuing care should be aligned to a nationally agreed level of need whichequates to a need for nursing care, so that free nursing care can be providedfairly and consistently to older people across Scotland.

25. The group also recommends that assessment should take place within a set timescale,to prevent unnecessary delays.

It is recommended that:

6. Assessment should take place within a set time, in line with, but notnecessarily the same as that set out in guidance. (Circular SWSG10/98"Community Care Needs of Frail Older People: Integrating ProfessionalAssessments and Care Arrangements" assessments expected to be carried outwithin 21 calendar days). This would be from the time that needs were firstidentified.

26. In addition, it is recommended that reassessment of need should be as frequent as theperson requires and at least annually. This recognises that the needs of older people admittedto nursing homes are not static and can change. All people should be reassessed within3 months of going into a nursing home, as their capacity for rehabilitation will be clearer atthat stage, as will their level of need. This is also consistent with the 3 month disregard as setout in the Executive's response to the Sutherland Report.

It is recommended that:

7. All older people receiving nursing home care should be reassessed at leastonce per year, or as their needs dictate, and should have their first reassessmentwithin 3 months of going into a nursing home.

27. The assessment process needs to extend further to include the rest of the nursing homepopulation that is not self-funding, which will have implications for those agenciesresponsible for carrying out the reassessments. It is important that someone who knows the

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patient, and is independent of the nursing home, carries out the assessment, and that thatperson consults with the multidisciplinary team and refers appropriately if required.

It is recommended that:

8. The assessments and reassessments should be carried out by someonewith the necessary skills and training, who knows the older person.Reassessment should involve, but be independent of, the nursing home provider.

28. There are training implications in this process, as well as timing implications. Thegroup recognises the difficulty in attempting to assess every older person currently in anursing home who funds their own care in the timescale, so recommends that those currentlyin nursing homes should be funded.

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It is recommended that:

9. Those older people already funding their own care in nursing homes priorto a set date will not need to be assessed, but after that date all those coming intonursing homes will be assessed. (DATES TO BE AGREED)

29. Agencies and individuals need to understand that the older person can refuseassessment, but need to be made aware that to do so will prevent their nursing care being paidfor. In addition, if a person is assessed as not having a level of need that equates with themrequiring nursing care, and therefore is not given funding for nursing care, they can stillchoose to go into nursing home care providing they agree to fund the nursing elementthemselves.

Testing and Piloting

30. This testing and piloting process will determine whether existing tools are suitable toprovide the single holistic assessment of need. This means that local areas must ensure that ifthey are not using Carenap, their assessment tool meets the validation criteria. In addition,the testing and piloting will determine whether SCRUGS, or a new variant derived for thepurpose, or Isaacs and Neville, is the best resource utilisation tool for the purpose of linkingneed with resources. Areas are currently being identified for this testing to take place.Piloting should take place in a variety of settings to test the flexibility and applicability of thetools, and professionals’ ability to use them. Because of the short timescales involved, thisprocess may have to take place at the same time as consultation.

It is recommended that:

10. Agencies locally who choose to use their own individual assessment ofneed tool will require to have that tool validated against the agreed nationalcriteria. In areas where the relevant agencies are unable to agree on anassessment model that meets the criteria they should use CarenapE.

11. Piloting in various settings throughout Scotland should take placebetween April-October 2001 to ensure that the resource allocation tool chosen isfit for purpose.

Training

31. Training will be a key issue. It must reinforce the need to:

• work together in assessment;

• trust the assessments of professionals from other agencies; and

• apply a resource utilisation tool consistently.

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32. This will require a change in culture in both health and social care agencies, as well asstaff acquiring the necessary skills in using a single shared needs assessment tool and aresource utilisation tool that is to be applied across Scotland. All practitioners who are to actas assessors and care managers under the new arrangements should be required to undertakejoint training prior to implementation.

