Examination of Witnesses (Questions 100 - 119)
THURSDAY 5 MARCH 1998
MR CHRIS
DAVIES and MR
MICHAEL HAKE
100. Am I right in thinking that perhaps a separate community
health trust enables you to identify more clearly the resources
to be devoted to particular areas in the community?
(Mr Hake) Yes.
101. From your point of view that would be helpful?
(Mr Hake) If it is co-terminous with social services,
yes.
102. In terms of mental health, in particular provision in
the community, from your experience what has been the impact of
wholesale closures of institutional care places? Have you been
able to evaluate the effect of moving away from institutional
care given the organisational structures? Am I right in thinking
that perhaps it is more helpful to have a dedicated community
health trust that has within its remit long-term institutional
hospital provision in the process of running down institutional
provision and moving people into the community—or have I
got it wrong?
(Mr Davies) I think that you are right. What we argue
for and the White Paper hints at is the need for dedicated mental
health trusts which, while perhaps having other functions, incorporate
the whole of the mental health service from end to end. I believe
that that is the only way that you can re-balance services successfully
without patients or users coming off poorly.
Audrey Wise
103. I was interested in Mr Hake's remark about joint equipment
stores. Could he provide an indication of how many of them there
are and where they are? What is being done to encourage that?
Equipment problems have cropped up in previous inquiries, notably
the children's inquiry in which it was made crystal clear to us
that there were frequent squabbles about who paid for what. In
the meantime, the child might go without the required equipment.
Could that be followed up?
(Mr Hake) We are shortly due to do a survey and that
can be added to one of the questions to be addressed.
Mr Walter
104. I believe that your memorandum to the Committee was
prepared before the publication of the Government's NHS White
Paper. I would like to consider the concept of primary care groups
and trusts in the context of the White Paper. Do you have any
concerns about that in relation to accountability, links with
local authorities and local people? What do you believe to be
the advantages and disadvantages of perhaps moving social workers
into the control of primary care trusts or groups?
(Mr Davies) First, there is a lot of flesh to be put
on the bones of primary care groups and trusts. From what has
been published so far, it is quite difficult to see how they will
operate in terms of governance, systems and so forth. Our broad
reaction is that it appears to us to be a positive way forward
and creates a more coherent planning and accountability framework
for primary care commissioners. We can see ourselves being able
to work effectively with it. But at the moment very little is
known about how those groups will come together, what their governing
structures will be and what role the local authority and social
services will have in them. In principle, we see it as a positive
development but we need to know a lot more about how those groups
will work. As to the second part of the question about social
workers and primary care, there has been a strong move perhaps
over the past five years towards much stronger links between social
workers and primary care, particularly in the area of the elderly
and those with physical disabilities. It does not work quite so
well in other areas. Those links vary from quite a loose kind
of attachment where the GP practice has a nominated social worker
who visits once a week and so on right through to locating social
workers in GP surgeries with a dedicated budget to serve the same
population. As far as elderly people and physical disability are
concerned, we see the links between social services and primary
care as being absolutely central. Therefore, the closer we can
bring our assessment and care management, which is what the social
workers and OTs do, to what primary care practitioners are doing
the better, short of control. I think that you referred to control
by the primary care groups. We say "short of that" for
a number of reasons. First, to shift that responsibility into
primary care would be to shift it out of local democratic governance,
so issues about how one chooses to spend one's money on elderly
and physically disabled people would shift. Secondly, we take
the view that there is enough on the plate of primary care groups
as they develop over the next four or five years to get on with
in the health world without entering into a whole new and different
area. Thirdly, at the moment there is little understanding within
primary care about the purchasing and commissioning of individual
social care arrangements. The question of what happens in 10 years'
time needs to be revisited, depending particularly on how PCGs
are linked to local democratic accountability. New opportunities
may emerge. In the present climate we argue for very strong links,
increasing attachments, co-location and shared budget allocations
but keeping control of the social care provision within the local
authority.
