Examination of Witnesses (Questions 319
- 339)
THURSDAY 26 MARCH 1998
MRS E MCEWEN,
MS L EASTERBROOK,
MISS M GOOSE
AND MRS
W HIGHAM
Chairman
319. May I wish you good morning and may I particularly
welcome our first witnesses this morning from Age Concern England
and The Stroke Association. We are most grateful for your written
evidence and for your willingness to come along today to give
oral evidence and answer our members' questions. May I ask you
each to introduce yourself to the Committee?
(Miss Goose) My name is Margaret Goose.
I am the Chief Executive of The Stroke Association. I am new to
the charity world having started in November. My previous background
was in NHS management and at the Nuffield Institute for Health
in Leeds. I recognise the faces of some MPs who kindly supported
us when we lobbied Parliament last October.
(Ms Easterbrook) My name is Lorna Easterbrook and
I am the Policy Officer with Age Concern England with responsibilities
for community care services and NHS continuing health care services.
I have worked for the charity for five years. I joined just before
the community care reforms came into being in 1993. Prior to that
I worked for a care and repair scheme dealing with adaptations
for older owner-occupiers in South Wales who had quite severe
disabilities.
(Mrs McEwen) I am Evelyn McEwen. I have been the Director
of Information and Policy of Age Concern England for 16 years.
I was also a member of a health authority. I was a carer for three
of my closest relatives who all had dementia of one kind or another
and I was a voluntary care manager for an elderly couple: the
lady, who died at the age of 96 was blind and deaf in her latter
years and her mentally handicapped son died at the age of 70 with
generalised cancer.
(Mrs Higham) My husband suffered a subarachnoid haemorrhage
in 1990 and subsequently a very severe stroke and I have been
caring for him ever since. Not only do I do that, I am secretary
of the local stroke club and have quite an involvement with people
who have suffered strokes. I sit on the Warrington committee for
disabled people which is a committee which is made up of voluntary
sector people and statutory sector people. I am also involved
in a carers' project at the moment in Warrington.
320. We are most grateful to you for coming
down this morning. The Committee particularly wanted to have a
user and carer perspective in this inquiry and we appreciate you
have put yourself out to be here. May I begin by asking all the
witnesses for their views on the comment that there is this alleged
"Berlin Wall" between health and social services? Do
you believe there is a "Berlin Wall" from your own experiences?
How does this in a sense impact on your particular perspectives
in relation to the services which you relate to?
(Ms Easterbrook) I have been thinking about this idea
of a "Berlin Wall" for quite some time. I am not sure
whether that is a very good analogy from the point of view of
the person. If I were going to have an analogy, I would say it
is more like a game of volley ball where the idea is that the
person is kept up in the air and being batted over one side of
the net or the other. Of course if the person lands one side that
is where their service will come from. There is a range of difficulties
for people in actually accessing care particularly where that
is going to involve health and social care services. There is
no doubt that we come across a large number of people who are
simply told, "Go to another agency. It is not our job".
The net result usually is that people spend a long time going
round in circles without actually getting the service they need
in the meantime.
(Mrs McEwen) At Age Concern we handle over 40,000
a year and our groups also provide information services and care
for older people and their families. We acknowledge that we are
likely to meet the difficult cases but we meet a great number
of those and over the last ten years the enquiries we have received
around community care services have escalated greatly. One of
our great concerns is the ditch at the bottom of the "Berlin
Wall", the extent to which so many of the services actually
drop out of the system: in NHS care chiropody, the giving of medication
and bathing; in social care the home cleaning services and the
shopping for people. In a sense what we have seen is a hidden
agenda which has meant in recent years that nobody feels obliged
to look at the strategies which need to be adopted in order to
ensure that people who have care needs actually have access in
some way to these services.
(Miss Goose) We would not use the words "Berlin
Wall" because that suggests it is finite. Our evidence from
colleagues in the field is that it is very much more of a lottery
as to whether or not people will actually get access to the particular
care services they need. I cannot find the right phrase so I think
I shall call them stroke people because it is not just the patient
going home and becoming a client, it is actually the families
and carers who are so much affected. Most of the stroke people
are moving from an acute medical setting through to a long-term
severe disabling condition and therefore it is sometimes not so
much who does what but the sheer coordination both on the discharge
planning side and then the delivery side in the end and the need
for a family unit to have one key person they can go to who will
access all the other services and know what will be done.
