Examination of Witnesses (Questions 140 - 159)
THURSDAY 5 MARCH 1998
MR CHRIS
DAVIES and MR
MICHAEL HAKE
Chairman
140. That would be of assistance. Northern Ireland is within
your membership, is it not?
(Mr Hake) Yes.
Julia Drown
141. Moving on to the current legislation, you mentioned
in your memorandum how successive governments had failed to establish
a consistent and cohesive legislative structure for community
care and retention of the 1948 National Assistance Act framework
has caused problems. There are also funding issues to do with
provision on the NHS side. What changes would you like to see
in the legislative framework which would underpin that and enable
us to have a seamless service?
(Mr Davies) The problem with the community care legislation
in 1990 is that it was overlaid on top of the Chronically Sick
and Disabled Persons Act, the 1948 legislation and so on. Subsequent
case law has demonstrated that there are some very real problems
with that, the most obvious one being the Gloucester case. It
arose basically as a result of various bits of legislation which
did not quite tie together in the way that duties were set out.
Our primary purpose in making that point was not so much to deal
with the health and social services issue—although tidying
up some of the charging could help in that respect—but rather
the need to take a look at the question of codifying the law in
the field of social care to deal with some of those problems.
(Mr Hake) One must look at the 1948 Act in the context
in which it was produced. Part III of the National Assistance
Act covered our responsibility for welfare along with National
Insurance and National Assistance as it then was. Unlike children's
services, we do not have a comprehensive set of principles about
how we now provide community care. The 1948 Act was very much
about residential care and taking over the vestiges of the poor
law. The 1948 Children Act dealt with children's services. That
has caused major difficulty, as one sees from the number of judicial
reviews that have taken place as to how the responsibilities and
resources are allocated. If one is to have a new NHS one needs
virtually a new social services policy agenda that forms a coherent
whole for community care. In that way people will know where they
stand. One needs overarching principles that informs legislation,
not contradictions in principles between a service-led 1948 Act
and a needs-led 1970 Chronically Sick and Disabled Persons Act.
Chairman
142. Are you looking to the social services White Paper to
follow that up?
(Mr Hake) I hope that we get a sign of a willingness
to engage in that review. It was not done under the 1990 NHS and
Community Care Act.
Julia Drown
143. It is not an issue about trying to close particular
loopholes or introduce particular bits of extra legislation. To
resolve the difficulty you suggest that those old Acts needs to
be replaced with a new one that provides consistency across the
board?
(Mr Hake) Yes.
Chairman
144. I assume that your experience takes you back to the
situation prior to 1974. In looking at the framework in operation
then, you have talked about models that move health into local
government. In a sense there was a partial model of that nature
within the health department, including home help provision and
district nursing, before 1974. In your view, was that a better
structure than that in operation at the present time, taking account
of all the changes that have taken place since then?
(Mr Davies) I do not think that we advocate going
back to the pre-1974 situation.
145. That was not the question I asked.
(Mr Davies) If one takes the example of community
nursing which was largely within the remit of local authorities,
one does not argue that to shift that provision lock, stock and
barrel will resolve the difficulty. One would have all the problems
of the acute/community links and everything else back on one's
doorstep. But there are two health questions touched on in the
Green Paper in which we are very interested. One is the role of
giving public health advice to local authorities. There may well
be a good argument for local authorities to have as a matter of
course a public health adviser. It might well be a joint appointment
by the local health authority of a director of public health.
That individual would advise the local authority of its public
health responsibilities. Flowing from that, there is a whole new
agenda of links. I am not absolutely clear whether the Committee's
remit is health/social services or health/local government.
146. That is a very good question.
(Mr Davies) If it were local government then there
would be a lot of other issues that could be discussed this morning,
particularly in relation to safe routes to school, safety in the
home, clean air and a range of matters that involves the functions
of local government completely separate from ours. That seems
to us to be an increasingly important agenda. What we would like
to build upon are those strong links between public health and
local government but not necessarily to go back to the delivery
of health services through local government.
(Mr Hake) I admit to being around in 1974. The change
then—we cite some of the documents in our evidence—was
debated for a long time. My view is that when you remove one set
of boundaries inevitably you create another that does not necessarily
achieve a wider health agenda. It would be interesting to reflect
on what might have happened if community health services had remained
with local authorities on the creation of social services departments
and what pattern of services we might have today in terms of community
health services. But we must be realistic and accept that that
did not happen. Look at the opportunities that the federal NHS
offers for new partnerships with local authorities whereby those
matters can still come together within the mechanisms that the
Government have indicated today. That takes us back to primary
care trusts and the scope for those to be primary health and social
care trusts in which local authorities co-operate, without taking
over each other's role—in the provision of services within
a clear framework of accountability provided by the health improvement
programme. How that programme is constructed may overcome the
difference in accountability to the Secretary of State and perhaps
may offer a new way forward.
