Examination of Witnesses (Questions 40 - 59)
WEDNESDAY 25 FEBRUARY 1998
MR CHRIS
KELLY, SIR
HERBERT LAMING,
CBE, MR NICK
BOYD, DR
SHEILA ADAM
and MRS ELIZABETH
WOLSTENHOLME
40. Let us look at it positively. Do you think there is a
danger, nonetheless, that through this resource mechanism and
the way in which these monies pass between departments, actually
the boundary between health and social services is going to progressively
become affected year by year by a reduction in social services
money and an increase in health money by exactly that kind of
process?
(Mr Kelly) In the past there have been two processes
going on, have there not? There has been the pressure on local
authority spending which has gone on throughout most of the period
of the last Government and settlements which in most years were
more generous for the health service; you are absolutely right
about that. There has also been a quite deliberate shift from
the social security budget onto the personal social services budget
as a result of community care. There is a mixture of things that
are happening deliberately and things that happen as a result
of unintended consequences. If you are saying: is not one of the
major issues about joined"-up thinking the fact that we have
two different financing flows subjected to different influences,
and different degrees of certainty? I would agree there is another
point you could have mentioned, which is that on the whole health
authorities have more certainty than local authorities about future
funding flows and that has implications for the way in which they
can have joint investment plans and so on. That is a very long-winded
answer. If your question is: do not the different funding streams
and the different funding time scales create difficulties? The
answer to that is yes, in my view they do. I do not know how we
can help that.
Ann Keen
41. There is a list of 11 non-statutory mechanisms which
have been established to encourage joint working. Have these mechanisms
worked in practice and are they widely recognised and adhered
to?
(Mr Boyd) The broad answer to that would be that they
have not been without gain but they have not achieved 100 per
cent seamlessness as is very apparent from the discussions today
which have been going on for the last hour and a half. The measures
listed here are quite an array over a period of about 15 years
but it could be argued that the measures introduced in the 1970s,
which were basically the joint consultative committees and joint
financing arrangements, did actually begin to bring people together
because they actually had hard cash to talk about which was part
of joint financing. They did not necessarily, in fact they certainly
did not, bring the kinds of services we are talking about and
the needs of individuals we are talking about into the centre
of planning and commissioning and purchasing, the core business
of the agencies. It seems to me that the measures which Ministers
have in mind looking to the future, which have been discussed
today, through the NHS White Paper and the Green Paper and the
consultation document which will be issued on flexibilities, the
overriding aim of that really is to bring these kinds of services
into the core business of the agencies involved and that would
be a departure from what was before. It would be wrong to say
that all these measures have produced no benefit as such. The
feedback I get in talking to different people is that there certainly
has been an advantage in having a joint finance mechanism available
because the agencies do get together and they do talk about projects
they can finance with all of that and the various strategy planning
mechanisms which were introduced but they certainly have not solved
the problem.
42. In relation to the White Paper and the changes that is
aimed to produce, could any of tell me that there is one particular
area you are going to focus in on the White Paper to bring about
this change in the relationship between social and health services?
If I tell you the way I am thinking it would perhaps be helpful.
Say in relation to what are sadly described as bed blockers, if
we were to look at inappropriate admissions of people in the first
place. Audrey Wise is asking you to look at certain pathways and
provide a mapping service. I should like to put in a plea for
an elderly person who lives alone with a chronic chest infection,
probably diagnosed with pneumonia. The out of hours duty service
comes out and the person is admitted to hospital, they stay on
a hospital trolley for 24 to 48 hours, they eventually get admitted
to the ward and they never return home. That would be to me a
very classic example of how social and health could work in particular
with the White Paper. Do you foresee any circumstances where you
would be targeting? The Government has targeted in on the winter
pressure which is a continual pressure really. The extra money
has been given, that was supposed to be distributed with social
services. Is there any evidence that that is working?
(Sir Herbert Laming) Yes. These elements you have
referred to are an indication that the Chairman's comment earlier
on which would somehow characterise the Department as just leaving
it all down to those people down there and we stand back was,
far be it for me to say, unfair.