(Mrs Higham) I would agree. The difficulties are that
there are so many different ways of accessing services. You might
go to one particular agency and then be sent somewhere else. In
my particular case, the difficulty I find is that it is when you
are long-term caring. At the beginning there might be quite a
lot of input into the help you get but then as the years go on
that drops away and it is very difficult to access the services
again.
321. I was very interested in the analogy of
the volley ball match and which side of the net the ball drops.
None of you has actually argued in your evidence for removing
the net. Do you take my point? We had evidence last week from
one organisation, the British Association of Social Workers, who
were suggesting that one option which could be looked at is the
combined organisation of health and social services. Do you favour
that? If you do not, why not? Can we not remove the netting in
some way that would address the issues you are concerned about?
(Mrs McEwen) There are many arguments towards the
integration of health and social services, particularly on the
community care side. I am actually minded of the fact that it
was not until the Seebohm reforms in the 1970s that we split the
community health care from the community social care and this
was really a very significant binder of support for people living
in the community. I do feel that the Cinderella of the services
is as Wyn described: what happens in the longer term when you
have passed through the phase of acute difficulty, the continuous
support you are going to need in the community.
322. May I press you further on that particular
point about the past organisation? Obviously the Seebohm reforms
brought the various elements of social services together in one
department. Are you actually referring to what happened in 1974
when the public health departments were abolished?
(Mrs McEwen) Yes; exactly.
323. You feel that was not a positive move?.
(Mrs McEwen) There may be with the medical officer
of health who is responsible for the district nursing services,
for chiropody services in the area, to an elected body which is
also responsible for social care—and I was on an authority
in this area at that time but it is a very long time ago—allowed
perhaps a daily communication in the integration of that long-term
support which we have actually lost. One of the problems very
clearly in all the writing and research on breaking down the boundary
is that so often it has been seen from the professional and from
the authority perspective and has left out the dimension of the
older person's budget. That of course is one of our primary concerns.
As the health care has shifted out of the health service in some
respect into the social area, so the older person and their family
are faced with a cost that they would not have faced before.
(Ms Easterbrook) Removing the net would leave a number
of issues. It would still leave the free/charged for divide and
that would have to be resolved in some respect. I am certainly
aware that there is a view that in mental health services it has
been possible actually to bring health and social care together.
What is important in that respect is that there are no charges
by local authorities for social care under section 117 of the
Mental Health Act. Effectively all those services can be free
to the person. There are also issues in terms of removing the
net, in terms of who actually leads where that provision goes.
We are very conscious of how much provision of services is hospital
led and that often the only point at which you are going to be
able to access services is by a stay in hospital. There are also
concerns in terms of removing the net that not everybody needs
both, not everybody needs health services and social care services.
There are particular concerns for people at the low level of help
who perhaps do just need the shopping, the cleaning, the collecting
of pensions, those sorts of services and that they may inadvertently
get left out of the pot.
(Miss Goose) As an organisation we have not addressed
that issue in so far as we are conscious that boundaries exist
somewhere and we are very conscious that most stroke people do
move through the whole spectrum. Our concern is at the boundaries
of where people do move from one to another and who is the lead:
is it a medical lead, a therapy lead or is it support in the home?
At any one time a stroke person can need a variety of those and
it is not necessarily going to be consistent. The multi-disciplinary
assessment and the work we are doing on evaluating community rehabilitation
teams and the work the Audit Commission and King's Fund have looked
at in rehabilitation does stress the multi-disciplinary nature.
From our point of view there are the issues of charging which
obviously have an impact on stroke people but the impact to us
is actually much more, whatever boundaries you have and wherever
you have a boundary it is going to be inconvenient in some way
and actually making sure the mechanisms are there and the expectations
are there for good coordination and working together, certainly
involving the patient, the user, the carer and the social worker.
One of the issues we have found from the feedback from the field,
particularly in discharge planning, is that social services and
social worker colleagues are often not brought in early enough
and therefore they find it difficult to give the support needed.
In some places, as in our written evidence, we have examples of
very good practice: in other cases a person goes home really wondering
what has hit them.
