Examination of Witnesses (Questions 120 - 139)
THURSDAY 5 MARCH 1998
MR CHRIS
DAVIES and MR
MICHAEL HAKE
Julia Drown
120. In your paper you say that "the case for the distinct
and separate responsibilities of health and social services to
be retained has much to commend it." You also recognise that
there is a huge grey area of provision where it is very difficult
or impossible to define the boundary. Can you expand on your reason
for saying that? To give an example, what would be wrong with
all mental health going to the health service and all learning
disabilities going to local authorities?
(Mr Davies) The example you choose is very pertinent,
and I believe that an argument can be made for it. In some parts
of the country that move is under way. My own authority runs the
whole of the learning disability service. Health passes us £9
million a year to do it. We are now transferring mental health
services to a health and social care trust. It can be done within
the structures as they are. In making those arrangements one is
not passing across the whole function in a way that allows one
to abdicate one's responsibility. In those two services there
is a good argument for continuing to tie health and social services/local
government responsibilities into it. Think of the difficulties
of mental health in communities and the sorts of problems that
arise from nuisance behaviour, housing problems and so on that
arise from volatile mental health conditions. Would we want the
transfer of mental health to be so complete that local authorities
could actually stand back from that responsibility? There are
advantages in being very clear about who has the job of delivering
the service but continuing to tie accountability to both local
government and health. Certainly, in mental health. Learning disabilities
are perhaps more difficult. However, even in that case what we
have found is that parents and carers are reassured by some health
input and responsibility in the learning disabilities field. I
refer to people with very severe conditions. One can largely say,
"Look, we'll give you the money. You take the lead and deliver
it", but one still argues that combined accountability is
healthier and more productive.
Chairman
121. In this division who would address the problems raised
by someone with learning disabilities and also acute depression?
I am worried that we put people into segments, because people
do not live in segments. The problem may go across the whole range.
(Mr Davies) That is a very practical point that we
come across a good deal. It also reinforces what I said earlier.
In a sense by having things all in health you do not deal with
the problems. Where one has a mental health and learning disability
trust as in many areas one has just those problems. Will a psychiatrist
take responsibility for people with learning disabilities when
they also have an overlay of mental illness, which is not uncommon?
We can allocate very clear responsibilities so that people feel
that it is their job to get on and deliver the service, but if
we parcel it up in such a watertight way the danger is that people
will tightly draw their boundaries and act defensively.
Dr Brand: I am surprised that you find that a difficulty.
People with learning difficulties get appendicitis and are entitled
to acute care for that. People with mental illness may need educational
facilities. I do not think that that is an argument for saying
that the boundaries should not be co-distinct, but it is for a
different job.
Julia Drown
122. As to those with learning disabilities, would you also
use that argument to say that local authorities should not take
over long-term care in the community and the NHS should deal with
that and the acute sector?
(Mr Davies) Our practical experience is that there
are some frail and confused elderly people who have such intense
long-term care needs that they need a health-type provision. The
notion which was very current in the late `eighties/early `nineties
that health was only a treatment service and that if people were
too stubborn to get better they were the responsibility of social
care has gone. That is one of the far too black and white divisions.
There are people who need a strong health component to their long-term
care needs.
Dr Brand: The continuing care guidelines that we talked about
last week say just that. Unless you need the intervention of a
consultant twice a week you are not the responsibility of the
NHS. That is nonsense as far as I am concerned. I am glad to know
that at least you think that should change. I hope that you will
address that issue. It is very divisive and clinically unsound.
Mr Lansley
123. Perhaps I may begin not directly with client or patient
groups themselves but with intermediate bodies and how effective
you think they are. Let us start with community health councils
to which you have made particular reference in your memorandum.
You said you thought that they could be made more accessible and
visible within the NHS. How do you think that might be achieved?
(Mr Davies) There are perhaps two matters to be considered.
First, giving them a high public profile is important so that
people know they are there and what they can do. The second thing
is to make strong connections between whatever the individual
complaints systems are and the policy role of the CHC. In some
areas the CHC has concentrated very much on policy in terms of
whether a hospital should close. The great value of the CHC is
that it can pick up from the discontent of local people the major
strategic issues around the health service.