Chairman
43. I was one of the people down there.
(Sir Herbert Laming) Exactly. What we have tried to
do is create a framework which is actually facilitating joint
working. When it comes to looking at the future and the White
Paper Ministers have placed a great deal of importance on looking
at getting better information about hospital admissions, looking
for ways in which we can avoid unnecessary admissions so that
we are monitoring very carefully what happens about admissions.
Some of the information which is coming through is most interesting
and some of the information that we are monitoring very carefully
is being done jointly, this is not health alone, we are very much
working jointly on the monitoring; people have to sign up to these
reports, health and social services have to sign up to the reports
on hospital discharge. They are giving us a great deal of information
which Ministers are taking very seriously about what happens to
people on discharge. The mechanisms which have been put in place
about joint investment programmes and about making sure that public
funds are used across the board and that people's needs are identified
by talking to them and talking to their carers is very much part
of the programme which Ministers want us to deliver on.
(Mr Kelly) My answer to your question as to whether
there is one thing we would single out is no, there is not, because
it is not a question of finding a simple solution. There is no
single solution to any of these things. It is a question of working
away at it on a number of fronts, all the things Sir Herbert has
mentioned, national service frameworks, using health action zones
as an opportunity to experiment with different ways of doing things
and seeing whether we can learn from that, the consultation paper
we are going to issue on flexibilities and so on. It is a question
of continuing to plug away on as many fronts as possible.
(Mrs Wolstenholme) May I comment on the lessons we
have learnt from the use of the winter pressure money? We are
evaluating that and we are learning that there are some often
quite simple things which can be implemented which unblock the
system. Like you we hate the term bed blockers and it certainly
is an undignified way of referring to anybody but we are getting
evidence that we will be very quickly feeding back to the field
so that they can inform their own planning about what seems to
be working, what is not working so well. Certainly last winter
just some very simple things like making sure there were adequate
pressure relieving mattresses for example enabled some people
to go home earlier than they would otherwise have done. If that
is what it takes, then people need to know that. There is a joint
evaluation going on.
Ann Keen
44. What puzzles me is that that knowledge is there and has
been there for many years; the mattresses have not been there
but the knowledge has been there. We have known that people need
not have been admitted to hospital if we had a 24 hour community
service which was available to give treatment in those first two
or three days and the person then is able to stay at home. That
knowledge has been around for a very long time. I am at a loss
as to why this is new information coming in because there are
people out there who can give this information now.
(Dr Adam) To turn that round, that might be a sign
that things have actually changed out there, that people are working
in different ways. Large bureaucracies take a long time to put
the service user at the centre of what they are doing and until
you start to do that you do not imagine your old person with a
chest infection or your child with emotional behavioural disturbance
and how the system works for them. One of the messages we can
take from the winter pressures story is that where people have
begun to establish better working relationships at a strategic
level between health and local authorities, between primary care
teams and social services, if you can then provide some targeted
money in the way that we were able to do with some fairly straightforward
guidance, the same guidance going to both health and social care
about how that might be used, then in fact people are able to
be really quite creative to draw on that evidence which has been
around for some time. It is only really in the last year or so
that we have begun to see people thinking about mattresses, thinking
about having the handyman who can go out at 24 hours' notice to
do aids and adaptations and prevent people sometimes waiting days
and weeks before they are able to go home. Reports like the Audit
Commission report in the way that they have drawn the evidence
together have been very helpful in pointing out the value for
money issues around whether people are in levels of care which
they have to be because we have allowed them to become dependent
and not built in the recuperation and rehabilitation programmes
and it is not a sensible thing to allow that to happen. My sense
is that people are working differently together, that there is
a better understanding of what can be done and there has been
opportunity for people to move quickly and to tackle problems
which there has been a better recognition of in the previous few
months than perhaps we have managed to establish before. The climate
has really begun to change out there.