324. Mrs Higham, obviously you have had practical
experience over a long period of time of this divide?
(Mrs Higham) Yes.
325. In practical terms has it affected your
husband's receipt of services and the support offered to you in
any way?
(Mrs Higham) Yes, I would say it has. There is a great
necessity to talk to each other. The people who shout the loudest
seem to get the services the quickest. There is another element.
You are talking about health and you are talking about social
services but also when you need adaptation you have to bring housing
into it, so there are three elements within that particular scenario.
That can create another difficulty and it can mean very long-term
waiting sometimes to have these adaptations put in place.
Dr Brand
326. May I ask whether in recent years the separation
of purchasing and commissioning has made a difference in your
experience? Do you think the role of the care manager and care
planning has been successful? Do they have enough access to services
outside purely social services departments?
(Mrs McEwen) One of the most significant differences
has actually come in the health service with the purchaser/provider
split and the break between acute trusts and the community trusts
and the problems this has created, which the clinical standards
advisory group documented, of acute services not really being
very concerned about what happens to somebody when they actually
fall to be the responsibility of the community trust. Certainly
when it comes to rehabilitation we would argue very strongly indeed
for the need for integration across all services. When people
really are at their most vulnerable, physically and emotionally,
the question of who pays for it should be the very last thing
that is raised with people and their families. Very sadly it is
often the first thing. Certainly we have to look at waiting lists.
We have the situation where the health service has a general duty
and is allowed to keep very long waiting lists. Social services
are not expected to have any and with adaptations you can have
a delay of 12 months. So you are sending people out of hospital,
perhaps promised adaptations but with a very long wait indeed.
(Ms Easterbrook) Within the NHS it is still immensely
difficult for the older people who contact us to understand the
purchaser/provider split. It is particularly difficult when someone
is in hospital but trying to explain to somebody that you may
be in hospital but you need to go to the health authority to find
out what the criteria are for continuing health care and how you
access that is very, very difficult. Within social services it
has been less clear generally that that split has not been quite
so clear cut. I do think that has also led to some difficulties
and some confusion. In terms of the care manager, care planning,
in many ways it could be and indeed in some instances no doubt
is a very good way of having one person who is the coordinator
for services, so there is one person who is your key worker who
is the care manager, who coordinates. In reality, certainly according
to the people we hear from, that is not the role the care manager
takes. The care managers are very much involved at the point of
agreeing budgets at the time of the assessment, but they may not
have a further role, certainly not an ongoing and regular review
role. In many respects, where the purchaser/provider split has
fallen down in social care for individuals is that there is a
very strong move for block contracts and it is a strong move which
is in line with best value concepts. If you are an individual
what you actually want is a spot contract. You do not want a block
contract and we know spot contracts cost more because they are
more expensive to administer obviously, there are more of them.
(Miss Goose) For stroke people it is rather different
in that it is only fairly recently that there has been any actual
understanding of what a good stroke service means. Until CT scanning
came in people did not actually know what to do with stroke people
when they were admitted. In some ways the purchaser/provider split
has helped us as an organisation to lobby now that the evidence
is there, for example, that hospitals should have acute stroke
units. We have in fact funded some stroke coordinator posts around
the country and are now in the second phase of those. At the same
time the issues around the care manager and the role of social
services in discharge planning is very variable as to how it operates
in practice and whether or not the person determining the care
package is the same person who commits resources. In some places,
where we as an association are in contract with health and social
services for family support, it is actually our family support
workers who are often providing that key role and finding the
way for the family and carer through the myriad of channels and
trying to understand the criteria locally. This is where one is
in a muddle as to where the national criteria do apply, what local
interpretation is going to be, what the historical pattern of
services is that can actually do the best in any given time and
what we should be moving towards. We find very different experiences
up and down the country: in some places it has worked well to
our advantage. In others we actually find our information and
education centres receiving enquiries: "What does it mean?"
"To whom, should we go?" "I've been discharged
but I don't have a wheelchair." "I'm housebound. I can't
get out. I can't even move out of bed".
Chairman
327. Basic provisions?
(Miss Goose) Basic provisions often not there because
things have not been done in a way which would make sense from
the family's point of view.