Audrey Wise
147. I should like to turn to the question of training. Before
I do so, do you have a particular point of view in relation to
Northern Ireland? You have said that social care is rather minimised
or downgraded or is a silent partner. The previous Committee visited
Northern Ireland and in south Belfast found the most vigorous
and effective provision of care and treatment of people in their
own homes that it had seen anywhere. That appeared to us to be
facilitated by the oneness of the authority. That seems rather
to contradict what you have said. Do you have any observations
to make on that?
(Mr Davies) There are some very good examples of provision
being provided in Northern Ireland. The references to which my
colleague has referred make that balanced point. It has achieved
some goods things. We do not paint a universally negative picture.
148. To turn to the issue of training, you recommend a joint
review of tasks and skills. How do you see this being developed
and delivered?
(Mr Davies) It is not easy to answer that because
the new framework of national training organisations is now emerging.
We strongly argue for close working between the national training
organisations in health and those in social care. If you take
a field like learning disabilities, there is an important balance
between the nursing contribution and social care contribution.
It is not even that, because there is a nursing element in what
social care workers do, and vice versa. Work around the right
skill mix and training base is very important. The same is true
of home care. For example, on a simple matter like eye care and
eye drops, home helps were forbidden to deal with that 20 years
ago. Now they do it as a matter of course. The boundaries between
the roles have changed, and that must be looked at in terms how
we equip people. The only way to do it is to get the NTOs to work
together.
149. You said that there needed to be an element of shared
training. Where do you think that should take place, and for which
kind of professionals or workers do you say shared training is
relevant?
(Mr Davies) We draw a distinction between basic qualification
training and in-service training. There is only so much that can
be done jointly in basic qualification training but something
can be done. We hope that within the training of doctors, nurses,
social workers and others there is an element of understanding
of those roles and relationships and some opportunity to find
out about one another. But it will be very limited because the
curriculum of each group is already overloaded with all that they
need to know. Our strongest argument would be focused on in-service
training opportunities that could be devised locally, trying to
find ways of drawing together all the partners in caring. That
is working very successfully in many areas with speech therapists,
physiotherapists, care assistants, social workers and others all
joining together in training opportunities.
150. What sort of problems do you see arising in seeking
to do this? One of the other matters to which you referred in
evidence on human resources was the need for agreed protocols
on methods of working and confidentiality in carrying out responsibilities.
There are differences in relation to confidentiality—reporting
and so forth—between, say, doctors and social workers?
(Mr Davies) Yes.
151. Do you see that as having any impact on the training
aspects and the use of different skill mixes?
(Mr Davies) The differences make the joint approach
to training all the more important. One of the things we frequently
see is that different constraints and professional codes and ways
of working under which people operate become interpreted at a
face-to-face level as an unwillingness to co-operate, being inefficient
or whatever else. Therefore, to understand the constraints and
framework within which each works is very important if one is
to get good ground level working relationships. One should not
try to make everyone the same but recognise the differences, in
a sense drawing on the various strengths and skills that people
bring to work in common areas. You asked about difficulties. One
of the biggest difficulties is time. There are different priorities
attached to different activities. If one talks about children
who are being looked after, the amount of time that a nurse, doctor
or teacher can give to learning about children who are being looked
after and their needs is much less than that which can be given
by a social worker, simply because of the incidence of such cases
within his or her daily life. The doctor may see one child in
care in a year. How does one get people to give the necessary
time to come together in training when it is a different priority
for different groups? It is a practical problem, not a matter
of principle.
152. Do you think that progress is being made?
(Mr Davies) The evidence is that there is a lot more
joint training going on. I am not sure how much further I can
go than that. It has probably worked much better in some areas
than others. Some of the training between district nurses and
social workers for community care implementation in 1993 was very
thorough and effective; and some of the joint training around
child protection has been very effective. I do not claim more
than that.
(Mr Hake) We see the human resource aspect of the
relationship as being very important. We make the point in paragraph
6.1 of our evidence about an ageing workforce and future supply
side issues that we must address. One sees the work that the National
Case Mix Office is doing about the skills that are required and
the nature of the job. Comparable work is being done on the social
care side. We have suggested to the NHSE that there is a strong
case for looking at this together, because unless you can get
seamless views of the staff involved whatever is done organisationally
will not work. At the moment, at local level the service works
because of the way that local professionals work together. We
have suggested a number of factors that may enable that to be
achieved, but with the changes in regulation and single status
care homes ending the distinction between residential care homes
and nursing homes—which I understand is to take place at
some stage—the skill mix must be looked at very carefully.
The work that we have done in our own activities in community
care with our health colleagues has sought to identify the nursing
task. What is the distinctive element which means that only a
nurse can do that? Nurses are expensive. The whole issue of skill
analysis and substitution so that we can deliver better value
and care to people needs to be looked at as an underpinning factor
in future relationships.