45. I really cannot accept this. Why have we had wards being
closed in hospitals now for the past few years because people
have been described as bed blockers, people who have been in hospital.
In my own constituency I have 57 people who have been waiting
to be discharged to residential or nursing homes for several months
and we are closing acute admission beds. That is a common problem
throughout the country and it has been a well-known fact for some
years, I might say. This information is not new. We have known
that we debilitate people by admitting them inappropriately and
they then have to wait a long period to go to residential care.
Why would you say that has been the case in the last few years?
(Dr Adam) I am sorry, I did not mean to say that we
have not known about the problems. We have also known about some
of the solutions. We have not had the climate to encourage people
to tackle it in the way that they have done much more recently.
I am not exactly sure why that is. A number of things have come
together, but particularly recognising that service fragmentation
is both bad for individuals and also-
46. Would you think the internal market has caused that?
(Dr Adam) The internal market in the health service
has been part of people thinking about their organisations some
of the time rather than always thinking about the people using
them. There has always been a tendency for large institutions
to think about themselves and the people who work in them rather
than to turn it round and think about customers who are using
them. It is important to recognise that the fractures are not
just between health and social care, they have also been within
the health service between primary and secondary care. One of
the encouraging things in the White Paper is really tackling the
primary and community health service interface which for the group
of people we have mostly been talking about this morning in many
ways is absolutely critical.
Mr Walter
47. I wanted to deal with what is obviously an important
part of the White Paper, primary care and particularly the impact
of primary care groups on this very problem. Could you describe
what you think the role of these primary care groups will be in
the development of a seamless service and how you think the community
services will operate in relation to those primary care groups
and whether, when you have these primary care groups which will
be different from what are today in many instances co-terminous
health authorities and local authorities, in fact you might actually
be increasing the structural barriers rather than knocking them
down?
(Dr Adam) One of the things about primary care groups
is that they will tend to form around natural geographical communities.
We are seeing co-terminosity with social services as being an
important although clearly not the only factor. As members will
know, with the various changes in both the health service and
local government over the last few years we have seen a reduction
in co-terminosity at authority level. Although obviously there
will be more than one primary care group for many social services
authorities, we will get a better fit in terms of people knowing
who they need to work with and being able to define the total
resource that is available. I keep coming back to involved in
commissioning specialist health services and with social services
involved, it does begin to give us the whole patch rather than
people just looking at their own part. I see primary care groups
as being important because they will be a way of shaping the total
pattern of health and social care for a clearly defined population
and because they will be able to coordinate that better than we
have been able to do to date. The other thing which will be important
will be the governance arrangements which there will be further
guidance on later in the year and also the fact that there will
be a degree of openness built into how primary care groups will
operate. That is obviously another theme in the White Paper about
making arrangements for decisions on health services more transparent.
That will apply at primary care group level inasmuch as it will
apply in other parts of the health service.
48. What arrangements do you envisage for holding primary
care groups to account for the way they work with social services?
We have the concept of local authority representatives on their
managing bodies. To whom are they responsible? How are those representatives
going to be identified and how will they be accountable? Do you
see any user involvement or patient involvement in the accountability
of those groups?
(Dr Adam) Obviously the accountability will be to
the health authority. In terms of some of the detailed questions
you are asking, further guidance is being developed and will not
be available until later in the year. This is again an issue where
we would be interested in the Committee's views. The proposal
is that users, patients on the list will be involved but there
is more detail to be worked through on exactly how that will operate;
here is a clear commitment from the Government that decision-making
will involve the community for which the primary care group is
responsible.
Chairman
49. At the risk of upsetting my two medical colleagues on
the Committee, one of the issues which might be raised in respect
of the role of GP-led primary care groups in respect for example
of mental health is that there is a risk of locking into a medical
model in that respect. You probably know what I mean. Do you see
this as a danger? Do you think it could be overcome in practice?
Is it a fear which is wrongly placed from my point of view?
(Dr Adam) It is a fear which is commonly expressed.
