Examination of Witnesses (Questions 73 - 79)
THURSDAY 5 MARCH 1998
MR CHRIS
DAVIES and MR
MICHAEL HAKE
Chairman
73. Mr Davies and Mr Hake good morning. Perhaps you would
begin by introducing yourselves to the Committee.
(Mr Davies) I am Chris Davies, Director of Social
Services for Somerset. I am currently senior vice-President of
the Association of Directors of Social Services.
(Mr Hake) I am Michael Hake, Director of Social Services
for Solihull and chair of the ADSS organisation and development
committee.
74. We are most grateful for the information that you have
given us so far. I begin by picking up one point in your evidence
that surprised me and perhaps a number of my colleagues. You say
that if a Berlin Wall exists between health and social services
it is "very much the exception rather than the rule and more
reflective of unsatisfactory resourcing than relationships."
That point is very much at odds with a good deal of the evidence
the Committee has received from a range of other witnesses. Certainly,
it is at odds with experience in my part of the world, and I do
not believe that my area is any worse or better than anywhere
else. Can you expand on that statement, which presumably reflects
the views of your association?
(Mr Davies) Chairman, I do not think that anyone knows
the real answer to this. One of the matters that we urge on the
Committee is the need for performance indicators that are common
across health and social services so that we apply the same measures
and look at the whole system. Performance scrutiny should also
look at both health and social services at the same time. At the
moment that does not take place. Most audit and inspection looks
at the two systems completely separately. We would argue that
many of the problems that people identify in relationships are
about other things, very often resources. For example, we can
consider the tension between local government and health particularly
in the late `eighties and early `nineties about the closure of
long-stay hospital beds and the so-called cost-shunting onto social
services. That was very much a resource-driven problem. In my
part of the world that was not a source of difficulty in relationships
or anything else, but the fact remained that with the availability
of nursing home provision the health authority did not need to
provide geriatric long-stay wards any more and the pressures on
the acute health side were such that the available money was moved
over to deal with them. But there was tension between local government
and health about cost-shunting and thus a cause of some mistrust,
with some questioning whether they were being put upon by the
other side. Therefore, the point we sought to make was that, first,
sometimes when it was viewed as a relationship difficulty it was
not and, secondly, that the existing systems could be made to
work well. There are countless examples up and down the country
where health and social services make the system work well together.
It would be difficult for us to make a judgment whether it works
well in 10, 50 or 90 per cent of cases. I take the point that
Members may want to quibble with our statement that Berlin Walls
are very much the exception rather than the rule. It would be
hard to make that judgment because we do not have enough performance
information.
75. The key point that your association makes is that the
Berlin Wall is a resourcing rather than organisational point?
(Mr Davies) It is a resourcing point and a point about
relationships that is not necessarily to do with structures; and
it is also about the need to build relationships of trust and
confidence between key people in health and social services locally.
There are some things that militate against that rather than assist
in the development of trust and confidence.
76. In the context of cost-shunting, can you offer a definition
that enables the Committee to understand the areas that social
services and health authorities address? There was a lengthy debate
last week about care in the community and the definition of the
boundaries between care bathing and nursing bathing. Having accepted
that the cost-shunting process has taken place, is your association
able to say where the boundary lies?
(Mr Davies) I do not think that in practice neat,
clear lines can be drawn between health and social care, certainly
not from the user's perspective. But there are other ways of tackling
the issue. Eligibility criteria have been used a good deal over
the past four or five years and can be useful in terms of a democratic
process through which people say, "These are the circumstances
in which we can or cannot help." The downside is that they
can be used simply to exclude people from help, so each service
uses its eligibility criteria to narrow its remit. As a result,
people are left in the gaps between the eligibility criteria.
77. If you cannot offer a definition—I suspect that
the Department of Health is in the same position—how does
one determine in the context of two separate provisions relating
to different statutory frameworks who does what, particularly
where on one side there is charging and on the other it is free
at the point of use?
(Mr Davies) I think that you raise two separate but
related points. It is possible to sort out who does what but not
necessarily by defining what is health and what is social care
but rather by saying, "Let's decide between us on a sensible
basis of negotiation who will respond to what kinds of circumstances."
Having come to that decision, if that means moving some money
about to reflect the allocation of responsibility then that is
what must be done. That can be made to work. There are snags when
one comes to charging, and later on we should like to say more
about that.
78. Returning to the cost-shunting that you referred to,
for example we now see home care coming within your own departments
whereas previously it was clearly within the remit of the health
service. But the resourcing problem that you see as being responsible
for the Berlin Wall is in part the result of the slippage between
the two services that directors in key positions have accepted.
They have not defended the clear boundaries that existed in my
time, say, 10 or 15 years ago, between the two services?
(Mr Davies) I think that is a fair accusation to hurl
at us. In a context where we are all aware of the kinds of pressures
that all services are subject to pragmatic decisions tend to be
made. A whole series of pragmatic decisions can lead to a shifting
boundary. A lot of these things do not happen at a policy level
but at case level. The decision about who is discharged or whether
a district nurse goes in is in part determined by policy but is
very much determined at clinical level. Often the shift does not
result from strategic negotiation at the top about policy but
because a thousand small decisions end up being a policy shift.
The boundaries have shifted. There are two separate issues. First,
has the money moved to reflect that? Secondly, is it a good thing?
We argue that there are some tasks better done within home care
than within the old district nursing services because it is a
better use of skills, or a better way of doing things. That is
a different issue from saying, "If the responsibility is
moved will money move with it?"
(Mr Hake) I should like to add to that by citing the
example of continuing health care and social care. My own authority
has a matched boundary between the two. We have a continuing health
care and social care statement. One of our neighbouring authorities
has produced a joint statement for users showing how health and
social services work together. I brought it with me in case the
question was asked. It is on the basis of documents such as this
that we advance our view that Berlin Walls are not about an inability
to work together but sometimes reflect resource difficulties.
It is also about accessing the service. Sometimes we are dealing
with perceptions about who is responsible rather than the realities.
The basic structure of the division of responsibility goes back
to 1948. There was a division of responsibility between National
Insurance, National Assistance and welfare services, which were
mainly residential care services rather than domiciliary services
provided by local authorities. One also had the children's services
and the NHS. The major change since 1990 has been the enormous
growth in community care services. For example, the number of
home care hours has grown from about 1.6 million to about 2.5
million over the past five years. That has had an enormous impact.
It is a more concentrated service which enables people to stay
at home. The old divisions were essentially long-term hospital
and residential care provided by local authorities which did not
match people's expectations.
Julia Drown
79. You said that in some areas the boundaries were not a
problem and things worked well. Can you give us an example of
those areas? Can you say that in those areas there are not people
who are simply stuck in the middle? Would the users of those services
and also carers understand who was providing the particular service
and why some were charged for and others were not?
(Mr Davies) We can take you to places where the relationship
between all parts of health and social services work extremely
well and there is a good understanding about who does what and
there is a good sharing of money to make things happen. However,
even in those areas there will be some who occasionally fall between
services. Occasionally, there will be major arguments about responsibility.
There are some particularly difficult circumstances in relation
to those suffering from chronic head injuries where care is extremely
expensive. It is very difficult to draw the boundary. However
good the relationship, that will test it consistently. The evidence
about public understanding of responsibilities is quite worrying.
Those surveys that have been done show that the public generally
has little understanding of the difference between health and
social services, between home care and district nursing and between
those services that are charged for and those that are free.
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