105. It almost sounds as if you do not believe that locating
these services within the control of primary care groups would
work because of lack of knowledge. I am more concerned with the
patient's perspective in terms of efficiency, a seamless service
and all the things that we have talked about before. Do you not
think that if you took a more adventurous approach to it and recognised
that it might be something that was moving out of your control
and into somebody else's that would provide a more effective and
efficient service for the patient?
(Mr Davies) I think that the patient sees his GP practice
as the most important and obvious port of call with a whole range
of problems that go much wider than just health, including social
care aspects. There is every logic in using that accessibility,
knowledge and the community's view that that is where one goes
with health/social care-type problems. One can do that in all
kinds of ways. In our own case, we have done it by co-location
and putting a carer's support worker in every GP practice, who
is employed by us, albeit that support worker is a member of the
GP's team. But there is a two-fold question: first, is there democratic
control and, secondly, is the requisite ability to manage and
make those social care systems work presently available within
primary care? At the moment, it certainly is not there.
Mr Gunnell
106. If one used a social worker who was employed by the
local authority would there be any legal bar to the primary care
provider controlling that person?
(Mr Davies) It would depend on what the social worker
did. A primary care practice can employ any sorts of skills that
it wishes. There are lots of examples of practices employing alternative
therapy skills. There are practices that directly employ social
workers. But as things stand there are legal limitations on how
far the local authority can simply hand over its responsibilities.
It has direct accountability for the arrangement of social care,
the assessment of people's needs and the application of eligibility
criteria which it cannot hand over lock, stock and barrel under
the present law to GPs.
Dr Brand
107. I am concerned with your understanding of locality commissioning.
I read the White Paper in a quite different way. I believe that
the locality commissioning group may include social services as
a member. To go back to Berlin Walls, they are created by people
having fixed budgets and indistinct responsibilities. The way
to demolish the wall is to give extra resources to both sides,
provided they bridge the wall. That is why the winter pressures
money has been useful and why every authority is now brilliant
at writing joint documents and having schemes on the shelf in
case there is some money on offer. But essentially one needs a
joint commissioning system. That would get over the problem of
having a provider-led service, because it would not matter whether
it was provided by an acute trust or a community trust as long
as you specified what you wanted. Can you contemplate a system
in which you are not talking of primary care trusts or groups
in the sense that they are GP-led but locality commissioning teams
in which social services play an equal part in the decision making?
As a clinician I know that I can save a lot of money on the acute
NHS budget by providing adequate social support, going back to
Audrey Wise's point about basic preventative support in people's
homes, but I cannot resource that at the moment because (a) the
savings that I make by not admitting people cannot be transferred
to social services and (b) I do not have access to the infrastructure.
(Mr Davies) I do not think that we differ from anything
that you have just said. So little is known about the detail of
how primary care groups work. What we do know is that they will
include a social services contribution to local planning.
108. If you agree with what I have just said then your previous
answers indicate that, although you agree on the desirable outcome,
you are not prepared to contemplate the method of doing it. It
requires a rethink about control mechanisms, and it requires that
you use other agencies to take on some of your responsibilities.
You do that very successfully in a number of special needs groups
where joint commissioning boards are set up with pooled money
and responsibilities and there is no legal problem about doing
that. I do not see why that cannot be extended even under the
present legislation.
(Mr Davies) I agree. There is no contradiction between
my two answers. I was asked whether I would place the social workers
and the assessment function under the control of the primary care
practice. My answer to that was that I would not. If the question
is whether one can see ways in which social care and the primary
care groups can come together in equal partnership so that they
can plan services locally together, the potential over the next
five years is quite considerable.
109. Paragraph 4.5 of your memorandum makes a lot of joint
consultative committees. My experience of joint consultative committees
was that membership of it was the short straw for any local authority
member, and certainly for any doctor, who might want to sit on
them. The real work is done in joint commissioning boards, if
there are any. These joint consultative committees tend to be
bidding mechanisms for everybody's favourite project but very
often run counter to the needs of the care groups that they are
supposed to serve. Do you think that a different system is required?
