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Providing cost-effective rehabilitation for older people depends on being able to match staff provision to the patient’s care and rehabilitation needs.

This requires a means of reliably measuring the patient’s dependency in terms of their needs for nursing and therapy staff time. We also need to demonstrate that the initial investment in rehabilitation is offset by long-term savings in cost of care in the community. We therefore need a direct measure of care needs and costs in the community.

Widely used global disability scores such as the Barthel Index and the Functional Independence measure (FIM) have been shown to correlate with care needs, but cannot be used to assess them directly as they do not measure the number of people needed to provide help for tasks or the time taken to complete them. They have recognised floor and ceiling effects: for example, at the dependent end of the scale they do not differentiate between the need for one or two carers. Similarly, at the opposite end of the scale, they do not identify the need for constant supervision of a patient who functions automatically at a basic level, but has poor safety awareness and tends to wander.

The Northwick Park Dependency Scale (NPDS) and Care Needs Assessment (NPCNA) have been developed to provide an assessment of care and nursing needs in a rehabilitation setting, which translates directly into an assessment of the care hours and costs of providing care in the community.

Northwick Park Dependency Scale
In development since the 1990s, the Northwick Park Dependency Scale (NPDS) is designed to assess dependency of patients in a rehabilitation setting, in terms of impact on nursing staff time.

• It takes account of the increased time taken to supervise while a patient undertakes a task for themselves, rather than simply doing it for them.
• It also allows for the extra time needed to communicate with patients who may have language or cognitive difficulties.

The tool is divided into two sections: Basic Care Needs and Special Nursing Needs.

The Basic Care Needs (BCN) section (range 0-65) includes 12 items associated with activities of daily living such as washing, dressing, eating and drinking, as well as safety awareness, behaviour and communication. Each item is rated on a scale of 0-5 and the cut-off points between levels are determined by the number of nurses required to help and the time taken to complete each task.

The Special Nursing Needs (SNN) section (range 0-35) contains seven specific care items which would normally need to be undertaken by a qualified nurse, or a specially trained carer. These are rated on a dichotomous scale of 0 or 5.

Use of the NPDS
The NPDS was first published in 19981 together with evidence of its reliability. Since then it has been widely adopted in the UK2, and has been explored in other countries including Sweden and Australia. Its merits include:

• Individual ratings may be scored prior to admission to quantify needs in advance of a patient’s arrival on the ward.
• During admission, the NPDS may be recorded serially to monitor improvement in independence.
• NPDS scores for the whole ward may be summated to assess case mix in relation to staffing levels.

A simple computer programme for data entry is available. This was written in Microsoft Excel and is available to anyone who has the Microsoft Office suite on a PC. The programme facilitates data entry and automatically produces a single summary sheet for ease of reference/filing. It also computes the translation to the NPCNA.

Northwick Park Care Needs Assessment
The Northwick Park Care Needs Assessment (NPCNA) provides an assessment of care needs in the community. It is derived from the NPDS by applying an algorithm based on a set of validated `rules' or assumptions, together with a small additional set of 5 questions about the community setting.

The rules are based on common habit, for example:

• If a person requires help from two people to dress and takes less then ½ hour, the NPCNA would allocate ½ from two carers in the morning (to get dressed) and in the evening (to get undressed).
• If the person requires help from one person to eat their meals, and takes less than ½ hour, the NPCNA would allocated ½ from one carer in the morning (for breakfast), at Midday (lunch) and in the evening (supper).

In this way the NPCNA builds up into a timetable of care needs throughout the day.

For examples of both tools.

Lynne Turner Stokes
Northwick Park Hospital