33. Training should be multidisciplinary and multi-agency. This will ensure that all staffunderstand the impact of this change, not only on older people who fund their own care, buton all nursing home residents, and on all of those older people who require care, whatever thesetting. The group is mindful that this type of cultural change is difficult, but is also awarethat without it, any joint/shared working will have difficulty. It expects that this training willease the path towards better joint working, to the benefit of all older people requiring care.This is demonstrated by research.

It is recommended that:

12. Training in partnership working and use of the single assessment of needprocess should begin as soon as possible, and be followed by training in the use ofthe chosen resource utilisation tool.

13. Training should be multidisciplinary and multi-agency and involve olderpeople and carers to develop a shared understanding of roles and needs. Thisshould help ensure the necessary cultural changes within organisations.

Consultation

34. Some consultation, with practitioners and others across Scotland has already takenplace in the form of focus groups. A summary of the consultation process and its findings isoutlined below.

35. The Needs Assessment subgroup identified the importance of getting practitioners’views from an early stage in the process. This view was echoed by the Stakeholder Group. Itwas agreed that focus groups of a mix of professionals working with older people in a varietyof settings would be beneficial

36. A total of 7 focus groups, met in November and December. The participants camefrom health and social care practitioners, private providers and voluntary organisations.

37. The groups were held in Edinburgh, Lanarkshire, Fife, Tayside and Aberdeen (whichincluded Grampian, Moray and Highland), and a video link was established with the WesternIsles, Orkney and Shetland.

38. Six groups discussed:

• which assessment of need tools were in use;

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• how to make it easier for the older person to get appropriate care;

• health and social care joint working: what does it mean for the practitioner; and

• how to link individual needs assessment with a resource allocation tool so that funds canbe allocated fairly and consistently.

39. The seventh group focused on the work of ISD, (Information and Statistics Division).A group of social work care managers were asked to apply SCRUGS methodology to a realcommunity care assessment. A SCRUGS interview was conducted in an open forum to testthe validity of the application of SCRUGS to a completed community care assessment. Theobjective was to test if the SCRUGs interview could be added to the individual needsassessment process, to determine the level of resources associated with a placement decision.

40. In general we received a very positive response from all the groups welcoming theopportunity to take part in the process.

41. The outcome of the groups can be summarised as follows:

• there are a variety of assessment of needs tools/processes used throughout Scotland, evendifferent ones across some of the local authorities areas;

• 60% of participants felt that a single tool should be adopted in Scotland. This viewreached 100% particularly in areas where it was felt progress on joint working had beenlimited;

• there was consensus that if a single universal assessment tool was not implemented thereshould be standard criteria against which any local assessment of need tool/process can bevalidated;

• if not a single tool, a single shared assessment of need process, should be implemented byall agencies;

• SCRUGS is a useful tool but needs testing and development to ensure its appropriatenessfor application to the assessment of need for free nursing care;

• Isaac and Neville’s intervals of need was not familiar to most practitioners but itsusefulness in a community setting should be tested;

• there was little evidence of the use of the RCN nursing assessment tool for older peoplebut it was considered not to truly reflect the full range of social care needs required, andtherefore not fit for the purpose in Scotland.

• in all groups participants who were unfamiliar with CarenapE asked for furtherinformation;

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• Carenap E, in one of the pilot areas, was being used in addition to all other assessments;

• there is evidence that joint working at practitioner level falls down when budgets for careand in particular equipment needs are requested to maintain the older person in thecommunity;

• a generic version of Carenap would be beneficial as CarenapE is often considered toocomplex for the purposes of initial assessment; and

• the current practice is that the agency who holds the budget does the assessment.

42. The December focus groups were in support of the use of validation criteria. Thefollowing comments were made:

• single budget more important than single assessment;

• need unified budgets;

• accommodation/housing requirements should be integral to the process;

• rehabilitation needs should include smart technology;

• views of person/carer should be recorded;

• non- intrusive could be interpreted as sensitive/relevant;

• support for the inclusion of advocacy involvement; and

• unmet needs should be recorded; together with an assessment of the likely consequenceseg absence of equipment = private nursing home admission.

