Examination of Witnesses (Questions 383
- 399)
WEDNESDAY 1 APRIL 1998
MRS ANNE
DUFFY, MRS
SUE BOTES,
MS LYNN
YOUNG AND
MR MALCOLM
WING
Chairman: Colleagues, can I welcome you to today's
meeting and can I particularly thank our witnesses for their willingness
to attend and for submitting written evidence to the Committee
in this inquiry. We have a number of declarations of interest
which slightly complicate our evidence session
Ann Keen: I would like to declare that prior
to being elected to this House I was General Secretary of the
Community and District Nursing Association, and I am now Honorary
General Secretary and am paid remuneration for editorial duties.
Therefore I will not be asking questions of the CDNA.
Mr Austin: I am a member of MSF, of which the
Community Practitioners and Health Visitors' Association is a
part, and MSF has a financial relationship with my constituency.
I will not therefore be asking questions of the CPHVA.
Dr Stoate: I am also a member of the MSF but
my branch is the Medical Practitioners Union, and as far as I
know there is no direct link to the Medical Practitioners Union.
I do not think there is any monetary arrangement at all between
the two, not that I am aware of. It is a branch of MSF.
Chairman: Just to add to the confusion, I have
to declare an interest. I am a member of UNISON and my constituency
party has a constituency agreement with UNISON, so I will not
be asking questions of UNISON, which may come as a relief or not
to UNISON. If I can appeal to Committee members and to witnesses
to be aware that obviously we have to tread a little carefully
to fit in with our own procedures. I think you will understand
the difficulties we are in. We will attempt to ensure that we
do not ask questions of those organisations we have a relationship
with, and perhaps in your answers to various people you would
be aware of those problems. Can I begin by asking John Gunnell
to start off the questioning?
Mr Gunnell
383. You can see so many people are unable to
ask questions of certain witnesses and we wanted to started off
with a question which came to each of you as witnesses and therefore
to each of the organisations, so it falls to someone who is interested
in health and social services but not a declared interest in any
of the organisations which are here. I am going to put a question
to you about the so-called Berlin Wall. We have had the Health
Secretary make clear on a number of occasions now his views on
the Berlin Wall which exists between health and social services,
and when we had a witness session from Age Concern very recently
they described the situation as rather similar to a volley-ball
match in which the ball kept bouncing over the wall and it depended
really which side of the wall it landed what happened to the particular
client. I want to ask each of you as organisations whether you
think there is a Berlin Wall and what you see as the main barriers
to collaboration between health and social services across that
potential and sometimes real divide?
(Mrs Duffy) My name is Anne Duffy, I am Vice Chairman
of the CDNA, and I have also been Community Nurse Manager in Gloucestershire
for the past 12 months. Prior to that I worked for 20 years in
Northern Ireland and I certainly would feel quite strongly that
on the mainland here there is a Berlin Wall. It does exist compared
to Northern Ireland. I see here there are different approaches
with two professional bodies, social services and health services,
coming together with a common goal, that being patient care, but
they have different cultures and different backgrounds through
their training. So I would feel very strongly that training should
be addressed, there should be further joint training for social
services and health services. I also feel that it creates tensions
and poor working relationships when you have these different approaches,
and it would certainly help get over some of the hurdles if we
had joint lectures at university level and when social workers
and community nurses are being trained. This would help them better
understand their role and get clarification. Throughout the field
worker level within this country I do believe there is good communication
and good working relationships, but at higher levels, especially
at director level, that is where there are lots of barriers. At
that level is where the budget responsibility is, so again separate
budgets are not always the answer, and perhaps maybe moving towards
a joint budget, just one pot, a central pot for the money, may
in my opinion be helpful. I also think that both health care and
social care workers are continually assessing every day, and we
may need to look at having a nationally agreed assessment procedure
for health and social care. These could help get over the Berlin
Wall.
384. I may come back to your experience in Northern
Ireland. We have had a number of witnesses over a whole series
of sessions who have talked about Northern Ireland. You see it
as a positive way of breaking down the barriers, and we might
return to that.
(Mrs Botes) My name is Sue Botes, I am Professional
Officer at the Community Practitioners and Health Visitors' Association.
I would reiterate a lot of what Anne has already said, particularly
about the training but more especially because the training is
actually long-term and that is for the future, people coming up.