(Mrs Higham) I would agree here. I spoke to somebody
only the other day who had actually been discharged from hospital
about nine months ago. For the last six months the lady has not
had a bath or her hair washed or even been able to access a chiropody
service. She just did not know where to go and she phoned me as
secretary of the stroke club. There is a great lack there of information
which needs to be given to people, especially on discharge.
Mr Austin
328. I want to go back to something Mrs McEwen
said about the first question asked very often being "Who
pays?". It has been suggested by some other witnesses we
have heard that without having a wholesale reorganisation of the
services, pooling of budgets may actually overcome some of that
difficulty. Does Age Concern have any experience of where pooling
of budgets has worked effectively?
(Mrs McEwen) What we have ascertained—and I
would say that it is sketchy at this point—with pooled budgets
and joint finance and the extra winter money is that in fact although
the budget was pooled and used together, who actually delivered
the service then affected whether it was free or means tested
to the person. It has not really helped an individual's budget.
Mr Walter
329. May I pick up on something in Age Concern's
evidence about nationally agreed eligibility criteria? Would you
like to indicate what form you think that would take and perhaps
give us some examples of where you think locally agreed eligibility
criteria have failed and whether or not you think that by setting
nationally agreed eligibility criteria you are not in fact taking
away the whole purpose of having local government involved in
the exercise anyway?
(Mrs McEwen) We certainly understand the difficulties
of this from local providers and it is a problem which has exercised
our minds for many years. When you come back to the people who
really matter, the older people and their families caught up in
difficulties, it just does not work unless you have some national
benchmarks which people can hang onto. Everywhere they go they
have to try to find out the different rules locally. We find people
who have been advised by their doctors perhaps to move to the
coast and they move to the coast and then discover the services
they would have received where they lived before are no longer
available. We have to see it from the point of view of the individuals.
We now have the local continuing care guidelines which health
authorities have to develop with social services authorities.
We argued at the time they were introduced that they should be
national guidelines. The process of developing them should enable
them nationally to come to a set of guidelines which could be
published, which can be informative. I would say that we also
need those about social care. They will have to look at people's
circumstances and people's needs as the key component. How then
the services are delivered locally, the different individual packages,
does very much depend on talking to the users in an area to see
what they want in terms of the local service, but they have to
know if their need is of a certain kind that they have a right
to expect their local authorities to provide services.
(Ms Easterbrook) May I add to that, very much to strengthen
the point Evelyn made, that it is not about how, it is about whether.
That is one of the key things where we see some kind of national
system having a very important role. It also has an important
role in terms of changes. In answer to your question about where
locally agreed criteria have failed, they have failed because
they can be changed. This has happened particularly in social
services, far less within the NHS for continuing health care,
but local social services departments can and do change their
criteria for community care services at any point in the financial
year. We know that there have been some who have changed them
just in the last few months and who may then change them again
in April. One of the difficulties is that you then have a very
large potential for a whole number of gaps to arise in terms of
what the local social services department is doing. It changes
its criteria with reference to owning its own resources and not
with reference to where it then is in terms of criteria for housing,
criteria for NHS continuing health care services, those sorts
of things. In terms of the national guidance which the Department
did issue for NHS continuing health care services, what that did,
particularly for continuing inpatient care was set out a range
of circumstances under which continuing inpatient care should
be provided by the NHS. What was quite interesting in that respect,
although that was far more detailed than there has ever been for
any other social or health service, was that one of the criteria
set in the guidance for NHS continuing inpatient care was patients
who are likely to die in the near future. There was no further
definition of "likely to die in the near future" so
a whole load of health authorities developed a whole load of different
criteria. Some of them said "if you are going to die in the
next four weeks", some of them said "if you are going
to die in the next six months" and some of them said they
were not sure and they would just look at it on an individual
basis. As a result of some of the health authorities saying "within
the next four weeks", what the Department then did was issue
more guidance to the health authorities that they actually thought
saying "likely to die within a few weeks" was not enough.
So if the Department are prepared to say "No, four weeks
is ridiculous, it is far too short a time", then we do feel
there is a role for them to say what is then an appropriate time,
if you are going to have the time element within something like
that.
330. I was interested in what you said about
local authorities changing the criteria every other month or every
couple of months. Do you have a specific example of where the
local authority criteria has moved away from what is provided
by the health service and left people in the middle?