I would see primary care groups as providing a very good forum
where doctors, nurses, social service staff, other health professionals,
with those who use their services, would be able to engage in
a fairly healthy debate around those sorts of issues. Yes, of
course it is always there; we all come with our baggage, whether
it is a medical model or whatever other sort of model. That needs
to be openly debated involving those who use the services as well
as those who provide them.
Dr Stoate
50. Speaking as someone who has been a GP for 15 years in
the health service I see it exactly the opposite way round. I
think what we should be doing and what we will be doing is promoting
a much more social model. The problem I have as a GP is the Sunday
morning call when you are called in to see somebody who quite
clearly does not need to be in hospital, but you scratch around
for alternatives and there are none. You end up knowing that it
is going to be a bad admission to hospital, knowing it is going
to go wrong, knowing that you are guaranteed to end up with somebody
who is stuck in a ward and is very, very difficult to place beyond
that. All it would actually need is meals-on-wheels, home helps
a nurse on tap then and there on a Sunday morning but of course
that does not exist. I think what we must do in primary care,
and I should like your comments as to whether this is envisaged,
is that the primary care groups should enable that to happen as
a reality rather than just an ideal. The biggest boundary I see
is that social services just are not there when you need them
to avoid that sort of admission. If we can get that right and
actually turn it into a social model of care, what is the best
thing for this person at this time and not in three weeks' time
when it is too late. That is where I see the real crux of this
debate.
(Dr Adam) I am looking for an integrated social and
health model, not medical but health. Ms Wolstenholme might like
to comment on some of the learning from the winter pressures because
there we have found that it is possible to prevent at least a
proportion of those types of hospital admissions; the classic
Saturday afternoon/Sunday morning admission when it is just too
long to wait until Monday and the GP has to do something. There
are some good examples where resourcing social care services out
of hours can actually prevent that happening.
(Mrs Wolstenholme) Yes, there have been schemes around
the country which have targeted just such situations you describe
and indeed the situation Dr Brand described earlier where benefits
in preventive social care can actually bring benefits to the health
care system. Like Dr Adam, I would hope primary care groups, certainly
as they move towards the third and fourth stages of moving towards
primary care trust status, would start seeing some benefits of
integrated provision which is often where the real benefits come
for patients and for people trying to manage those patients in
the community.
Mr Walter
51. To go back on the point you raised as you moved through
the tiers to the primary care trusts, I wonder whether you would
envisage maybe just as a concept that in fact the primary care
trust took over all the responsibilities of social services in
this area, in fact they were not just commissioning them they
were actually responsible for all those services. It may be a
bit radical.
(Mrs Wolstenholme) Certainly the issue of NHS trusts
providing social care is something that this Government is looking
at as part of the package of measures around the interface. Some
NHS trusts are doing that already as a small part of their activity
and selling their services to social services.
Dr Brand
52. There is a tremendous amount of enthusiasm in certain
localities for commissioning groups and all sorts of things are
evolving, very often based on existing local commissioning groups
or multi-funds. No doubt the Department is aware of that but is
the Department also aware that there are local health authorities
who seem to be doing their best to stop that actually evolving
from the grassroots up, they are actually trying to impose a pattern
although they have not yet been instructed what the pattern should
be, and you made it very clear in your responses you are certainly
not quite sure what the pattern is going to be, but they are trying
to impose a pattern on the initiatives which are coming up from
the grassroots. Does that concern you?
(Mr Kelly) If that were happening it would concern
us. We are issuing a circular today addressed to the implementation
of the White Paper including preliminary guidance on the way in
which primary care groups should be set up.
53. I should be grateful for a copy and I will send you some
examples of people with great enthusiasm trying to achieve exactly
what we have been talking about here today who are being sat on
by people who want to protect their empire rather than allowing
services to flourish.
(Mr Kelly) We clearly want neither thing to happen;
neither do we want imposition by health authorities, nor do we
want an existing group to charge ahead in ways which do not actually
meet the needs of the local community.
54. Then you have to be fairly specific fairly quickly.
(Mr Kelly) I am sure we have copies of the circular
with us which we will be happy to give to you afterwards.
