Examination of Witnesses (Questions 580
- 599)
THURSDAY 30 APRIL 1998
COUNCILLOR BRIAN
HARRISON AND
CATH CUNNINGHAM
Chairman
580. Can I just butt in with a question that
relates to the area that Audrey has raised, and your answer, and,
again, referring to our visit this week to Dorset, it was put
to us by one representative of the social services department,
I am talking here of, I think it was, the Director of Social Services,
that there was a frustration within local authority social services
of the way in which where there may be some directive from Government
that impacts upon the relationship between health and social services
they often find out about this through their Health Service colleagues
locally, rather than directly down the line from the SSI. Is this
a factor that you would agree with, is it a problem that you have
faced?
(Cllr Harrison) I have not noticed that problem, no.
(Mrs Cunningham) Anecdotally, I am aware of that,
I am aware that social services departments have expressed that
view. I would also like to add a little bit of information about
the impact of DETR funding on other departments and the impact
of that on social care, if I may. One of the classic examples
for social services departments of that is the funding of adaptations
through disabled facilities grants; significantly, that is a funding
stream that needs to be resolved, we need to see some more parity
of funding through the various different funding streams. I would
also make reference to links with the Benefits Agency and the
impact that changes in the welfare structure in the Benefits Agency
have on cost-shunting on to social services departments and the
provision of services for individual service users. I think the
whole issue of funding strands for welfare needs to be looked
at so that an overview can be sought. I do not believe that there
is actually a widely shared overview of the funding streams in
a way that is helpful, and that could be very usefully produced.
Audrey Wise
581. I am interested that you have mentioned
adaptations, because I have tried to come to grips myself, in
my constituency work, with how this is supposed to operate, and
I find myself in a state of total confusion, which I am not normally
in and I resent, and I have, to an extent, a similar sort of feeling
about SSA, and it does seem to me, from the outside, not trying
to put your case, that policy without funding can become exhortation
rather than anything more practical or more helpful. And I have
tried in the past to find the basis for Standard Spending Assessment,
because the word assessment implies that somebody looks at what
it should cost to provide a given level of service, and I have
discovered, some years ago, that this is not at all what is meant
by Standing Spending Assessment. So how do you react, what do
you try to do to indicate to the policy department, as opposed
to the DETR, or the old DoE, the impact of the funding on how
you can actually carry out their policies, how do you go about
this?
(Cllr Harrison) With great difficulty.
582. Do you have to discuss, if you raise a
funding question, is it like, "Oh, well, that's the DETR",
just as if we put down a question and it is an inappropriate department,
we are told, "That's the Home Office" and it is just
passed over, is that what happens to you; or can you, in discussing
policy with the department, tie it in to funding questions, and
do you?
(Cllr Harrison) Yes, we certainly do.
(Mrs Cunningham) I think it is more difficult for
member authorities perhaps than for the Association. Personal
experience for me has been around work on the Green Paper and
the need for there to be some consistency between policy messages
that are being received. If I can just give an example which is
within the Green Paper on Public Health, there is a recommendation
in there, at the local contract level, that local schools can
do much to develop the physical education of children at a primary
school level, yet we see that, from the National Curriculum, from
September, compulsory physical education disappears from the National
Curriculum, and that, for me, is a massive indication of the fact
that policy streams often, by default and by pressure of time,
are developed in isolation from each other. The mapping exercise
that I described for funding could also usefully be undertaken
for policy. I know we are in an agenda of major change but I fear
that we run the risk of ending up with a fragmented policy picture,
if we are not very careful. Certainly, the Association's move
to work in a corporate way, in response to Mr Gunnell's question,
and to look at things across departments has helped us to focus
some of those issues, and hopefully our responses will help Government
to focus at this stage as well.
583. Yes; my question in my mind was more related
to the individual local authorities than your Association, because
it is at the individual local authority level that you can be
more and more concrete. I am aware that you do discuss the funding
as an Association, but at the actual local authority level are
you satisfied with the influence you can have on policy and funding
linkages, or is this a source of frustration?