(Mr Davies) I recognise the picture that you paint
in relation to joint consultative committees. What each area needs
to do is to construct joint planning and commissioning arrangements
that work for them. In some parts of the world the JCCs have been
moulded into useful top layer sanctioning bodies for lots of joint
planning that goes on lower down, but in other areas they are
quite moribund and tiresome.
110. It may be useful to have some idea of best practice
of where the present legislation works well. I can provide a few
examples where it does not work well. It is important to see what
the relationship between a JCC and joint working on the ground
ought to be.
(Mr Hake) The situation you describe is really a system
that we have made. JCCs have quite a limited remit. Legally, the
only thing that they decide at the moment is joint finance and
a mechanism for collaboration. One of the more interesting aspects
of Our Healthier Nation is the notion of revitalising JCCs.
If one is looking at partnerships within the context of a health
improvement programme there is an existing organisational bridge
between health commissioners and the local authority as a whole
of which we can make better use. There is a variety of way of
doing that. For example, our local practice is to ensure that
the community care plan goes to the JCC. Both of the authorities
have adopted it separately and jointly so it is clearly a joint
plan. We need to take that forward slowly. The JCC is at the commissioning
level. The primary care groups to begin with are at a slightly
different level. In that way one can assure accountability. Through
a joint consultative committee, which may become a joint health
and local authority social services committee, one may be able
to deal with the issue of democratic accountability for pooled
or partnership resources. I always speak in terms of partnership
resources. Both sides know what they are putting in and it is
all audited and accounted for. As to the public health functions
in the Green Paper, there is a role to be played here. One has
a forum that is not being used. When it is used one will get people
on it who want to do something. With the chief executive of the
health authority I co-chair the local joint commissioning board.
We report upon and the JCC sanctions the activities of officers
and gives us, we believe, joint legitimacy to take it forward.
Traditionally, the one group that is missing is general practitioners.
I believe that there is an issue within primary care groups and
health commissioning locally about how to involve GPs in that
process and what incentives are made available to them to become
involved in it. I do not think that you can suddenly ask a GP
who has patients to look after to spend an afternoon or evening
at a joint consultative committee or joint commissioning board.
One must recognise that doctors are good at looking after patients.
People like myself may have a different range of skills, for example
organisational skills that make the systems work to improve patient
care. I think that we should begin to look at JCCs as a bridging
mechanism to achieve that.
111. I think the answer is that GPs would be happy to contribute
to anything that achieved a positive result. Perhaps they are
voting with their feet. I certainly did. Is joint finance still
a sensible arrangement given that that is really tinkering round
the edges?
(Mr Hake) It is a useful mechanism provided the issue
of pick-up can be overcome. The main issue of joint finance is
that it is very nice to agree to a project which is fully funded
for five years but at the end of that period the project must
either be picked up within mainstream funding or, if it is a new
venture within the cash-limited discipline on the local authority
side, something must be given up elsewhere to fund it. My own
authority's arrangement for overcoming that is to treat joint
finance agreements as forming contractual inflation, so whatever
else we do or do not do in any new financial year we must arrange
the pick-up. But it can be a very useful mechanism if it is used
more flexibly to get joint projects going. For example, at the
moment we are trying out a stroke co-ordination project to co-ordinate
activities on strokes. We had a very successful joint project
in the form of a continence adviser with a view to getting positive
approaches to continence. I believe that joint finance has a role
to play in that area, but it is at the edges. What one must do
is make sure that one's decisions on joint finance fit in with
the community care plan and one's wider set of priorities.
Chairman
112. You have touched on accountability. Obviously, some
people argue that shifting NHS provision to local authorities
is one model for solving the issues that we have talked about.
The opponents of that argue, "God forbid that our local council
should be a health service as well", because they feel that
perhaps the health service is too important to place in the hands
of local authorities. I do not argue that but some people take
that view. You have also referred to the democratic process. What
do you feel the democratic process offers within local government
that is missing in the NHS as it is currently constituted?
