Examination of witnesses (Questions 680
- 699)
WEDNESDAY 6 MAY 1998
RT HON
FRANK DOBSON
MP, MR PAUL
BOATENG MP SIR
HERBERT LAMING,
MR ALAN
LANGLANDS AND
DR SHEILA
ADAM
680. I was not suggesting that somehow they
should turn their backs, but we should actually transfer those
resources from the local authority into the primary care group
and, as we talked about in the Bournemouth example which the Chairman
was talking about, here you had social services in a practice
saying, "This is what the patient needs, so why is it necessary
for that to be the resources of the local authority? Why should
it not be the resources of the National Health Service?"
(Mr Boateng) Well, I think I would respond to that
specific question within the overall response I make on the issue
of the Social Care White Paper because what we seek to do is have
a holistic approach to the work of the Department, so it is important,
I think, to recognise, and the White Paper on Social Care will
make this absolutely clear, that you have three legs to the stool
in that you have got the NHS White Paper, the Public Health Green
Paper, and the White Paper on Social Care, all meshing in with
each other, an integrated, holistic approach. So you are not having
conflicting social and medical models, you are having a health
model. All the evidence is that a health model is indeed a holistic
one, and therefore we anticipate the White Paper will set out
a vision for the next century about social care and the role of
those who deliver social care as a service, and that role will
be seen in many areas as being complementary to the role of the
health and clinical worker. Let me give you a practical example
to link in to your question about the work of the primary care
groups as they develop into trusts—rehabilitation and recuperation.
If ever there was an area which called for an integrated approach
between health and social care, that is it. The clinical evidence
shows, in relation to strokes and elderly people, that they do
in fact recover better in a domestic, homely setting than on a
ward. If that is the case, we want to see health and social care
workers working in tandem around the needs of that patient. Mrs
Wise correctly, with respect, in my view puts the emphasis on
the patient, and what the patient needs there is a focused approached
from both sets of professionals and workers. One expects the White
Paper to provide a new focus for adult social work and social
work with the disabled around rehabilitation and recuperation.
When you look at how the primary care group would operate in that
setting, that is an ideal area for the health improvement programme
which will be developed with the input from social services and
from users to set that out as a local priority. It may well be,
without anticipating questions from the Committee, that this is
an area that will be serviced by a pooled budget, in which the
current rigid demarkation lines and the difficulties that local
authorities have in, say, spending what is determined as health
money and vice-versa will be overcome. But it would not be helpful
if you are dealing with rehabilitation and recuperation to look
to some new entity to deliver that, because if you were to do
that you would have a new boundary in relation to, say, housing.
The work you are going to need to do there, where the local authority
works with the GP and that whole team, can take the issue forward
together with the local authority in its corporate role. So I
would expect the NHS White Paper, the Green Paper and the White
Paper on Social Care, to make that clear, not least, and in conclusion,
in the area of how you train workers in this area. You know we
have a national training organisation developing for health, a
national training organisation for social care, the Secretary
of State has made it clear that he will expect the heads of both
those national training organisations to report to him once a
year jointly as to how the work of those two training organisations
is in fact developing, because you need to train a workforce to
deliver the domiciliary care in a complementary way. The White
Paper will be spelling out the relationship between the NTO and
the general social care council, so it is addressing it at all
those levels.
Chairman
681. Can I pick up a point about the previous
debate which went on over a number of years with regard to the
possible transfer of health into local government? I recall that
the Labour Party produced a policy document called Health 2000
which included that as one of a number of possible options. It
certainly was the policy of the AMA until relatively recent times
and when we had the Local Government Association witnesses last
week I specifically asked them why their organisation had apparently
changed its position, were there merits in alternative arguments,
and the answer I got in terms of the previous model was they dropped
it "because one of your ministers now, when he was shadow,
told us to forget it". Why? Bearing in mind that no one is
able to define the boundaries and, with respect, Secretary of
State I do not think you have and I think you are accepting you
have not today—
(Mr Dobson) I do not think there is one, that is why.
682. You say there is not a boundary, so how
come we have separate organisational structures? The Parliamentary
Under-Secretary mentioned separate training bodies between health
and social care. The feature I get certainly, as one member of
the Committee, is that these boundaries are no longer there and
we are accepting out-dated models, that we are training people
as social carers or health workers and they are actually going
broadly in many respects the same job, and no one can define where
that boundary is. So are we not in a sense in danger of coming
up with a botched-up job rather than radically looking at what
is a serious problem which is not going to go away?