43. There has been widespread support from all areas to participate in testing and pilotingof the resource allocation tools, and it is felt that it would be beneficial to follow this up. This testing and piloting could help create the culture which would enable successful jointworking and management of resources for older people's services.

44. Members of the Stakeholders’ and sub-groups have consulted with theirconstituencies where appropriate, but the view is that wider consultation should follow theMinisterial response to the report. The likely timescale needs to be consistent with thatapplying to the consultation on the introduction of Single Care Homes. The period should belate January to the end of March.

It is recommended that:

14. Consultation on the recommendations of the report should begin as soonas possible in 2001, and be concluded by the end of March.

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Payment rates

45. Following review of work undertaken in some areas in Scotland, it was concluded thathaving a pricing structure according to different levels of dependency is difficult to managefor the following reasons:

• financial planning difficult for the care home;

• expectation of frequent re assessment;

• disincentive to rehabilitation; and

• increase in bureaucracy.

46. As a result, and in accordance with the aim of having a simple structure, it was agreedto recommend a flat rate payment where nursing care is required.

47. Those funding their own care presently have no requirement for assessment and inrecognition of this additional group requiring assessment (4,500 at March 2000), associatedcosts of assessment should be included in the costs.

It is recommended that:

15. A flat rate of payment should be implemented for nursing care. Thiswould be allocated where the individual's assessed need equated with the needfor nursing care.

16. The flat rate payment should include an element, which recognises theneed for equipment associated with nursing care. This is for equipment that wewould expect any nursing home to provide in order to carry out its function as acare home. This will link with the standards put in place by the Commission forthe Regulation of Care and with the wider issue of provision of equipmentaddressed by the Joint Future Group.

17. The following variables either singly or in combination should beconsidered for a flat rate payment. The need for nursing care because of needsrelated to:

· Activities of daily living· Difficult behaviours· Complex clinical need

Inclusion of the difficult behaviours variable should ensure the needs ofdementia sufferers trigger payment for nursing care. The care required to meet

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these needs will contribute to the maintenance of the older person's quality oflife.

Management of the Allocation of Funds

48. The group is advocating that the process should be kept simple. Simplicity could beachieved by the formulation of a joint resource pool, which would be jointly managed byNHSScotland and Local Authorities in each area. This method is in line with therecommendations of the Scottish Executive Response to the Royal Commission and the JointFuture Group.49. Whatever mechanism is agreed for the allocation of funds an accountability andmonitoring framework needs to be established. It is suggested that the nursing homeproviders make a quarterly return to the local authority covering their area.

50. Any monitoring framework should reflect the recommendations in the Regulation ofCare Bill and the national care standards being developed for the Scottish Commission forthe Regulation of Care.

51. The funding arrangements put in place should be sufficiently flexible to allow fundsallocated to provision of nursing care in nursing homes to support care in other settings, overthe medium to long term if it appears that the use of nursing home beds is inappropriate forthe assessed needs of a proportion of self-funders.

It is recommended that:

18. From April 2002 a mechanism should be agreed to pay the funds for freenursing care from the Scottish Executive into the local funding pool for olderpeople, which will be jointly managed by local health and social care agencies.Local Authorities and Health Agencies will be operating joint or pooled budgetsfrom April 2002 and the expectation is that funds for free nursing care could bemanaged through this route

19. An accountability and monitoring framework should be establishedwithin which the nursing homes will provide quarterly returns to the localauthority.

Appeals Process

52. It is necessary to develop an appeals mechanism for disputed cases. The process inplace for NHS continuing care provision could be used as a model.

It is recommended that:

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20. An appeals process could mirror the procedure in place forNHS continuing care but further discussion is required to determine the nursinginput. This too will have accountability and training implications.

Implementation

53. The timescale for implementation is short, and there may be conflict between:

• the requirement for training;

• the need to consult; and

• the need to identify the resource utilisation tool that should be used.