124. Do you acknowledge that because CHCs have a statutory
right to be consulted in relation to hospital closures it is not
surprising that they acquire a prominent role in relation to precisely
that function? In that sense, when one is re-designing NHS and
social services accountability does it follow that if one wants
community health councils to have a greater role one must build
that into the legislative framework?
(Mr Davies) First, I think that the White Paper is
an opportunity to look at the CHCs' role in relation to primary
care which is much weaker than its role in relation to secondary
health care. If primary care is to grow in importance, as it will
and should, there needs to be some tinkering to change that relationship.
There is also an argument that CHCs should have a role in relation
to social care so that they can look at whole systems. The argument
against it is that local accountability and local governance lie
with the local council. Many of us have taken the step of voluntarily
inviting CHCs to take a wider view across health and social care
systems on behalf of the local community.
125. There is a clear distinction between elected accountability,
which means setting protocols and establishing criteria and allocating
funding and resources, and bodies who are designed to reflect
community views, user involvement and practical issues as to how
the system works, including a role in relation to complaints.
The logic of having CHCs is that you would not constrain their
role in relation to social services as well as health simply because
social services were a local government function. Would you be
happy to see CHCs as user-driven bodies in relation to social
services as well as health?
(Mr Davies) Perhaps I may enter a caveat that I should
have entered earlier. We are paid servants of our locally elected
councils. It is important we make the point that we come here
as professional managers. When we come to the role of the CHC
in relation to the local authority there are political views that
must be taken into account. Nevertheless, the argument you make
is a powerful one. In particular, if we keep saying that we must
see these things as whole systems and look at the impact overall
then there is an argument for the CHC having a role in relation
to social care.
(Mr Hake) We can let you have our response to the
previous Government's review of CHCs, recognising that the present
Government are still to determine their stance on it. In our evidence
we raised as a point for discussion—it has raised some interest
in my own authority—the scope for local dialogue with health,
that is, having health and social care fora whereby all the agencies
can sit down with local people and say, "This is what we
are thinking of doing." One thing that CHCs can do to improve
their visibility is to get dialogue going with local communities
so that people feel that they own their NHS. At the moment, I
suspect that many people believe that it is not the people's NHS
and it belongs to someone else. We must try to build in the same
level of patient involvement that we and many other authorities
social services have. CHCs can be a valuable mechanism for empowering
local communities to talk about the fact that in some of the most
deprived areas there are no health centres but many stand-alone
GPs. Sometimes one can use CHCs to flag up the complications of
the NHS. CHCs do not have much of a remit on primary care, as
Mr Davies has said.
Chairman
126. Would you advocate CHCs having a role in respect of
closures or changes in social service provision?
(Mr Hake) We send details to our CHC. It has no formal
role, but we consult widely with the community. That is one of
the groups to which we send all our documentation.
127. That does not quite answer the question. Obviously,
a CHC can object to a hospital closure or change of use. How would
you view their role in dealing with proposed changes in social
services provision?
(Mr Hake) I see it as an influential local group but
not one with a formal standing because the nature of the accountability
is different. The CHC has a role in relation to hospital closures
because there is no local accountability to local people. That
accountability goes upwards. In the case of social services provision
there is local accountability through the democratically elected
council, but the role of the CHC is persuasive rather than mandatory.
Mr Lansley
128. If we envisage for the sake of argument a wider role
for community health councils in relation to health care and social
services provision, that does not remove the need for those bodies
with whom you are responding, the CHCs, to feel that they are
delivering a persuasive view, not simply because of any legal
backing or because of the composition of CHCs. What do you think
might be done to make CHCs more responsive, not simply to be a
substitute for elected persons but to represent a user or patient
viewpoint? How do you feel we may do more to make them active
proponents of interaction between health and social services in
a seamless service from the point of view of the patient?
(Mr Hake) I think that you start looking at performance.