(Cllr Harrison) Actually, I suppose the linkages could
be better, and there are times, of course, because of the kind
of policies and if the funding is not adequate then you are in
danger of failing to meet your statutory requirements, and sometimes
that can be quite threatening, and we do, indeed, negotiate with
Government Departments on occasions such as that. Also, I think,
in relation to funding and policies, in relation to community
care, we find that recently nearly all the resources are having
to go into, if you like, the heavy end, and I find this frightening.
I would like to see greater emphasis on the preventive measures,
the measures I mentioned of the resource centres, because if we
had to close any of these resource centres, and many older people
go there and it has been mentioned to me by a care worker who
did not actually understand what the resource centre was about,
she was complaining that people were going, and she said, "Okay,
they are into their seventies, 75, or whatever, they're quite
able to walk, etc., etc., I don't know why they come here"
and that, of course, is the whole purpose of the centre, so that
is a need for training there. But I am convinced of one thing,
that if we withdraw the primary preventive measures which just
keep people together in a social way, old people, as they get
frailer, then what will happen is there will be an acceleration
of people from the lower need into the higher need, that will
accelerate, because you will find social isolation, all the indicators
and the predictors of poor health, they will come in sympathy.
And I think that we are at a stage right now, in social provision,
where we are having to put nearly all the resources, are indeed
going in, at the very, very heavy end, and we need to be very,
very careful about that.
584. Finally, I have focused on the relationship
between the authorities and the two Government Departments. To
what extent do you think the difference in the way the funding
is directed, in one case, directly from the Department of Health
to the Health Service, in the other case via another Department,
to what extent does that complication act as a barrier to collaboration
between NHS on the ground and local government on the ground,
or are you resolving the problems?
(Cllr Harrison) I think we are beginning to resolve
the problems. I think that the problems that we have had in relation
to health in recent years, and I think it is perhaps to do with
the recent history of the health authorities, health services,
have been cultural as much as anything. When I say cultural, in
the broadest sense, even the language was different, issues of
accountability, of methods of consultation, they are all completely
alien to the local authorities. And it has taken us, I have been
on the health authority four years, I think it has taken us about
five years recently, perhaps slightly longer, since community
care was implemented in 1993, I think it has taken us till recently
to really begin to get our act together with the health authorities,
and part of that really was cultural.
585. Do you think both sides are moving and
making efforts?
(Cllr Harrison) Yes, certainly; yes.
Mr Lansley
586. I suspect I should declare an interest,
in that I am an Honorary Vice President of the Local Government
Association, but strictly honorary, you understand. Could I move
on to winter pressures, because, obviously, the availability of
additional financing to accommodate winter pressures gave rise
to some interesting issues about joint working between health
and social services departments. First, to what extent is it your
experience that the availability of additional funding not only
enabled additional activity but actually promoted new joint ways
of working?
(Mrs Cunningham) If I may, Chairman. We welcomed the
significant additional funding, and particularly in terms of its
timing, because it came at a time when many authorities had developed
a history of joint working, so it went into that context of collaborative
working. I think there are very good examples of its innovative
use, jointly, by local authority social services departments and
health authorities. A number of very concrete, if I may, examples
of that, of how that collaboration can be facilitated by targeted
funding. I would have to say that we have had a very mild winter
and perhaps the shortfall in expected demand has had its part
to play in how winter pressure monies has been used. One area
where I think we can see a fairly major positive shift is in the,
if I can use the euphemism of bed-blocking that is so popular;
whilst we have no national definition of a blocked bed and figures
produced by colleagues within the health authority were often
produced without an agreed local definition of what a blocked
bed was, and were then disputed by local authority social services
departments, was not helpful in dealing with delayed discharge.
Increasingly, we are finding that there are local agreements around
delayed discharge, and winter pressure monies has done a lot to
help that. But now that we have regular reporting of figures on
delayed discharge to regional health authorities and that these
are required to be agreed with directors of social services, have
actually brought us, through the winter pressures money, to a
position where people are positively, collaboratively approaching
the issues around winter pressures and pressures on beds.
587. I wonder if it is possible to separate
out, because you have given an explanation of the way in which
winter pressures money assisted what was often pre-existing joint
working but not necessarily joint working with available budget,
but to what extent can you separate out the extent to which the
availability of ring-fenced money, in effect, permitted joint
working that would not otherwise have taken place?