Mr Gunnell
55. There does seem to be a little difference in perception
between yourselves and Ann Keen for example on the effectiveness
of collaboration which is taking place already. I wondered whether
you would be able to give us some examples of where effective
collaboration is taking place. It seems to me that if we are going
to do any visits to places then we ought to be looking at somewhere
the collaboration is working. If you could give us some examples
of where there is effective collaboration that would be helpful.
As a sub-question, not intended to be asking a question about
visits, I wonder what work you have done on effective collaboration
between health and social services in other European countries.
We are aware of the fact that in the Netherlands and in Sweden
there are boards which cover both health and social services.
Do you have any work which would suggest other patterns elsewhere
in Europe where the collaboration is actually more organic and
more effective than it is here?
(Mr Kelly) We should be happy Chairman, to give the
Committee examples of good practice. There are some examples of
good practice; there are also some examples of very bad practice
around the country. The trick is to publicise the examples of
good practice and find ways of generalising. It is also true to
say that the good practice is not necessarily across all services.
There are some places where there is good practice in one area
and not in another. We should be very happy to give you examples
of good practice.
56. It would be helpful to the Committee to know your experience
of this.
(Mr Boyd) We are not claiming that everything is perfect
out there by any means. We are well aware that there are difficulties.
We are in fact aware that there are difficulties in certain west
London trusts as well. It is actually the case that the Department's
regional arms of the social care group and the NHS Executive,
the regional offices, are very often engaged in what you might
crudely call trouble-shooting but more generously developing best
practice and trying to sort out where things have gone wrong as
they are in fact doing in that particular case. We know there
are several on the go at any one time where the two regional offices
are working intensively with agencies because there has been a
breakdown or there have been difficulties of some kind to try
to sort them out. On the international examples, I wonder whether
we could offer to provide a note on that. I do not in my head
have international examples. I happen to know the German experience,
which is something in my mind and relevant to the conversation,
where they have a quite different funding system because they
have health insurance funds, but they still have disputes about
baths, to use that one again. In effect they have a health sickness
insurance fund and they have a long-term care insurance fund and
the two funding systems argue with each other about when somebody
has exited the acute phase of their care and are entering the
long term. These disputes happen where there are frictions at
boundaries even in quite different systems. If it would be helpful,
we can put in a note on international experience.
Chairman: It would be very helpful. We should be most grateful.
Mr Lansley
57. You refer in your memorandum to joint investment plans.
I wondered whether you could tell us a little more about this
and how they will operate. In particular, how far forward in time
do you anticipate that joint investment plans will look? Would
I be right in assuming that they are intended to cover both the
investment plans of health authorities and social services in
respect of continuing care and community care services. How then
do you foresee that the joint investment plan will overcome the
uncertainties and difficulties in differential funding streams
to which our discussion adverted earlier? Which way round do you
think it is going to work? Do you think that the establishment
of investment plans will constrain discussion on revenue and resources
for future years in line with the investment plans or do you foresee
that the investment plans will be an intention but will be subject
to change in the light of year by year decisions on revenue and
resources?
(Mr Kelly) They have to be the latter, as in any other
part of the public services.
(Mrs Wolstenholme) We are still working with the field
about exactly what a joint investment plan will look like. We
have set 1998-99 as a developmental year where people will be
working with us to determine what would be feasible, helpful and
build on best practice that is currently already there in the
best of places. We had a workshop about two weeks ago with a range
of stakeholder interests and out of that came the suggestion that
a three-year time horizon seemed probably about right and realistic,
but nevertheless accepting the problems of annuality that there
is in local authority budgets. Nevertheless there are things about
direction of travel and about shared vision and principles under
which you would be working which would transcend changes in year
on year financing.