CHCs have a role in going out and talking to patients, getting
feedback, talking to users, sitting in an A&E department and
seeing how long it takes and having a feel for what it is like
to use the service and trying to structure that information in
a way that can be used. One of the difficulties faced by CHCs
is that they do a piece of work and when it comes forward it is
largely anecdotal, in the sense of one case here and one case
there. That is sometimes the problem one has with complaints.
But if one has a structured complaints system one can see whether
one has had 10 complaints about a particular function. That should
provide a key for someone asking why that number of complaints
is being made about the particular service. To structure their
work more clearly and enable them to feel that they have an influence
over what happens will lead to a change in the way that some CHCs
operate. There is enormous variability across the country in the
way that they handle the matter. Some are very good at dealing
with complaints and see that as their main function. Others do
audit and customer satisfaction work which goes wider than complaints
to form a view on how the local health service is working for
local people.
Mr Gunnell
129. I should like to return to an issue mentioned very briefly
at the outset. We have examined the evidence given to us by the
NHS Confederation. One of the matters about which it has written
is pooled budgets. Based on your view of the pooling of budgets
for health care, how would you set about organising it? Would
you organise it for specific aspects of the service? What is the
appropriate method?
(Mr Davies) Our view is that it is a very useful tool
in particular areas. We have given a few examples: mental health,
learning disabilities, aids to daily living and equipment stores.
It probably does not work for the generality of provision like
elderly care, because that is so complex and all-pervasive that
you have to find different ways of achieving the objectives. But
the evidence is that pooling budgets is a very effective way of
dealing with some areas of joint service delivery. There are perhaps
three advantages. First, you will get some economies and efficiencies.
By coming together you avoid duplication. Secondly, there is no
doubt in the user's mind as to where to go. Thirdly, one makes
the best use of the skills available. We see it as a tool to use
in some instances. We are not arguing for a major structural change
but that there is probably a need to look at the regulations to
see whether some of the obstacles to that kind of operation can
be swept away. There are certain legal and financial difficulties
that stand in the way of pooling budgets and running genuine joint
services at the moment. We want to remove as many of those obstacles
as we can. An examination of that to free up the system would
be in everybody's interests.
130. You would recommend that this Committee look at that?
(Mr Davies) Yes, with a view to trying to sweep away
the impediments.
131. Do you suggest it is possible to do that where a social
services authority has already identified budget heads with particular
amounts of cash for particular services, or do you suggest that
first one has the principle of pooled budgets and then the allocation
of cash?
(Mr Davies) In terms of winning confidence it is a
vital step honestly to identify current spend and be prepared
to ring fence that. Without that it is hard to make much further
progress on the pool.
132. Do you think that many of your colleague directors of
social services would regard it as a loss of sovereignty?
(Mr Davies) No. Both within health and social services
there are a lot of people who want to deliver the best outcome
for the local community and are not too concerned about such a
loss. I believe that there is evidence of that in the way that
people have made unselfish decisions to shift services around.
One cannot say that no one will ever be territorial in his behaviour,
but it is not a dominant consideration.
133. Do you think that in practice it is something that can
lead to genuine savings in resources through the elimination of
duplication?
(Mr Davies) Yes.
(Mr Hake) The key point is that the lead responsibility
is in the commissioning role. That is how accountability is ensured.
One must have the right agreements and stable financial systems,
and the two systems need to match up. There is to be a government
consultation paper on the pooling of budgets, partnership spending
or whatever it is called. But once in place it must be auditable
and accountable; otherwise, one loses control of spending. The
other issue that arises from the pooling of budgets is the need
to address at some point the issue of charging. Where the services
are free—for example, a hospital discharge service that
we operate or intermediate care—there is no difficulty about
it. One can pool easily. Where there is a charge for a service
but someone else does not charge for it there can be a source
of difficulty. The practice in my authority has been to provide
them free in those circumstances, but it constrains how far you
can go. Income is a necessary part of our balancing of the budget.
134. If the user is charged for a service provided by social
services and he can get the same service without charge from the
NHS then the user will be very reluctant to take the charged for
service?