(Ms Easterbrook) In one of the more recent ones which
I have in mind what the local authority have done is a two-fold
thing. They have set an upper ceiling limit for the amount they
will provide for services at home which is an increasingly common
mechanism which local authorities are using, a cash limit in this
case. Other authorities set an hours limit, perhaps 10 hours or
20 hours of care at home. They have reduced their maximum limit
and in this case it is a money limit. They have set it now at
£140 per week as the maximum value of services for people
at home. This is not going to buy a huge number of services. What
they have also done is take away the bottom level of services.
What they have said is that they are not going to provide that
bottom raft of shopping, cleaning and collecting pensions unless
you are in the next rung up which is that you need personal washing
and dressing assistance as well. There has been a squeeze at both
ends. The problem for the people at the bottom end is that many
of those people were having shopping and domestic cleaning done
for them because they are unable to do it for themselves. Certainly
what has happened for one or two people who have rung in, because
they are so concerned about it, is that they are now very depressed
and are actually seeking GP advice because of depression. As one
lady said to me, "I can just about get myself washed and
dressed. What I really want is a clean house. What I don't want
to do is sit in this house and watch the dust gather. It really
is making me depressed and I have had to go to my GP and I am
now on medication because I am depressed". That is one very
small example at the bottom end of how that affects.
Chairman
331. I have been very interested to note in
recent years that one of the most distressing issues facing elderly
people who are attempting to continue to function in the community
is the inability to obtain someone to do their gardens. That is
the most public manifestation of apparent failure. Is that an
issue which your organisation is aware of? Are there other similar
issues?
(Ms Easterbrook) All the time; all the time. Gardening
and domestic cleaning and shopping and handyman repairs, changing
a light bulb in a ceiling, those sorts of small details.
(Mrs McEwen) I clearly cannot do it for myself now
and although my husband skis, he needs chiropody to keep him walking.
We recently published a report on chiropody services. These services
are absolutely essential. Agencies such as our own do provide
a growing number of handyperson schemes. We have tried to work
on gardening schemes. It is very labour intensive. What I should
like to see is the Government working creatively with voluntary
agencies at a national strategic level, not just perhaps to fund
individual pilot schemes, which I am pleased to say the Department
has now agreed to do with nail cutting services, but actually
to look at the positive role that the voluntary sector can play
across the country in the future and how perhaps the expertise
at national level can be used to help them develop a planned programme
for the future.
Mr Walter
332. May I come back on the local criteria and
pick up the example you gave of the £140 cash limit? This
is a cash limit irrespective of the needs of the particular patient
or user. Is it a cash limit which is the amount the authority
is prepared to pay in net terms or in gross terms, in terms of
what the user's contribution is?
(Ms Easterbrook) The sum of £140 a week is based
on the average net cost to the authority of buying places in residential
homes. What it says is that if you need more than £140 of
care at home, that is a net amount at home, then your assessment
will say residential care. Alternatively your assessment will
say you need more services than our upper limit allows for you
to have at home but you have turned down the offer of a place
in a residential home which would meet your needs, therefore there
will be a shortfall to you of services. We will provide the £140
a week but you are accepting the risk because we have offered
you something different. Of course out of that £140 a week's
worth of services you may still be charged. So the net value to
you could be significantly lower.
(Mrs McEwen) For older people many authorities have
a different cash and time ceiling than for younger people and
older people do not have access to the independent living fund
1993 which for many families was an enormous boon in caring for
an older person.
(Ms Easterbrook) A lot of authorities are doing that,
a lot of authorities are saying they will look at the average
net cost to them of providing a place in a residential home which
takes into account overall people's contributions according to
the means test system. That figure is very different around the
country because it very much depends where you are and in some
of the inner London boroughs that figure might be £300 a
week. In some of the much cheaper parts of the country, in terms
of the cost of places in homes, it might be £100 per week.
There can be huge cost differentials. What actually happens is
that there is not the same cost differential in terms of buying
home help type services. Actually what happens is that you have
quite a significant difference in the maximum hours of help you
will get.