(Mr Davies) We must distinguish between the ideal
and the reality. Ideally, it seems to us to be entirely right
that people who are elected by their local communities with very
good links with those local communities and who listen to their
neighbours and constituents should have the overall control of
social care. They decide what they want to achieve for frail elderly
people and people with mental health problems and physical disability
in their communities. That seems to us to be an important principle.
Quite apart from the issue of what works and the managerial arguments,
that appears to us to be an important principle, and it would
be sad to lose sight of it. We also believe that it gives the
ability to lead the community. There are examples of where local
authorities can lead change, for example in my case in the field
of learning disability services and the closure of old hospitals,
in a way that is much more difficult for health alone because
it does not have that local credibility and stamp of authority.
It also enables one to achieve some change within communities
because of the leadership that local government at its best can
give.
Mr Walter
113. If I were a cynic I would say that in terms of local
control of social services the only control was whether or not
the social services SSA was spent on social services. I can think
of examples of that in a number of authorities. What do you believe
that kind of control by local politicians would bring to the NHS?
You seem to suggest in your memorandum that it works in your system
but somehow the NHS is deficient in that respect.
(Mr Davies) If our evidence has given that impression
it is not what we intend. There is no doubt that local government
has much stronger local democratic accountability than the health
service. I do not think that that can be questioned. On the other
hand, people in health argue that they have an equally strong
framework for accountability but it is straight to central government.
We simply make the case that if greater local accountability is
required local government is the place to put it. We are not suggesting
that local government should take over health functions. That
is not necessarily a fixed principle, but if we want to improve
the services on the ground and get good collaboration the last
thing we want is a turf war for the next three or four years between
health and local government, with health demanding to take over
local government functions and local government demanding to take
over health functions. That would be a real setback for what we
are seeking to achieve. Our basic argument is that the responsibilities
and structures should be left broadly as they are and they should
be made to work better at local level.
Chairman
114. Is it not the case that you fear a loss of your empire
to some extent if there is a real debate about some of these areas?
It could move the other way. The picture one gets is that increasingly
the role of social workers is disappearing and it is moving into
the health service. In the course of our previous inquiry into
children looked after by local authorities we heard that in some
areas the role of social workers had virtually disappeared. Are
we not in a sense seeing you defend a crumbling empire?
(Mr Davies) We must be vulnerable to the accusation
that we are defending an empire. I do not think that the evidence
of what we do supports that. I spoke earlier about mental health
services. My Authority is in the process not only of bringing
commissioners together but transferring all our mental health
provision to a health service trust which will become a health
and social care trust. That is not the behaviour of people who
are out to defend their empires.
115. Some might perceive the way that you acceded to the
cost-shunting of the health service spending as part of a defence
or expansion of your empire. You have some serious concerns that
any debate about a re-configuration of the arrangements may lead
to what you call a turf war whereas I would hope that it would
lead to some more sensible arrangements for the people we represent
at grass roots level, which is the whole purpose of the inquiry?
(Mr Davies) We do not make an argument against change.
We argue against change at the highest organisational level. We
say that in part to avoid a turf war and in part to avoid the
disruption that that will create for at least three or four years.
Look at local government reorganisation and all the rest of it
and the way that the eye goes off the ball in the provision of
services. There is no evidence that to bring services within the
same organisation results in an improvement in the collaboration
between the bits. There is just as much evidence of difficulty
between acute trusts and community trusts within health as there
is between social services and health. In our own backyard there
is just as much evidence of difficulties between social services
and education departments within councils as there is between
health and social services. The notion that by bringing things
together under one body deals with all these problems is mistaken.
Mr Lansley
116. How do you view democratic accountability? Leave on
one side accountability to users and stick to democratic accountability.
One has local priorities and control versus national accountability
and priorities. When one starts to bring things together what
should be the balance between the two? First, let us take the
example of putting mental health into a health and social care
trust. What is the democratic accountability structure appropriate
to that? Secondly, if one goes down the path of primary care groups
that embrace both health and social care, where is the structure
of accountability?