I would also say there needs to be a lot of in-house, multi-disciplinary
training going on all the time around particular issues that both
health and social services are dealing with. There is a huge need
to have a greater understanding of each other's roles because
this is where the main barriers are, and this would be part of
what the training would produce, but also to just sit down with
people with other roles and talk over their philosophies and their
aims and objectives is really helpful. I think one of the things
which has increased the barriers is the internal market which
has gone on since the early 1990s. This has been very detrimental
because there have been very restrictive budgets and everybody
has been very careful to hang on to their budgets and there has
been a real barrier with money, to try and pass work over to someone
else so it does not have to come out of your budget. I think this
culture has to be broken down and changed, and people have to
work their way out of it before they can happily work together
and do joint working.
(Ms Young) I am Lynn Young, one of the Primary Health
Care Advisers at the Royal College of Nursing. Looking at the
public here, many patients have a whole range of rather complex
needs and feel they are in the middle of a Berlin Wall very often
when we are not able to sort things out. Having said that, we
have to acknowledge there is great diversity in the way practice
is executed in the community, and I think people with a great
level of commitment and genuine desire to see things made better
have actually caused great cracks to appear within this so-called
Berlin Wall, and I think we have to acknowledge that is going
on and congratulate those people who achieve success despite the
structures not because of them. I would also go along with the
notion of more shared training and shared learning, I think that
is a genuine way forward. I think also that one solution is to
have an integrated budget at the practice level and actually to
give people who are providing the care the authority to use an
integrated budget where then, as far as the patient is concerned,
there would be no wall because they are receiving care. Also for
the public, they seem unable to comprehend why they are getting
some services absolutely free and then at some point the wall
comes down and in comes the means-testing machinery, and I think
it is really very confusing for a lot of people. I think we can
overcome a lot of those difficulties by improving the interface
between health and social care and there are lots of ways we can
do that, but I think the key to this is actually at the practice
level, as close to the public as possible, an integrated social
and health care budget so that those providing services can literally
sort it out themselves.
(Mr Wing) I am a late replacement, I should say, for
Mr Abberley. I am Malcolm Wing, Deputy Head of Health in UNISON.
I am not sure whether a Berlin Wall exists. It is a great soundbite,
but I think it perhaps in some respects does not reflect adequately
the successful joint working that does take place in many areas
between health and social services, but problems do exist and
UNISON would not want to minimise those. I think the so-called
Berlin Wall does reflect, as one of the previous contributors
has said, an obsession with markets and competition that characterised
both social services and health care in the 1990s and the fact
is that there are lots of incentives in the existing system for
cash-strapped statutory authorities, whether they are health or
local, to cost-shunt and shift responsibility for service provision
to other agencies and other authorities. I also think that the
problem of barriers and walls has also been intensified as a result
of the growing reliance on charging and means-testing for services.
We also think that the so-called Berlin Wall has manifested itself
in a problem of mistrust and suspicion and, as I have already
said, there are lots of incentives to off-load the cost of care
from one agency to another, so there are lots of problems. I think
the suggestions around joint training and greater co-operation
around joint learning would undoubtedly help, but I think what
is much more important is that we are moving away from this competitive
culture, this market culture that we have seen over the past seven
or eight years into what we perceive to be a much more collaborative
era where there is much more of an emphasis on co-operation and
collaboration, much more of an emphasis on joint working and shared
decision-making and much more of an emphasis on sharing information
because it is a fact that information sharing within health and
within other agencies is a relatively recent reinvention. We also
think that the statutory duty to co-operate, which has been set
out in the new NHS White Paper, is going to make a huge difference
because it is sending out a very, very positive message that we
think will help overcome many of these problems and difficulties
that we have seen at the local level. For one, there is talk of
the way that the winter crisis was dealt with this year. Well,
I suppose there was not really a winter, but the fact was that
the Secretary of State made it clear that he did expect joint
collaboration and joint working between health authorities and
social services and I think that the message was received loud
and clear and I think that the fact that we did not have the problems
that we have had in previous years is due obviously in part to
the mild weather, but to a great extent to the fact that there
is a new expectation that there is co-operation and collaboration.