54. In addition, if the new mechanisms are to take effect from October 2001, it is clearthat there would be some difficulty in meeting the needs for training of staff, assessment ofresidents and getting any necessary legislation in place. While the October deadline would fitwith the Joint Future Group's recommendation on the implementation of single assessment, itwould not fit with the timetable for introduction of the single care home, or for the changes inDSS arrangements, both of which are scheduled for April 2002. Perhaps more importantlyfrom a resource point of view, local authorities and health boards will be required to havejoint management of resources for older people in place by April 2002(JFG), which shouldmake the management of funds for free nursing care for those funding their own care easier.

It is recommended that:

21. The changes proposed should start from April 2002, in line with thoseproposed by the Joint Futures Group, and in the Regulation of Care Bill.(Relevant timetables are illustrated in Appendix 9)

CONCLUSION

55. The Group(s) have attempted at all times to set the provision of free nursing care innursing homes in its broader context. It has sought in its recommendations to encourage jointworking and the joint use of resources with the primary aim of improving the care of olderpeople. It has recognised the possible effects of its work on the wider provision of care tothis group of people at what is a difficult and vulnerable stage of their lives.

56. It is acknowledged that while initially the funds provided must be used to supportthose who fund their own care in nursing homes, as the balance of care continues to shiftmore to the community based care, funds released by this shift may be more appropriatelyused for provision of nursing care in other settings.

57. The group freely acknowledges the difficulties implicit in the effort to change theculture of those providing care from being organisation/profession-centred, to being patient-

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centred, but it also acknowledges that staff want to provide the best service possible to olderpeople, no matter what organisation they belong to.

58. We are aware that provision of free nursing care in nursing homes is a small aspect ofthe provision of care to older people, but we also believe that if the changes we are proposingare adopted, services to all older people in need of care will be improved.

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RECOMMENDATIONS:

Recommendations are prioritised under the following 5 headings:

1. Single Shared Assessment

2. Resource Allocation Tools

3. Financial Mechanisms

4. Training

5. Consultation

1. Single Shared Assessment

a. All older people with identified needs should have a single shared holisticassessment of their care needs carried out by the person/professional mostsuitable to do so. (Rec 1)

b. It is vital that the professional undertaking the assessment works inpartnership with the older person, and, if appropriate their carer, and engagesfully with the multidisciplinary team to ensure the needs of the older person havebeen appropriately identified. (Rec 2)

c. The tool used for assessment should be CarenapE, or a tool meeting thevalidation criteria established by the assessment of need group. (Rec 3)

d. Assessment should take place within a set time, in line with, but notnecessarily the same as, that set out in guidance. (Circular SWSG10/98"Community Care Needs of Frail Older People: Integrating ProfessionalAssessments and Care Arrangements" assessments expected to be carried outwithin 21 calendar days.) This would be from the time that needs were firstidentified. (Rec 6)

e. All older people receiving nursing home care should be reassessed at leastonce per year, or as their needs dictate, and should have their first reassessmentwithin 3 months of going into a nursing home. (Rec 7)

f. The assessments and reassessments should be carried out by someonewith the necessary skills and training, who knows the older person. Reassessment should involve, but be independent of, the nursing home provider.(Rec 8)

g. Agencies locally who choose to use their own individual assessment ofneed tool will require to have that tool validated against the agreed national

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criteria. In areas where the relevant agencies are unable to agree on anassessment model that meets the criteria they should use CarenapE. (Rec 10)

h. Those older people already funding their own care in nursing homes priorto a set date will not need to be assessed, but after that date all those coming intonursing homes will be assessed. (DATES NEED TO BE AGREED) (Rec 9)