(Mr Davies) It is much easier to see it in the mental
health example than in the primary care side, simply because it
is such early days in the development of the thinking about primary
care groups. At this moment I do not believe we have a view as
to how accountability can be achieved other than that there must
be a way. On the mental health side it is not terribly difficult,
in that the local authority simply becomes a commissioner with
a commissioning relationship with that trust. It is setting out
service specifications and expecting compliance with those specifications.
One can also bring the commissioning together but the accountability
of local government can be achieved through a commissioning relationship.
The key role of members is to decide what pattern of services
and what balance of priorities they want to see. There is an issue
about the Secretary of State's role in relation to the two bits
of the system. It is not often that I sympathise with a Secretary
of State, but on this point I do. With a clear command structure
on one side and its absence on the other, more thought needs to
be given to the constitutional relationship between local government
accountability and the Secretary of State's responsibilities for
care of the whole population. I am not sure that as it is we have
got it quite right. I believe that it needs to be thought through.
117. I acknowledge that we do not know enough about primary
care groups to be able to be certain about it, but by the same
token we are in a position where we are able to influence the
formation of primary care groups. Let us examine what it is that
is desirable in relation to primary care groups. Without prejudging
the question whether democratic accountability is its primary
purpose, this body may be able to achieve its purpose without
substantial democratic control if it responds to the priorities
of patients as perceived by general practitioners and practitioners
generally. But if democratic accountability is desired how is
it to be funded, because if the local authority puts its element
in does it not tend to see that diluted down by virtue of it forming
only a part of the primary care group which essentially has been
established by and is accountable to the Secretary of State? Is
the accountability of the Secretary of State not diluted by virtue
of the fact that this has turned into locality commissioning based
on local criteria? On the one hand the centre is saying, "You
decide locally", and on the other hand the locally elected
persons have inadequate control over it. Who is in control?
(Mr Davies) I think that the root of the question
is: at what level does discretion lie? The Secretary of State
must decide what standards and basic parameters he will set with
which every primary care group must comply. What is he prepared
to leave to discretion at that level? Local authorities will have
to do the same thing. They will have to decide what is important
for them as councils to determine and where they are prepared
to allow discretion at the level of local groups. The idea of
locality planning has not simply emerged in health; it emerges
in other aspects of public service. I believe that it will demand
of councils that they make these judgments more explicitly: "That
is what we want to see for the whole population, and we are not
prepared to see one bit going astray from that. On the other hand,
there are large areas where we are prepared to see localities
coming together and making decisions." That may be a bit
of a cop-out answer, but it is about where discretion lies.
118. It is helpful. It rather points to the importance not
necessarily of focusing on the control of organisations but elected
bodies, ensuring that there are protocols and eligibility criteria
that properly cover the ground so that nobody falls in the gaps
and nobody is without the responsibility that is vested in a particular
body to provide services.
(Mr Hake) I add that when things go wrong people know
where to go to call people to account. One must have partnerships
underpinned by performance. Essentially, if one is to have a partnership
at locality commissioning level one must have a performance structure
for social services to run in parallel with that for the NHS.
That must start nationally and come down to locally agreed targets
and standards that are jointly owned and find expression in health
improvement programmes so that people know what is intended and
what their responsibilities are. If they are clear about responsibilities
then there can be accountability. If one looks at the model for
the development of primary care groups, one's experience demonstrates
that there is a need for something below that to make the whole
thing work. A population of 100,000 is quite large. If we are
to get the primary care groups to develop we must be clear about
who is responsible for that service. If it is a social work function
people know that they can come straight back through our complaints
procedure into the social services department. If it is another
function they need to know where to go with their concerns. We
have prepared a statement on the White Paper which sets out the
matters with which we agree and those about which we require further
information. This is one of those areas where we need much more
information.
Chairman
119. You have raised questions about the size of the population,
have you not?
(Mr Hake) Yes. Our view is that it needs to be flexible
to suit local circumstances. If one has an area that divides naturally
for social services and local authority purposes between a population
of 75,000 and 135,000, why have two at 100,000 which do not make
sense in terms of co-terminous working?
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