385. So you actually feel that the emphasis
that the Secretary of State has given to joint working has actually
had some effect in terms of the practical situations in which
you find yourselves and you do find that actually as a result
of the emphasis that has been put on the importance certainly
in terms of the winter crisis management, and there were many
specific statements made, you think that the Secretary of State's
work on this has had some effect in terms of joint working?
(Mr Wing) Yes. There are artificial barriers, there
are boundaries, but we feel that the problems that boundaries
create can be overcome by people working together, by collaboration
and co-operation and of course the extra money helped enormously,
but we feel also by the fact that local authorities and social
service departments and the Health Service did work together to
demonstrate that you do not need major upheaval and structural
change, but what you need is a commitment to collaboration and
co-operation and I think those messages are getting through. I
do not want to answer a question I have not been asked, but people
do not want upheaval, people do not want dramatic reorganisation
and change; what they want is to make existing structures work
and moving away from a culture of competition, moving away from
that era of markets and secrecy and getting one over on the next
door neighbour and replacing it with an expectation that organisations
and agencies will co-operate and work together, we think, works.
There are examples, like health action zones and the GP commissioning
pilots that we think will probably demonstrate that the structural
obstacles can be overcome by collaborative working and certainly
we expect those pilots and those experiments to be properly evaluated
as a strong alternative to major upheaval, big bang structural
change, and of course we are just getting over the big bang of
1991.
Chairman
386. One of the witnesses that we had last week
from Age Concern, and I put this question to the three witnesses
other than the UNISON witness obviously, made the point that the
changes that occurred in 1974 whereby the health functions of
local government were moved to health authorities had a bearing
on the difficulties that we have now. I am not assuming that the
witnesses who are here today were around at that time—I
was, I am afraid—but assuming that you may have read the
theory, what are your views on whether that organisational structure
offered a better framework for collaboration than the current
organisational structure?
(Mrs Botes) I think as far as health visitors are
concerned, my colleagues who worked in that era certainly have
said that that was a downward turn really and have said that life
has not been the same, that it has not been so easy to work constructively
and to be effective for clients after that time, so, not having
had personal experience, certainly that is the feedback I get.
(Ms Young) I would say that since 1974 there has been
such phenomenal change with regard to life itself and how families
are structured, how communities are and how care is provided that
we provide care in a totally different way than we did all those
many years ago, and I think we are now into an era of building
stronger primary health care and I would like to keep that drive
continuing. I do not believe that is the way to go and I would
challenge actually saying how it was then, because so many other
things have happened which I think make it practically irrelevant.
(Mrs Duffy) I agree as well with the other speakers,
but I feel Northern Ireland is still practising very similar ways
to the ones you had in the 1970s. They were the last to make the
break and move and go separately. I think both ways—then
and 1988—are currently worth looking at and I do believe
that the way forward is very much on the Northern Ireland approach.
Mr Austin
387. Those of us who visited Northern Ireland
in the last session and looked at the way in which a unified service
operates very much take the point you have made, where there is
not clearly this cost-shunting that goes on in the rest of the
United Kingdom. One of the witnesses recently, I think it was
the Age Concern representative, when we were talking about the
possibility of pooling budgets as a way of overcoming this without
having structural change, suggested there may be within a pooled
budget the reverse effect, that there is then a decision to try
to maximise the effectiveness of the budget by shifting more services
from a free-at-point-of-use NHS provision to an assessed charged-for
social service provision. Do you feel there are those dangers
in a situation of pooling budgets?
(Mrs Duffy) I think a very good example is the winter
crisis money we had this year. Social services and health were
pooled together and the budget was shared between them, so they
had to get round the table, they had to talk to each other. I
feel that was a success in the area I work in in England.
(Ms Young) There is a genuine danger with that but
I think what we are probably looking for at this time is stronger
guidance from the centre as to what the NHS is truly here for.
Over the last seven years we have seen some services which have
always been provided free at the point of need by the NHS but
by stealth have kind of withered away. The provision of long-term
care for elderly people I would obviously want to highlight. Maybe
we need to have it reconfirmed as to what the NHS provides free
at the point of need without the debate then of the means testing
agenda.
Mr Walter
388. I am slightly intrigued by some of the
answers suggesting the situation was so much better when in fact
there has been no real structural change. The winter crisis money
was very much health service driven and not social services driven.
I was concerned at some of the comments you made about the so-called
internal market, because what we have had is social services really,
if you like, creating the barrier. Are you suggesting that that
barrier has simply come down—and this is a question particularly
to Mr Wing and Mrs Botes—because there is a change of attitude?