2. Resource Allocation Tools

a. A single resource utilisation tool, either a variant of SCRUGS(Appendix 7), or Isaacs and Neville's Intervals of Need (Appendix 8) will be usedacross Scotland to determine entitlement to payment for nursing care. ResourceUtilisation Tools proposed will need to be tested; work should be undertakenwith practitioners during January–March 2001 to test the application of the twotools mentioned above. The resource utilisation tool will be used in parallel withthe tool used for assessment of need. (Rec 4)

b. Local eligibility criteria for social care services and criteria forNHS continuing care should be aligned to a nationally agreed level of need whichequates to a need for nursing care. Free nursing care can then be provided fairlyand consistently to older people across Scotland. (Rec 5)

c. Piloting in various settings throughout Scotland should take placebetween April-October 2001 to ensure that the resource allocation tool chosen isfit for purpose. (Rec 11)

3. Financial Mechanisms:

a. A flat rate of payment should be implemented for nursing care. Thiswould be allocated where the individual's assessed need equated with the needfor nursing care. (Rec 15)

b. The flat rate payment should include an element, which recognises theneed for equipment associated with nursing care. This is for equipment that wewould expect any nursing home to provide in order to carry out its function as acare home. This will link with the standards put in place by the Commission forthe Regulation of Care and with the wider issue of provision of equipmentaddressed by the Joint Future Group. (Rec 16)

c. The following variables either singly or in combination should beconsidered for a flat rate payment. The need for nursing care because of needsrelated to:

• Activities of daily living;

• Difficult behaviours; and

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• Complex clinical need.

Inclusion of the difficult behaviours variable should ensure the needs ofdementia sufferers trigger payment for nursing care. The care required to meetthese needs will contribute to the maintenance of the older person's quality oflife. (Rec 17)

d. From April 2002 a mechanism should be agreed to pay the funds for freenursing care from the Scottish Executive into the local funding pool for olderpeople, which will be jointly managed by local health and social care agencies.Local Authorities and Health Agencies will be operating joint or pooled budgetsfrom April 2002 and the expectation is that funds for free nursing care could bemanaged through this route. (Rec 18)

e. An accountability and monitoring framework should be establishedwithin which the nursing homes will provide quarterly returns to the localauthority. (Rec 19)

f. An appeals process could mirror the procedure in place forNHS continuing care but further discussion is required to determine the nursinginput. This too will have accountability and training implications. (Rec 20)

g. The changes proposed should start from April 2002, in line with thoseproposed by the Joint Futures Group, and the Regulation of Care Bill. (Rec.21)

4. Training:

a. Training in partnership working and use of the single assessment of needprocess should begin as soon as possible, and be followed by training in the use ofthe chosen resource utilisation tool. (Rec 12)

b. Training should be multidisciplinary and multi-agency and involve olderpeople and carers to develop a shared understanding of roles and needs. Thisshould help ensure the necessary cultural changes within organisations. (Rec 13)

5. Consultation:

a. Consultation on the recommendations of the report should begin as soonas possible in 2001, and be concluded by the end of March 2001. (Rec 14)

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APPENDIX 1

FREE NURSING CARE STAKEHOLDERS GROUP

REMIT

In the light of the Scottish Executive's response to the Royal Commission on Long TermCare: to consider and to report to the Minister for Health and Community Care on theissues involved in providing nursing care free of charge in all settings, with particularemphasis on developing a system which takes into account the assessment of need forsuch care, the relevance of professional roles, and the necessary financial framework.