Chairman
333. Have you sought legal opinion on this procedure?
(Ms Easterbrook) There is a possibility for a challenge
but it would have to be brought on an individual case and that
would be on the basis that somebody's assessed needs could not
be met in a residential home and therefore their needs should
be met at home at a higher rate. Having said that, in terms of
existing case law, the judgment in 1996 concerning Lancashire
County Council allows for this to happen that where there are
two service options the local authority can legitimately choose
the option which costs less for it to provide. For most older
people with quite significant needs, that is inevitably going
to be residential homes.
Julia Drown
334. Getting back to eligibility criteria for
a moment, we have been asking other witnesses to say what the
difference is between health and social care and whether they
could exactly define it. We have been round the houses a few times
and so far ended up with everybody saying there is a grey area
in between. That is one of the reasons why the department of Health
says decisions need to be agreed locally and people just have
to make the best they can of it locally. I should be interested
in your reaction to that and whether you could distinguish one
from the other for us. Also, can you tell me whether where people
do locally agree eligibility criteria it does actually help? I
have seen one local authority and health authority who have agreed
the criteria but they just say you need health services when a
clinician says you need health services, which to the users of
those services does not really get them much further forward.
I was just interested in your reaction to those points.
(Mrs McEwen) There really is very little difference
now between the roles of the nursing auxiliaries, the health care
assistant and the social care worker. Sir Roy Griffiths in his
report did talk about the need for the community carer. One of
the things we are most concerned about is the importance of having
the qualified, the skilled backup to whoever provides the work.
For instance, we have argued in our evidence to you that if bathing
is provided as part of the social care service, we really must
have the specialist district nurse in there supporting the activity,
just as with chiropody, if you are going to have voluntary or
social carers cutting nails, you do need the qualified podiatrist
to ensure that there is no clinical need for a more skilled service
to provide the task. We come back again to the question of who
pays and it is really extremely important to older people. We
cannot brush this under the carpet by talking about generic workers
without facing up to that issue.
(Ms Easterbrook) In terms of whether we have the definition
of what is health and what is social care then the answer is no.
One of the things we would say is that where there have been some
attempts to give some kind of form to it, if not a definition,
is that it is very, very much based on what the professional worker
in different organisations does. That is one of the things where
we feel there has been the most enormous muddling. There is no
doubt that the role of qualified registered nurses has changed
hugely, even over the last ten years, and will change again with
their role as nurse prescribers with possibly a role for them
being involved in outpatients surgery, all those sorts of things.
It is very, very different. If you say that a health service is
what qualified registered nurses do then inevitably over years
other things fall by the wayside. It probably is one of the things
that very much happened. In terms of where there are local agreements,
and you were asking whether that helped people or not, I think
that it does but only if those criteria go hand in hand with frontline
staff understanding the system and knowing where to point people
in the right direction. They actually need to have a level of
information which is quite sophisticated in terms of all the different
agencies and where people should go. One of the big issues, one
of the great difficulties, is that people get left to pursue it
themselves. Certainly we nationally but also locally get involved
hugely with individuals who simply cannot find the right person
and have been told, "It's a health thing. Go away".
If you are actually going to go away and make that contact yourself,
what you need to know is the name of the person, their job title,
their working hours, the telephone number they are on, how else
can they be accessed if telephone is not an option, all those
sorts of details. You do actually also need somebody who would
be prepared to do it for you or with you.
(Mrs McEwen) I should also like to say that traditionally
we have seen personal intimate tasks as being performed for us
by nurses and nurses who came and went. What we are now developing
in social carers is a form of worker who is performing those intimate
tasks, but who is also a continuous presence with the person in
satisfying some of their other needs. There really has not been
enough exploration, if any, of how people react. So often it has
been accepted that if I am going to reveal my body in all its
intimacy, it is actually a health worker who has the right to
do it, which enables us to break down the barriers. I do think
that should be an area which is looked at for the future. Clearly
as eligibility criteria for social services have narrowed and
narrowed for people who are at high risk you are going to find
social carers who are performing health tasks. If one looks back
to one of the last published attempts to divide the line which
was published by NAHAT and was based on definitions developed
in Essex health authority, looking at what was on either side
of the line even then, which was probably about five years ago,
you got for instance on the side of the nurse the giving of medicines.
It quite clearly now is so common for home carers to give medicines
and if I might say so, to go back to the hidden area, for no-one
to give the medicines to people who are not capable of giving
it to themselves continuously.