Or do you perceive there is some structural change?
(Mr Wing) Obviously it is early days and I think UNISON's
principal concern is that we do not have yet another major reorganisation.
We are arguing that the winter crisis was an example of structural
barriers being overcome by some very strong messages being sent
out about the need to work together and co-operate to overcome
the problem. In terms of whether we can make lasting and positive
change as a result of bringing in a duty to co-operate and local
authorities and the NHS working collaboratively, then we would
simply say that pilots and experiments are being put in place
and that we should not have major upheaval but we should try to
dismantle the walls by placing a duty to co-operate, by putting
in place structures that bring different organisations together
to see whether that can deliver the seamless services we all want
to see. So it really is a question of saying that there has been
a shift in approach and emphasis which we very much welcome and
we have argued for. We have seen the very negative effects of
competition and markets and we think that the new NHS does offer
a way forward.
389. But that does not alter the fact that part
of the problem is social services budgets being reduced.
(Mr Wing) We would argue that there is an unfortunate
distinction between free health care and means tested social care.
If we can identify pressing needs then they ought to be financed,
they ought to be free at the point of delivery. We certainly recognise
many of the problems that users face are not as a result of structural
problems and may not be overcome by collaborative working, which
have their origins in the fact that services need better levels
of funding. There are some major difficulties in expecting people
to pay for, as Lynn has said, services which were previously free.
(Mrs Botes) I have not got a lot to add to that but
I think it is not just a case of having the joint funding. There
is joint ownership and then there is joint working at what you
want to achieve rather than it being in two separate camps.
Chairman
390. Can I say to our witnesses, other than
Mr Wing, that the concern we have had expressed time and time
again by users and carers is this complete lack of clarity in
relation to the provision of certain services. The most obvious
example is the famous community bath, which we are all well aware
of. Are you and your members clear as to where the division actually
lies between what your members would do and what the nursing staff
would do and what the care staff would do? Can you define the
boundaries?
(Ms Young) I think that is over-simplistic. People
do not fit into little convenient boxes in order to fit into the
needs of the service. People's needs change, their conditions
change, and very often it is the case that you do not need a nurse
because of the activity, you need a nurse because of the condition
of the patient. So I think we are not going to make any progress
if we try and produce a list of what one person can do and what
another person can do, because this will vary according to how
the patient's condition is on a particular day. People with long-term
chronic conditions, and this is the bread and butter of community
care and where all the problems of the health and social interface
come in, are very often quite well for a long time and do very
well with a certain person looking after them, but their condition
can change very quickly and they will need a qualified nurse on
that day, maybe to carry out the same activities but the condition
demands somebody else to do it because that is how it is. So I
am afraid I am not going to give you an easy answer.
(Mrs Botes) I would say that the assessment of need
at the on-set, if it is a discharge from hospital or a new patient,
should actually be a nursing assessment and then the social services
assess from that, or else joint assessment.
391. So you are making the point that, for example,
the person who is leaving hospital who may need some community
care support, whether that be full-time care in institutional
provision or care within their own home, that initial assessment
should be a nursing assessment?
(Mrs Botes) Yes.
(Mrs Duffy) I would definitely agree with that. For
everybody discharged from hospital, the first assessment, I feel
very strongly, should be a nursing assessment in collaboration
with social services to help put together proper packages of care.
392. And you feel it is possible at the time
of discharge from hospital to determine whether that person's
needs are geared more to the nursing side than the care side?
The assumption would be, from what you have said, that a nursing
assessment would be made where the person's needs are deemed to
be related to nursing care as opposed to social care.
(Mrs Duffy) Most discharges that are properly planned
begin on admission to hospital and during the stay at hospital,
community staff are in regular contact with the hospital staff.
Hospitals have their own social workers based there and they will
link back with community nursing staff and I feel that there is
a lot of positive work ongoing out there between hospital health
workers and social workers and community nursing staff and that
is putting together good packages.
393. But why is it in practice that Members
of Parliament not infrequently end up dealing with disputes between
the elements of the services over where the division is in a particular
case? I have had this and colleagues here have had this, particularly
on the bathing issue, and the dispute often arises of course because
the user of the services is aggrieved at perhaps having to pay
for services that, provided by another agency, would be free.