MEMBERSHIP

Miss Anne Jarvie, Director of Nursing, Chief Nursing Officer ChairMr Gordon Brown, Information and Statistics DivisionMr Cliff Gordon, Director of Finance, Fife Primary Care TrustMiss Thea Teale, Head of Community Care Division, Scottish ExecutiveMr Sandy Stewart, Social Work Statistics, Scottish ExecutiveMs Gill Ottley, Assistant Chief Inspector, SWSI, James Craig WalkDr David Findlay, Senior Medical Officer, Advisor, St Andrew’s HouseMr Harry Garland, Association of Directors of Social WorkDr Bill Reith, Royal College of General PractitionersMr Joe Campbell, Chief Executive, The Scottish Care CommitteeMs Anne Thomson, Royal College of NursingMs Anna Daley, Community Practitioners & Health Visitors’ AssociationMr Jim Devine, UNISONMs Liz Duncan, Help the Aged (Edinburgh)Mr Paul Gibbons, Director of Nursing, Argyll & Clyde Health BoardMrs Anne Hawkins, Chief Executive, Forth Valley Primary Care TrustMr Jim Jackson, Alzheimers Scotland (Edinburgh)Professor Mary Marshall, Dementia Services, University of Stirling (represented by Sylvia Cox)Ms Maureen O’Neill, Age Concern ScotlandMr Tony Ranzetta, Chief Executive, Fife Health BoardMs Fiona White, Confederation of Scottish Local AuthoritiesMs Marjory Naylor, Association of Directors of Social WorkMs Kirsteen Cameron, Old People’s Services Co-ordinatorMr Robert Samuel, Nursing Officer, Scottish Executive Health DepartmentMr John Froggatt, Associate Nursing Officer, Scottish Executive Health DepartmentMrs Winona Samet, Nurse Adviser, Scottish Executive (Secondee)

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APPENDIX 2

FREE NURSING CARE

THE ASSESSMENT OF NEED SUBGROUP

REMIT

To review assessment of need tools and make recommendation to the Stakeholders’Group.

MEMBERSHIP

Mrs Anne Hawkins, Chief Executive, Forth Valley Primary Care Trust Co-chairMs Fiona White, Confederation of Scottish Local Authorities Co-chairMs Anne Thomson, Royal College of NursingMs Irene Schofield, Royal College of NursingMs Kirsteen Cameron, Older People’s Services Co-ordinatorMs Marjory Naylor, Association of Directors of Social WorkMs Anna Daley, Community Practitioners & Health Visitors’ AssociationMs Rosemary Bland, SWSI, Scottish ExecutiveMs Susan Scott, OT Adviser, Scottish ExecutiveMr Jim Jackson, Alzheimers ScotlandMr Gordon Brown, Information & Statistics DivisionMr John Froggatt, Associate Nursing Officer, Scottish ExecutiveMrs Winona Samet, Nurse Adviser, (Secondee), Scottish Executive

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APPENDIX 3

FREE NURSING CARE

FINANCIAL FRAMEWORK SUB-GROUP

REMIT

To determine the financial framework for the allocation of resources for theimplementation of free nursing care and make recommendations to the Stakeholders’Group.

MEMBERSHIP

Mr Cliff Gordon, Director of Finance, Fife Primary Care Trust ChairMr Joe Campbell, Chief Executive, The Scottish Care CommitteeDr David Bruce, Community Care Policy, Scottish ExecutiveMr Neil Rennick, Local Authority Finance, Scottish ExecutiveMs Karry Murphy, UNISON, GlasgowMr Chris Naldrett, Finance Policy Development, Scottish ExecutiveMr Paul Gibbons, Director of Nursing, Argyll and Clyde Health BoardMr Harry Garland, Association of Directors of Social WorkMr Kenny Low, Association of Directors of Social WorkMs Jean Downie, Association of Directors of Social WorkMr John Froggatt, Associate Nursing Officer, Scottish ExecutiveMrs Winona Samet Nurse Adviser (Secondee), Scottish ExecutiveMr Gordon Brown, Information & Statistics DivisionMs Rosemary Bland, SWSI, Scottish ExecutiveMs Susan Scott, OT Adviser, Scottish Executive

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APPENDIX 4

ASSESSMENT OF NEED TOOLS REVIEWED

The Assessment of Need subgroup has been given the task of identifying a means ofreviewing the tools in use to assess people moving into or already resident in nursing homes.

In Scotland, we have some home grown ‘tools’, one of which may be suitable for identifyingthis group of people with high levels of need for care.

The Joint Future Group (JFG) was to identify a way of improving assessment of serviceusers’ needs, so that they were not subject to repetitive assessments by a process of differentprofessionals, and to end the service inefficiencies that this approach caused. A single,shared assessment was proposed to the Group and accepted. CarenapD (for people withdementia) and CarenapE (for assessing the needs of elderly people). The JFG recommendedthat where joint assessment tools had already been adopted in local sites, and were enablingbetter joint working, these should continue to be used. Where joint working was poor or non-existent, it was suggested that CarenapE should be adopted.