58. May I just pursue for a moment the difficulty of looking
forward three years in investment terms in respect of two separate
funding authorities, when each of them is also going to be subject
to the annual change in resources? Presumably the situation could
therefore begin to arise, as it does at the moment in a sense,
that one or other of these authorities would undertake an investment
project based upon assumptions about priorities and the revenue
resources of the other authority. It cannot constrain the other
authority. By what process are the joint investment plans going
to be able to override this uncertainty that is clearly, as your
previous answers suggested, part of the abiding difficulty in
establishing a longer term relationship between health and social
services?
(Mrs Wolstenholme) As you say, this is not going to
solve some of those problems, nor did we ever intend that it would.
What we saw the benefits of joint investment plans being were
an effort to get greater transparency on both sides as to what
is on the table when that is known, but also what the problems
are as they arise. The problems are brought to a discussion rather
than happening unilaterally. They may still need to happen unilaterally
because the two authorities will be separate authorities but the
discussion about the consequences will take place jointly. That
happens in the best of places already but in some places it does
not.
(Mr Boyd) It should be a feature of good planning
that you are setting out what variations might be. You are setting
out in the planning what happens if they come in at two per cent
below or two per cent above, what it is that would have to change.
I suppose the argument is that there will be fluctuations in funding
between agencies anyway as a fact of life and it must be better
to try to manage those through some kind of ordered planning jointly
together than just in a rather ad hoc way that happens at the
moment.
(Sir Herbert Laming) It relates to two principles
which very much chime with the concerns of the Committee expressed
earlier on. They are first of all that there should be a joint
assessment of need and that includes, if I may say just as an
illustration, out-of-office hours because it should link in with
emergency admission to hospital, and what happens to those people
or people who have been inappropriately place thereafter in expensive
nursing homes where it may be that could have been avoided by
better working arrangements and recognition in that, I have to
say, that the plan will have to reflect the different patient/client
groups in that the plan for children with health problems or social
care problems will be different from the elderly and certainly
mental health will be quite different. We are not looking for
one plan, we are looking for a planning mechanism which brings
health and social together, which then is based upon certain assumptions
and those assumptions will change over a period of time. The second
point, which I hope the Committee will welcome, is that there
should be a joint commitment to avoid unilateral decision-making.
The point which was made earlier on this morning was about closure
of units in hospitals and movement away from the health service.
Where that is seen to be in the patient and community interests,
well and good, people would not wish to work against that, but
it has to be handled in a way which makes sure alternative provision
is in place to meet their needs. This planning mechanism is not
going to carry such authority that it will be able to commit funds
a long way ahead, but it will set out and it will be public, it
will be transparent, users of services, carers other interested
groups will be able to see it, the direction of travel and it
will be taken step by step according to the funding changes which
come year on year on.
59. To what extent do you foresee that the presence or otherwise
of a joint investment plan between the two authorities will influence
your, the Department's, own view of investment proposals or resource
decisions in those two authorities?
(Sir Herbert Laming) We see that thinking, the thinking
which is going on at local level, as being very important in setting
not only the Department's agenda but ministerial priorities in
that ministerial priorities will be fed into the planning mechanism
and any information which came back would inform Ministers in
terms of some of the financial debate that they have to get into
allocation of funding. We are trying to create some kind of coherence
in this mechanism.
Julia Drown: In your evidence you picked up the differences
between the two systems and talked about how health authorities
tend to know their allocation before the local authorities. Though
I accept in the short term that is true at health authority level,
by the time you get to the providers and the trusts they are still
arguing about it in April or May so there is not that same certainty
on the ground. It is true that health authorities know how over
or under target they are and they know whether they are heading
in a more positive direction in terms of their funding or a negative
direction whereas on the ground local authorities do not seem
to know that, the SSAs change all over the place. They are never
able to plan for the future. Would it be useful for joint working
community care if the same sort of system were adopted at least
for social services so that social services could see whether
they were over or under target and could see themselves moving
towards that target over a number of years? One thing the health
service finds valuable is that most health authorities do not
lose money. If they are over target they simply keep the same
amount, they have no growth.
Dr Brand: With respect that is a loss. If you do not have
growth and you have inflation you have a loss.
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