(Mr Hake) The Government must recognise that in the
shifting of the boundaries between health and social care—if
one looks at long term care one can have regard to the previous
report of the Health Committee in that regard—health has
never been a major provider in terms of total provision. One needs
to look at how the boundary has shifted and then how the charging
mechanisms can reflect that shift. Since 1948 there has been a
national charging system for residential care. Certainly, there
is power to charge for domiciliary services. The situation varies
up and down the country. If there is an issue for people it is
on the domiciliary front as opposed to the long term care front
for residential care, which has always been charged for. Some
people have different understandings of that and whether there
or not there should be a charge. That is an issue that the Committee
has considered in the past.
Chairman
135. I should like to take issue with you on one point. My
constituents are extremely aggrieved that over the past 15 or
16 years elderly people in particular have found themselves, having
contributed all their lives for the cost of long term care, having
to pay again for the service that previously was free. I see people
who were once accommodated in hospital settings either for respite
or long-term care now living in the nursing home care sector paying
a substantial amount of money. Is there not a further issue that
the slippage to social services in terms of domiciliary care has
meant that, for example, in the case of bathing, people are now
means-tested for a service which previously was free? Have I misunderstood
the point that you have made?
(Mr Hake) That is a perceived unfairness which stems
from beliefs about what was promised and what was happening. But
those perceptions do not necessarily match the reality everywhere.
The NHS was always a minority provider of long-term care. The
issue that you are identifying is the massive expansion of community
care and the support of people at home. That has always been funded
on an annual basis. It is not something that is funded like National
Insurance; it comes through council tax payments. Previously,
the benefits regime helped only those without assets, not those
with assets. This is an issue which the Royal Commission is now
considering. The Royal Commission is trying to clarify the central
issue as to where the balance between state and public funding
responsibilities lie in relation to personal funding responsibilities.
But I accept your point that it is perceived to be unfair, and
that perception must be responded to.
Dr Brand
136. I believe that the Audit Commission has made it clear
that thousands of hospital beds have been lost for long-term care.
You may be right in the sense that Part III homes were filled
up with people who are quite fit and who have found it convenient
to be in Part III homes instead of their own homes. I know of
people in their early sixties who decided to move into Part III
homes some 20 or 30 years ago. A different population is now being
looked after, but the dependent population was always looked after
by the NHS. There were hospital beds for the long-term care of
the elderly, confused and mentally ill and those beds have now
disappeared.
(Mr Davies) As to the issue of charging for social
care, one would find a wide range of views in local government.
There are three particular issues on which we as an association
can identify common ground. The first is the issue of hospital
care and nursing home care. There is a feeling of betrayal as
to that. To be clear as to the history, it was in 1980 that by
the stroke of a civil servant's pen people became entitled to
income support to go into private nursing homes. There was a tremendous
expansion of private nursing homes in the `eighties and the health
service took the opportunity that that offered to withdraw from
the long-term care of frail, elderly people. That decision was
taken for good reason. That is not a critical comment. Money was
moved into other important areas of spending. But the net result
was that the person who might have gone into a long-stay geriatric
ward up until 1980 free will now normally go into a nursing home
with means-tested help from the local authority, which often involves
paying quite a lot of money. People feel that they are now paying
for health care, since nurses look after them. The general public
have an appreciation of the distinction; namely, that the NHS
is free at the point of delivery but social care is paid for out
of means. It is the nursing home issue that has confused the issue.
The predecessor Select Committee strongly recommended teasing
out the nursing costs element of nursing homes and making those
free at the point of delivery, charging people only for the so-called
residential component. That would restore the boundaries of the
NHS in terms of the service being free at the point of delivery.
The other issue, which is far more ad hoc, is that as some
functions—bathing is probably a good example—have
shifted from district nursing to home care so the charging basis
has shifted.