The Assessment of Need sub-group considered the work of the Joint Future Group andagreed with its recommendation that a single shared assessment should be used acrossScotland. The tool should be used across disciplines and be able to be completed by anyprofessional working with the older person. The requirement to assess which people have“nursing care needs”, whether or not these needs are being met by a registered nurse, shouldbe part of a brief addition to the community care assessment.

The Department of Health in England has already reviewed a number of assessment ‘tools’for the purpose of establishing a standardised means of identifying such people across thecountry. Included in this review were 11 tools, which were narrowed down to 2.

The tools which the Department of Health narrowed their selection down to, were theMDS/RAI (translated from the American to English by Professor David Challis at PersonalSocial Services Research Unit, University of Manchester), and the RCN Assessment tool fornursing older people. The MDS/RAI is extremely detailed and unnecessarily complex forour purposes. It is a tool for use in residential homes or nursing homes only.

Scottish contenders

In Scotland, we have 4 tools which, we suggest, are worth serious consideration:

1. SHRUGS/SCRUGS2. CarenapE3. Isaacs & Neville’s Intervals of Need Scale4. RCN Assessment Tool for Nursing Older People

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From the focus group feedback and further review by the sub-group it was agreed torecommend that the tools of choice for:

Needs Assessment;

• Carenap D• Carenap E• Local Joint Community Care Assessment Tools

In areas where Carenap D or E was not used, the tool had to be validated against the criteriain appendix 4.

Resource Utilisation;

• Scottish Care Resource Utilisation Groups (SCRUGS) or an adaptation.

Linking the needs assessment and the resource utilisation tools;

• Isaacs & Neville’s Intervals of Need Scale.

A description of the above can be found in appendix 7 & 8 respectively

The assessment of need sub-group concluded that a core single shared holistic assessmentprocess be adopted but that it fell into 2 distinct parts:

1. Needs Assessment2. Resource Utilisation

It is thought that the resource utilisation tool could be adapted to form a small addition to theholistic needs assessment process and be carried out by the same person. This will beconfirmed through the testing and piloting with practitioners.

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APPENDIX 5

FREE NURSING CARE

NEEDS ASSESSMENT SUB-GROUP

VALIDATION CRITERIA

Validation criteria against which current needs assessment tools can be assessed. (mustmeet a minimum data set, be able to identify categories of need, which can be applied toresource allocation a tool

Criteria:

! Single-shared assessment, (reference JFG), applicable across health and social care

spectrum.

! Includes assessment of full range of needs, including rehabilitation needs, and trigger

mechanism to specialist involvement.

! Evidence-based, concise and easy to use, by variety of health and social care disciplines.

! Applicable to all settings.

! Assessment of need, should be carried out as sensitively as possible, be relevant, recorded

in plain language and shared with user/carer.

! Views of person in need of care determined, recorded and signed by *person being

assessed.

! Views of carer determined and recorded and signed by the carer (*with consent where at

all possible).

! The involvement of an advocate where appropriate.

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! Data collected and documented only once, with assessment tool linking to resource

utilisation tool, the latter identifying categories of need.

! Review process which accepts and identifies changes in need.

! Unmet needs should be recorded together with likely consequences.

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APPENDIX 6

FREE NURSING CARE

Draft Quality Specification for Resource Allocation Tool

The resource allocation tool to determine “free nursing care” should comply with thefollowing standards:

• A single tool to be used across the health and social care spectrum.

• It’s primary focus is to identify characteristics that determine the relative value ofindividual resource use.

• Evidenced-based and able to meet standard tests of validity (for purpose), reliability andconsistency.

• Cost-effective, concise and easy to use, by a variety of health and social disciplines.

• Applicable to all settings.

• Recorded in plain language and able to be shared with user/carer.

• Resource use assessment derived from holistic assessment process.