(Mrs Cunningham) I actually do not have information
about individual schemes with me, but we would be happy to supply
that for the Committee, if that would be helpful.
588. But overall is it your impression that
this, in a sense, when responding to the previous question, you
suggested that much had already occurred, and indeed it is my
experience, much had already occurred within local authorities
and health authorities to plan for winter pressures, but this
did not necessarily mean that either of those authorities felt
they had the necessary resources to implement those plans?
(Mrs Cunningham) What I think you will find is that
there have been very locally responsive, innovative projects developed
to respond to the preventive side of looking after particularly
older people in the community, which prevents their falls, admissions
to hospital, that then cause the problems at a later stage. There
are very good examples of those sorts of innovative projects at
a local level, which could not have been developed without additional
targeted funding, or would not have been developed around that
area or that service user group without that additional targeted
funding.
589. But looking forward now, to what extent
is it necessary for there to be top-sliced or ring-fenced money
related to winter pressures in order to require local authorities
and health authorities to sustain joint working to deal with winter
pressures?
(Mrs Cunningham) That is a difficult question to respond
to, and one that I would actually like to ask member authorities
what their view locally is.
590. Councillor Harrison has an instinctive
view about this?
(Cllr Harrison) Yes. First of all, in Manchester,
the money enabled us to reduce delayed patient discharge from
130 to nil, to zero, and that was very useful, but, as a consequence
of that, it has also triggered off much closer working, we did
not just take that as a one-off, as a winter, I think the work
and the co-operation has got to be ongoing and has got to be rolled
out. We have got about three projects, we have got intermediate
teams working at GP practices,—
Chairman
591. This is a consequence of the winter funding?
(Cllr Harrison) No, but it is accelerating pilots,
they are pilots.
592. I think it would be helpful if you could
explain how the money was used in Manchester, because I think
many of us are interested in learning how it was applied?
(Cllr Harrison) We had the intermediate care team,
with the local GPs, that was one of them, that was in a particular
area of south Manchester. The short-term assessment and rehabilitation,
what they call Star teams, that was along with the Mancunian Community
Health Trust. And they had rapid response teams. And, the pilots,
they have all been proved successful and now they are beginning
to be rolled out, right across the City; but these were essentially
pilots, there is no doubt about it, they were influenced by that
money there, and the need, and the consequences, the success,
actually, now has meant that we are going to roll it out right
through the City.
Chairman: It strikes me that Andrew's questions
have taken us on to the issue of pooled budgets, which I know
he wants to address.
Mr Lansley
593. I am moving in that direction, I promise
you, Chairman, but I think there is an intermediate stage, if
I may, which is that, of course, one of the problems that is much
referred to is that of cost-shunting, but there is also the question
of the extent to which budgets follow costs, and one of the sentiments
that has been expressed in relation to winter pressures money
is that it is Health Service money that is being used essentially
to pay for social services costs. Now to what extent do you think
it is appropriate in future for there to be a continuing route
of money through Health Service sources in order to meet pressures
that are eventually accommodated through expanding social services
accommodation?
(Cllr Harrison) We do know that in winter there are
indeed pressures, but I would like to see development of the teams,
the combined teams, quick response teams, the intermediate teams,
etc., I would like to see a development of them that anticipated
the winter so it should not come as a surprise, winter should
not come as a surprise to the services and they should be adequately
organised in order to meet that. That is what I think the objective
should be.
594. If you will forgive me pressing this one,
let me be more blunt. Do you think that over time what are, in
effect, social services costs are increasingly being accommodated
through Health Service money, and would it not be more rational
for the social services themselves to receive that budget provision
rather than for it to be redesignated health money and then provided
to the social services departments, through health joint agreed
plans with the Health Service?
(Mrs Cunningham) I am sure most social services departments
across the country, if not all, would welcome any additional resources
that were made to them to help meet some of their costs. I think
what winter pressures money has done, by the route of its funding,
is ensured that issues relating to winter pressures are approached
on a collaborative basis, because of the nature of the route of
the funding. I think that if health improvement programmes deliver
in the way that we would hope to see them deliver, that will require
collaboration at a level which means that that sort of circuitous
route for funding becomes unnecessary. Does that answer your question?
Mr Lansley: Somewhat.