153. I shall read your reply carefully. I should like to
move on to the difficulties in the interface within local government
which has an impact on this point. One of the major interfaces
is social services and education. In relation to child services,
one has a triangle: health, social services and education. Two
of those are within the remit of local government, and yet so
far I have been bemused by the fact that there is just as much
a gap between social services and education as between health
and either of those, and sometimes the gap is even greater. Do
you have any comment to make on that?
(Mr Davies) I cannot say much more than that I do
not believe that you are wrong to draw that conclusion. To bring
functions into one organisation is not the simple answer. It is
clear that in new areas the link between education and health
is growing in importance. Perhaps the obvious one is the drugs
action teams which in my area have brought education, youth service,
social services, health and police into a new relation to try
to address those difficulties. But whatever difficulties are identified
in the relationship between health and social services in a vast
area of the country health will have a much stronger relationship
with the social services bit of local government than any of the
other bits. One of the duties that I and my colleague have is
to try to act as a bridge between health and some of the other
functions: education, environment, road planning and all the other
areas that we have touched upon.
154. What do you think can be done about the social services
and education aspect? The Committee has come across a great deal
of this in its inquiry into children being looked after. I have
come across it on a constituency basis. Only yesterday it was
brought forcefully to my attention. Left to itself, it may get
worse because the pressure is in a different direction, that is,
education. You cannot really cope with problems relating to children
without getting closer worker relationships. What do you think
can be done about it?
(Mr Davies) Strangely, I think that many of the things
we have talked about to improve relationships between health and
social services apply equally to the education/social services
issue. In large measure, although education/social services are
within local authorities they operate as separate functions. To
some extent, the quality of co-operation depends on how much of
one's agenda coincides. In social services more of one's agenda
coincides with health than with education, if one looks simply
at the volume of work and number of contacts from GPs and district
nurses compared with schools and teachers.
155. Perhaps that is so not because it is right but because
you also need to make more contact with schools that are not now
being made?
(Mr Davies) Yes. There are signs of some progress
being made in that area. Authorities are looking at setting up
behaviour support teams which draw social services alongside educational
welfare, psychology support and so on into single support teams.
Some of the work being done to try to reduce the incentives to
schools to remove some children and encourage them to work with
them within schools is showing signs of progress, but that interface
needs as much attention as the health one.
156. In a way, it gives the lie to claims about the importance
of democratic accountability. There does not appear to be a great
recognition within local authorities of the spread of responsibilities.
This is difficult for you. Perhaps it should be addressed to local
authority councillors. What relationship do you have with your
corresponding professional groups in the education service? Are
you jointly addressing this problem?
(Mr Davies) There is some useful joint work going
on, including a jointly commissioned piece of research relating
to problems of exclusion and truancy by the Society of Education
Officers and the Association. There is a will to get together
at that kind of level. In defence of my employers, where councillors
fix on an issue like the needs of children who are being looked
after—their educational requirements and so on—and
give an impetus to that they can make an enormous difference by
bringing their range of responsibilities to bear on the problem.
157. Possibly, the emphasis should be on "can"
because that could usefully be replaced by "do". The
example of the work on drugs is interesting. There is also the
issue of children in school who are troublesome and troubled.
Sometimes those are the same thing; sometimes they are not. That
affects both social services and the running of schools. Do you
contemplate doing any joint work with your colleagues in education
in a rather wider way? I appreciate that there is a joint initiative,
but what about behaviourial problems in general which may have
mental health implications? There may be a social services implication
and an educational implication.
(Mr Davies) The evidence is that there is a good deal
of local initiative in this area simply because it is quite high
on the "worry" list for people. Things like joint behaviour
support teams have been put in place. There are reviews between
education social service and health of what treatment facilities
there are for troubled children across the board. At the moment,
whether one goes to one's GP and ends up in child guidance or
knocks on the social services' door and ends up with a social
worker can be very much a matter of accident. Whether that is
a well judged definition or pure accident one does not know.
158. Or one may knock on both doors and end up with neither?
(Mr Davies) Yes. Quite a lot of attention is paid
to these issues at local level, and that is fuelled by concerns
like rising rates of school exclusion, juvenile crime, the worries
of early parenthood and so on.
159. To what extent do you think this is influenced by the
fact that there is a big division in responsibility at government
level? The Department of Health is responsible for policy on social
services but does not fund them. Funding is done by the Department
of the Environment, Transport and the Regions. There is a similar
dichotomy in relation to education where the Department for Education
is responsible for policy but not funding. One has three corners
none of which is complete. Do you as professionals believe that
there is adequate collaboration at governmental level, or do you
feel that it is viewed in boxes?
(Mr Davies) We believe that for a good part of the
time it is seen in boxes and we find different messages coming
down the different channels to local level. Equally, there are
problems between social security arrangements and community care
where things that happen on the social security side appear to
cut directly across what is sought to be achieved in community
care policy. I do not make that as a critical statement. We know
how difficult it is to draw all these threads together. However,
we do not believe that central government is any better at it
than local government.
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