• Review process that identifies changes in relative resource use associated with changes inthe characteristics of the person.

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APPENDIX 7

Briefing note on the use of SCRUGS in Private Nursing Homes

The past 2 years has seen the development of what was originally a Health Service baseddependency and resource use measure for application in Private Nursing Home andResidential Care facilities for older people - SCRUGS (Scottish Care Resource UtilisationGroups).

The Scottish Care Resource Utilisation Group (SCRUGS) approach seeks to identify themain characteristics of older people in care facilities as these characteristics relate to resourceuse. It is not in any sense an assessment of the full range of needs of any individualresident/patient. The information can be used to describe individuals, facilities and/or groupsof facilities.

The information is collected on the basis of individual named residents/patients and in doingso ISD complies in full with the confidentiality requirements of the individual residential careand/or private nursing home facilities.

The uses of SHRUGS/SCRUGS include:

• a standardised needs/resource use measure to describe the characteristics of residents andto provide a valid & reliable comparators across a range of residential settings/serviceproviders (NHS; Local Authority; and, Independent Sector).

• A baseline for the application of ‘best value’ criteria.

• A baseline to assess quality parameters.

• A baseline to assess the application of eligibility for admission criteria.

The SCRUGs measure comprises categories of Dependency (Feeding; Toileting;Transferring Position & Moving Location), Special Care Needs and BehaviouralDifficulties. Supplementary information is collected on both special needs anddependency items; including incontinence, emotional and psychological supportand encouraging independence. In private nursing home settings, a trainedinterviewer collects these data from a qualified nurse who knows the residentswell. Data are returned to the home shortly after the visit.

The following is an illustration of how, for example, the dependency information canbe applied.

Score Description4, 5 Low Dependency6, 7 Low to moderate dependency8, 9, 10 Moderate dependency11, 12 High dependency

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29

APPENDIX 8

ASSESSING PEOPLE WITH ‘NURSING CARE NEEDS’: THE POTENTIALUSEFULNESS OF ‘NEED INTERVALS’ (Isaacs & Neville 1976)

People's health and functional ability affects the type and amount of services they require.Dependency or need can be measured by the frequency and predictability with which peoplerequire help to perform a number of daily activities.

There are 3 need intervals: long, short and critical:

People with critical interval needs are the most dependent, requiring assistance on afrequent and unpredictable basis.

People with short interval needs also need assistance several times a day but at longer,usually predictable intervals.

People with long interval needs are more independent, requiring assistance with severalactivities but usually less than once in twenty-four hours, and predictably.

People with critical interval needs are unable to carry out certain activities of daily livingunaided, such as:

• getting in and out of bed or a chair

• getting to and using the toilet

• controlling bladder or bowel movements

• demonstrating inappropriate/anti-social/violent or risky behaviour due to severe mentalimpairment

• being disoriented for time, person and place and being liable to wander if left unattended

• being acutely ill and needing constant nursing attention.

People who have any of the above difficulties have critical interval needs and could be saidto have ‘nursing care needs’, irrespective of whether it is a registered nurse who actuallygives the care. In the SWSI Tayside inspection (1996), on average, 19% of people living in asample of nursing homes had critical interval needs (due to 'confusion', incontinence or beingbed or chairbound).

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People with these high level (or critical interval) needs should be able to be easily identifiedfrom a completed assessment, since their needs, and how frequently these required assistanceor care, would be explicit.REB, 10.1.01.

APPENDIX 9 FLOW CHART FOR CONSULTATION AND IMPLEMENTATION OF FREE NURSING CARE

CONSULTATION, TESTING AND PILOTING

2001 2002

Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr

*Free

Formal Consultation Nursing

care imple-

Testing of Tools Piloting of Tools

mented.

Training in use of Tools

JOINT FUTURE GROUP / REGULATION OF CARE TIMETABLE

2001 2002

Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr

*Single *Joint/

shared Pooled

assessment budgets

beginning for older

(JFG). people

(JFG).

*Single

care

homes.