(Mrs Duffy) A health need has to be identified through
a proper nursing assessment and when the health need is identified,
it is taken forward. Quite often people are assessed and they
may not have a health need at that time.
(Ms Young) Can I come in here because you are never
going to arrive at a situation where there is a wonderful straight
line as to those services are health and those are social care.
394. Therefore, what do you do about it?
(Ms Young) Well, this is the point and this is where
you can actually sort out the problem or the issue with people
at the practice level. This is where you have got the problems
of variation because in one street you might well have the bath
being provided free and in the next street it might be that the
person has had to pay for it and this is why people are very,
very confused. Brain surgery is health and meals on wheels is
clearly social, but there are things in between that could be
either or indeed both. I would say does it really matter?
Audrey Wise
395. Do you think that in fact with a particular
patient in any case and even if there was an initial assessment
by a nurse that there would often be a case for a continued nursing
input, and I do not mean constant, but at intervals as a sort
of supervisory arrangement? I notice that in one of the pieces
of evidence, and I cannot remember whose it is, they give an example
of joint working and they are talking about the care worker being
able to ask for an opinion from the district nurse, but do you
think that even that might not be adequate because, especially
in the way of old people, there is a tendency for lots of people
to attribute problems to simply, "This is an old person",
whereas a nurse might say, "This is a particular deterioration
which is capable of improvement with nursing intervention"?
Do you think that there should be more which is continuous, not
continual, but from time to time?
(Mrs Duffy) I think district nurses actually do have
a big responsibility in taking care with continuous assessment,
continuous supervision of patients in the community. Quite often
they may not need hands-on care at certain points in time, but
the nurse on her caseload does carry a huge number of patients
where she will oversee the care that is going into this particular
patient in a supervisory capacity.
396. Might that be sometimes expressed by giving
a bath because then the doing of that gives opportunities to assess?
(Mrs Duffy) Quite often a nurse is not just doing
a bath, but she is doing a complete assessment. She is observing
areas for pressure sores, for example, she is taking a holistic
approach really throughout her assessment, not just giving a bath.
I do not believe nurses ever go in and just give a bath. There
is a lot more on a visit.
Julia Drown
397. I would like to ask the RCN about some
of their proposals to improve the relationship between health
and social services. You talked in your written evidence about
merged and devolved budgets and you talked about how the primary
care groups could be extended to be primary care and community
care groups. Obviously that would involve the two funding streams
from health and social services being together. It would be interesting
to know how you think that would operate and who would make the
decisions, and would it be around a monthly meeting because obviously
that would be a delay for many people wanting services, and to
whom would that group be accountable?
(Ms Young) In our written evidence we simply came
up with an idea that we thought would be actaully hopefully achieving
some progress on issues around whether the bath is health or social
because, as far as the person is concerned, it does not matter
because they want their bath and they want it done by someone
who is polite, kind and competent and when they want it basically
as well. We would see that the health authority and the local
authority would devolve some of their money to the primary care
group which would be a mixed team of people which would include
somebody like a district nurse and care assistants, non-qualified
people, who have actually been trained in personal care, so those
people would be working under the supervision of a district nurse
which would work very well because when needs change, there would
be very prompt access to the nurse and, therefore, hospital admission
would hopefully be prevented and added distress. Now, if the integrated
team, the district nurse and the social care assistant kind of
a person, has a budget which they are able to use for the care
of a number of people in the community, this, we believe, is a
reasonable and manageable way forward. It is giving those people
who provide the services the authority to spend money in the way
they see fit for the people they serve and then, as I say, we
would not get into this argy-bargy about whether it is health
or whether it is social. If it is personal care, the people providing
the care will sort it out with the budget that they have been
given by both the health and local authority. I hope I have made
that clear.
398. So you are saying that it would be the
district nurse who would be making the budget decisions?
(Ms Young) Well, in discussion with the people she
is working with. I think teams of people have to come together
to actually agree on the best way of spending a rather limited
resource.
399. Then what about the accountability? Who
would that group then be accountable to? They would be writing
reports to the health authority and the local authority?
(Ms Young) Yes, a kind of financial management, and
it depends what the level PCG there is, I guess, in the brave
new world, but at this moment it would be back to the health authority
and the local authority with the social care money that has come
down to the practice level.
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