Mr Gunnell
137. All I can say is that there are very few MPs who are
unaware of the fact that people feel that there is a certain unfairness
about being asked to pay for a service that they anticipated would
be provided free. A constituent has been to see me two or three
times over the past three months. His mother had died while in
care and he was concerned about various aspects of it. However,
he was concerned about the fact that at the end of the day he
received a bill which he did not think it was reasonable for him
to pay. My correspondence with him did not resolve his questions
about care and treatment but he secured the return of his money,
so he had a certain degree of satisfaction. It is very surprising
that his sense of unfairness of the whole procedure was based
on the fact that his mother had always been a contributor to various
things. It is amazing that he still retained that sense of injustice
about charging despite the overall tragedy. One cannot underestimate
people's sense of injustice if they feel that the service for
which they have paid all their lives is suddenly charged for.
Can you suggest how, given that as far as charging goes local
authorities take somewhat different views and approaches, you
can resolve the situation of charging without compromising or
detracting from local discretion?
(Mr Davies) One issue that has been under discussion
for some years is whether there should be stronger guidance given
to local authorities which would result in greater uniformity
of charging. One has a rather odd situation in which on the residential
and nursing home side there is not guidance but an absolutely
fixed and rigid national scheme and on the domiciliary side there
is virtually nothing in the way of guidance. That issue takes
one back to local democratic accountability, national frameworks,
standards and so on. It is very much the nursing home issue that
causes the greatest angst but there will be more issues
if we take the route of partnership funding and pooling and shifting
the responsibilities that we have been discussing. They are probably
good for the service but they will throw up more charging issues
similar to bathing. The subject of a national framework of guidance
would repay some thought in terms of how those particular cross-over
issues should be handled. It is very different from what one chooses
to charge for domiciliary or day centres, which is probably rightly
a local government decision.
Mr Lansley
138. I am sure you acknowledge that if you went down the
route of making free nursing care in the nursing home sector and
treating it as an NHS service and so free at the point of delivery
the consequence would be an increase in the current cost of that
provision, which is £250 or £400 million. To an extent
local authority costs will reduce but there will also be a reduced
contribution from people in those nursing homes who now pay from
their own resources. First, is that the best use of resources
from your point of view? Secondly, am I right to deduce from what
you have said that the simple dichotomy of social care subject
to means-testing and health care which is free at the point of
delivery is one that should be investigated and perhaps escaped
from so that there is social care means«testing at one end
and health means-testing at the other end but with a category
of longer term mixed care which has intermediate status?
(Mr Davies) I do not think that we are suggesting
that. Our argument is that the notion that the health service
is free at the point of delivery and social care is not is very
ingrained in the population and is very widely understood. We
move away from that at our peril. We have moved away from it in
some of these cross-over areas like nursing homes, home bathing
and so on. Those matters probably need to be sorted out in a way
that the public can understand and feel is fair. That is probably
not quite the same thing as having an intermediate range that
could increase the degree of confusion in the public mind.
Julia Drown
139. I should like to ask briefly about the Northern Ireland
experience. You refer in your paper to the tension in relation
to the Northern Ireland model, in particular the interface between
primary and secondary care. Outside that tension are there other
tensions in the Northern Ireland model that would make you less
keen on it?
(Mr Davies) First, the Northern Ireland model takes
social services entirely out of local accountability. Secondly,
the evidence from Northern Ireland is that all the tensions that
exist between organisations can exist within them. Within the
various bits of health in the Northern Ireland structure, whether
it is community care, secondary care or primary care, all of those
tensions and difficulties are still there. The third point I make
is one mentioned earlier by the Chairman. There is a social model
of helping and a medical model of helping. While one does not
want to overplay that distinction, one would not favour any shift
that resulted in a dominance of the medical model. One is presumptuous
enough to believe that neither is necessarily better than the
other, but the tension and balance between the two is quite important
for users. In terms of personnel and budgets, the Northern Ireland
health boards are vastly more concerned with health than social
care. Social care is a very little brother to the health provision.
I think that there is a danger in that.
(Mr Hake) If it is of assistance, we can supply the
two references that we have cited in our evidence. In my view,
they present a balanced view of the strengths and difficulties
of the Northern Ireland model, in particular the way in which
social care can become the silent partner within it in an arrangement
still dominated by acute concerns.
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