(Mr Dobson) I think I am probably the person who told
them to forget it, so I will not mince words about it! My own
view is that the chances of the Labour Party subscribing to the
view that the National Health Service should be taken over by
local authorities is very small.
683. Can you tell us why, from your point of
view?
(Mr Dobson) Because, for a start, the Health Service
is sick to death of being reorganised and reorganised and reorganised,
quite frankly. In those circumstances what we have to do at the
moment is to address the problems which we see and the shortcomings
we see in the present organisation of the Health Service, and
make the minimal changes necessary to bring about the improvements
we are seeking. To go wider than that and start talking about
a whole new way of running the Health Service would, I think,
just throw all the balls up in the air and in the meantime the
12 million people who are referred to out-patients might not be
the first priority in the minds of people who think, "Oh
my God, I am going to have to reapply for my own job yet again
for the fourteenth time in 20 years." That is one of the
reasons why at least for the time being—and the time being
may be fairly lengthy—they ought to forget it. The context
of that discussion which I had with people at the AMA was that
I was very keen for them to take a bigger role in promoting public
health than they appeared to be interested in. When we produced
the Labour Party's policy document on local government it was
I who wrote out the whole lot, but the important phrase in relation
to what we are talking about now was to place a basic duty on
all local authorities to promote the economic, social and environmental
well-being of their area. That seemed to me to place a duty on
them to address the things which systematically make people ill,
and also there would be a duty to co-operate with the Health Service
and any other agencies to promote the health of people in the
area. The trouble with all this talk about boundaries—and
there is rightly concern about the boundaries, I am concerned
about the boundaries between social services, social care and
the National Health Service, and I want to break them down in
practice whatever the theoretical arrangements are—wherever
we look there are boundary problems. You could argue that there
are quite a few boundary problems within the National Health Service
between certain professions actually dealing with the patient.
So I do not think a major structural change would necessarily
address the problem. I simply do not think there is a readily
definable boundary in the end between social care and the social
care end of medical care, of health care, just as there is nobody
in the end who can, other than by statute, define where doctoring
starts and nursing ends.
684. Whilst you reject the radical suggestion
which has been put to us by at least one organisation, as you
are probably well aware, whilst you reject the model of moving
health to local government, would you not accept that a part-way
arrangement would be some common budget-sharing which avoids this
nonsensical dispute over, well, the community bathing thing is
probably the best example we have got, but there are many, many
others of where a discharge is held up for the lack of a ramp
or something like this, and surely that is common sense and that
overall it must save the Government money because money is wasted,
as you have accepted, with the winter pressures initiative by
people wrongly being in acute care who do not need it, so surely
there is a huge amount of money to be saved? If one only looks
at it from the point of view of the economics, it makes sense
to have common budgets, and I know that John Gunnell wants to
explore this in a moment or two, but is that not an area that
you would look at favourably in the future?
(Mr Dobson) Well, in effect the arrangements which
we made for the winter provided, in practice, common budgets over
a certain area and there was, as will be described in European
institutions, a degree of co-determination of how the money was
spent, quite rightly, and about a fifth of the money which was
made available to health authorities was spent on social services
and that was done. They had to put together schemes which involved
the local council at a regional level, the NHS regions, and Sir
Herbert's regional arrangements for the Social Services Inspectorate
were also involved in identifying and sort of verifying the probable
effectiveness of the schemes that were being put forward, so that
was a short-term measure. It is our intention to introduce pooled
budgets and I think that that will be a big step forward.
685. But did I misunderstand you because the
last time that you gave evidence when this issue was raised, you
indicated that that would require primary legislation?
(Mr Dobson) Yes.
686. So it is your intention to bring forward
primary legislation in terms of establishing pooling arrangements?
(Mr Dobson) Yes.
687. Will this be as a consequence of the White
Paper?
(Mr Dobson) Well, I do not know whether it will be
in the White Paper or not, but Paul probably does. Will it?
(Mr Boateng) It is our intention in the next few weeks
to issue a consultation paper around issues of pooled working,
pooled budgets and greater flexibility of working as between the
NHS and social services, but we anticipated in the NHS White Paper
that we will be bringing forward legislation on pooled budgets.