Mr Gunnell
595. I will ask a question on this area, which
came from a specific letter which I had from a constituent, who
wrote to me, which is fairly rare, actually, to write to me praising
a particular service which he had received, which was basically
an after-care service, and he had recognised that what had happened
was that a particular mental health team had been strengthened
as a result of the winter pressures funding. Now his understanding,
and I have taken this up directly with Alan Milburn, but he said
specifically that he understood that when the winter pressures
money finished this team would revert to its normal size, and
therefore he would not have got the help that he got if he had
not been asking for it at a specific time. And I am wondering
what the Local Government Association is doing with its members
to advise Government of the success of particular schemes, and
urge that there is planned further funding to ensure that those
schemes which have been a success are actually maintained; is
that something which you have taken initiatives in?
(Cllr Harrison) I would like to think that that would
happen. I said earlier on that far too many people are still being
placed in residential homes, and, I think, as a consequence of
some of the pilot schemes that we have developed, the intermediate
scheme, the quick response schemes, etc., as a consequence of
them, these are schemes that are supporting people in their own
homes, in hospital, or, in some cases, they might be in danger
of being put in hospital and it is not really necessary, they
are being supported in their own homes. And, there, we should
be looking at liberating resources that otherwise would have gone
into residential homes, and we should be using those resources
in a much better way.
596. You would not see a role for the Association
actually in collecting such examples of significant improvement
in practice that have come as a result of the winter pressures
money, to make sure that that experience is not lost and is something
which can be followed up?
(Cllr Harrison) Yes, and it has also created a very,
very positive environment for the local authorities and the health
authorities to work closely together, and the fact that we are
able to work successfully is very, very good, it is very positive,
they are all pleased with themselves, and it can only be to the
good.
Chairman
597. Before I bring in Andrew Lansley on pooled
budgets, which is a logical next step in terms of where he was
raising questions on the winter pressures issue, can I take you
back to the first question that I actually asked you when you
came in, which was why your Association had taken a different
position from certainly what the AMA position was, and I suspect
possibly, Councillor Harrison, what your personal position still
is, in respect of the relationship between local government and
health, going back to the example that I gave you of the primary
care setting that we visited on Monday of this week. And I mentioned
that we saw an excellent example of the social services care manager
working within a practice, and carers saw this as a one-stop shop
of access to a range of services, it was a good model that we,
well I certainly was impressed with, my colleagues will speak
for themselves, but the barrier to that being extended was, of
course, the different budget heads, one being local authority
and one being health. Now you are, in having shifted your position,
not your personal position, Councillor Harrison, but the Association's
position, from a number of years ago, into pointing towards the
model envisaged within the NHS White Paper of social services,
having a similar presence to this model we saw in Dorset, in future,
elsewhere in the country, we still remain with this problem of
the two separate budgets, and the difficulties that you, as a
social services chair, face in improving the system, because that
improvement, in the way we saw in Dorset, hammers your budget.
The ability to undo the bed-blocking problem lands you with a
difficulty, when you have had a care assessment, of funding the
care placement, where that may be; how do you get round that,
on the basis of your changed position, as an Association?
(Cllr Harrison) It is very, very difficult, and, I
would say, in the ideal world, of course, it would be that the
budget would be a pooled budget, for health and social services,
in order—
598. You would favour that, but how would you
bring that about; this is partly overlapping, perhaps, what Andrew
Lansley wants to raise, but how would you, having argued against
one common organisation, which you clearly do, how would you have
a pooled budget between two separate organisations, how would
it work, particularly when you have got two separate statutory
frameworks, one of which envisages free provision at the point
of need, the other which is means-tested?
(Cllr Harrison) Actually, that would be difficult.
Just on a point, organisationally, again, the ideal, organisationally,
would be that the local authorities, when I say local authorities,
I think now I would have to have a look at what local authorities,
the size of local authorities, whether it would be a sub-regional
or a regional authority should be the strategic commissioners
perhaps of health services. I have accepted that that was not
on the cards, so I take that as given, that it is not to be considered.
599. Is this because the message got down to
you that the leadership of the new Government did not favour that,
or is it because you feel that it is not a practical solution?
(Cllr Harrison) Because one of your Ministers now,
when he was a shadow, told us to forget it.
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