Mr Austin
335. Turning to the complaints issue, in Age
Concern's evidence you raised two major issues: one is the division
of responsibilities between the Health Service and the Local Government
Ombudsman, which I should like to deal with first and then come
on secondly to the question of self-funding residents and purchasers
of private care and equipment. You have indicated that there is
a problem for the Ombudsmen to be able to carry out a comprehensive
investigation where there might be responsibilities for the two
agencies. Is this a really problem?
(Ms Easterbrook) Yes.
336. Does it necessitate two separate complaints?
(Ms Easterbrook) Yes; certainly in the initial stages.
We have come across a number of people. It is primarily complaints
about hospital discharge. There are complaints about how the hospital
handled the discharge, there are possibly complaints to the health
authority about its criteria for continuing health care and there
may well then be complaints to the local authority in terms of
what is provided post hospital. The difficulty that many people
have is that you are actually pursuing a number of separate complaints.
Certainly at the local level you are first pursuing local services
via their complaints procedure, you are probably pursuing the
hospital via its complaints procedure and the health authority
via its complaints procedure. Once you have moved through that
the logical route takes you into two Ombudsmen, for the Local
Government Ombudsman to look at the social services side and the
Health Service Ombudsman to look at the NHS side. We have certainly
come across one or two people who have persisted to the Ombudsman
level and where there just has not been the possibility for anybody,
never mind which of the Ombudsmen it should be, actually to pull
all those things together and consider the complaint in its entirety.
337. Are you really saying the two Ombudsmen's
services cannot come to an agreement?
(Ms Easterbrook) I do believe there is a mechanism
for them to do so.
(Mrs McEwen) I think they would argue that they do.
I think it was the Leeds case which was dealt with by the Health
Service Ombudsman but which had very strong social services implications.
Certainly then they argued that they did talk to social services
but talking to social services is very different from being in
a position to understand how social services work, which obviously
is the role of the Local Government Ombudsman.
338. You mention in your evidence the possibility
of integrated regulation for residential and nursing homes, taking
in also the domiciliary services. Would you like to tell us something
about how you feel that might be carried forward in terms of a
complaints procedure?
(Ms Easterbrook) It allows for the pulling together
of a complaints system which could deal with complaints about
ongoing services. Maybe there needs to be that sort of distinction,
particularly if domiciliary care services will be brought, as
seems entirely likely, into regulation. It allows for the possibility
for complaints to be looked at in that area regardless of who
is actually funding the care. It is one of the things that I know
you said was the second point you wanted to raise, that we do
have very significant concerns about people who privately pay
for services actually not being able to access a statutory complaints
system. That is the key to it really in a way. It could be looked
at in any number of ways. It could be set out in a whole range
of different ways. There is an inability to access anything which
is a statutory system for those individual private purchasers.
339. Are you really looking for an Ombudsman
service? In terms of the kind of complaints which are received,
are they by and large complaints which come within the remit of
the Ombudsman or are they more about the quality and quantity
of care and how it is delivered?
(Ms Easterbrook) The quality of care is an issue which
both Ombudsmen's offices can consider but only where it has been
statutorily purchased or provided. The Health Service Ombudsman
could consider issues about care and attention in private nursing
homes if the NHS has bought that care and similarly for the Local
Government Ombudsman could consider issues about care and attention
in local government purchased places in residential nursing homes.
(Mrs McEwen) We certainly find that there is a great
deal of maladministration within the social services, particularly
from the enquiries which come to us and therefore the Ombudsman
clearly has a role there. The kind of maladministration is exemplified
by the fact that regulations which exist are not referred to by
frontline workers or sometimes of course that authorities covertly
tell their staff to use new rules which they do not publish until
they are challenged. The other thing we would say is that it really
is so important that housing is brought within the milieu of a
complaints procedure similar to social services complaints and
then it does really raise the issue of whether local authorities
should have a statutory complaints procedure which is similar
across all their services because your route of access to complaint
is so very different. The route for social services complaints
is obviously very well documented, has clear time lines within
it and it is not the same for other services. If you are involved
with trying to obtain a disabled facilities grant that necessarily
means an occupational therapist, social services assessment, but
then housing delivery, you do really need an integrated complaints
procedure.
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