That is, as the Secretary of State has indicated, our intention
and this will also be reflected in the White Paper on Social Care,
but the NHS White Paper anticipated pooled budgets and it is something
that we are actively working on, but I think it is important,
and I do not want to anticipate Mr Gunnell's contribution, to
recognise that pooled budgets are a tool. They are not a magic
wand, as I think many around this table know only too well and
there has to be the will to work with them. What the Secretary
of State has initiated in his response initially to the winter
pressures and then carrying that forward is beginning to influence
the culture and the mind-set that in the past has sometimes militated
against successful joint relationships, but that is changing and
pooled budgets will be there as a tool to help in that process.
(Mr Dobson) Can I just say on the pooled budgets that
they ought to make it easier for people who genuinely want to
co-operate, but there are stupid people around who are virtually
incapable of co-operating and the existence of pooled budgets
will not make them co-operate.
688. What you are saying to us is that the example
that I gave to you earlier on of a practice within Bournemouth
where there was a problem of spreading this excellent practice
elsewhere because of the lack of pooled budgets could be overcome
by what you are proposing to bring through in terms of legislation.
(Mr Boateng) Except that, if I may say so, Mr Hinchliffe,
I think many people, when confronted with good practice to be
translated from one area to another, find every reason under the
sun not in fact to adopt it and the lack of pooled budgets is
sometimes prayed in aid. As the Secretary of State has indicated,
where there is a desire at the moment to work together, in the
main the absence of pooled budgets has not prevented them doing
so. We have pooled budgets because they are areas, and I believe
officials outlined some of those areas, where it would help enormously
to have pooled budgets, but the lack of pooled budgets should
not be an excuse at the moment for not transferring good practice.
Pooled budgets will help take the agenda forward, but of themselves,
as the Secretary of State has indicated, they are no magic wand.
689. But you would accept in the example that
I have given you that it is perfectly reasonable for the Director
of Social Services to say, "I cannot afford to spread that
elsewhere" because she is picking up the problems of the
NHS? She is saving the NHS money, but it is coming out of her
budget.
(Mr Boateng) Well, if the pooled budget is an agreed
vehicle between health and social services to pool and use more
effectively the limited resources they have together, the answer
to your question must be yes.
Mr Gunnell
690. I have two questions. We met a second group
in Dorset which was really organised by the Community NHS Trust
there and they talked to us about a scheme which they have got
which appeared to be the one example I found where there was a
very good working relationship and that working relationship was
based on a rather long experience of working with one another,
but it did seem that the charging problem was largely overcome
in that arrangement. I rather thought that it was overcome by
the fact that where extra costs were required, the NHS Trust was
actually meeting the costs. Now, they gave us some suggestions
for improvements in joint working and one of those was that there
should be incentives for pooled budgets and where this occurs,
the requirement to charge clients for services provided should
be removed. Would you be intending that?
(Mr Dobson) I would need to think about it.
691. I certainly think that we did meet there
a group where charging was not an issue, I think, because in part
the social services person who was part of the team could manage
in many cases to deal with the charges, but where that could not
be managed, then the joint working and the way in which they were
working was so important to them that it was obvious that the
Community NHS Trust made up the charges. I hope you will think
about that because I think it is quite interesting.
(Mr Dobson) At the risk of being too honest for my
own good, I think it is probably right to say that there may be
problems over pooled budgets if the pooled budget is going to
be at the total discretion of the local authority as a whole to
spend it on things not to do with social services and things related
to health, and I am sure that the Local Government Association
will not like me saying this, but it seems unlikely to me that
either I or any future Secretary of State would be very keen on
putting money into a pooled budget that could then be dispersed
for purposes other than things related to the relationship between
the local authority and health and that would mean it would either
come down the National Health Service chain or if it went down
the local authority chain, there would be specific grants.
Chairman
692. And ring-fenced presumably.
(Mr Dobson) And ring-fenced.
Mr Gunnell
693. Can I ask you on that whether the way in
which you look at pooled budgets might mean that you might want
to establish joint statutory committees so that both health and
social services were actually involved in the decision-making
on the spending of the pooled budgets?
(Mr Dobson) Well, I do not know what the mechanism
would be and Paul may have some more advanced thoughts on it than
I do, but clearly there will have to be joint decision-making
of some sort, but at what level and what the machinery might be,
as I say, Paul is doing an enormous amount of work on the White
Paper and may be more advanced in his thinking than I am.
(Mr Boateng) This is an area very much where the NHS
White Paper, the development of the primary care groups and the
health improvement programmes and the work which is being done
at the moment around the preparation of the Social Care White
Paper, come closely together. The discussion paper I mentioned
earlier will be actively seeking the views of the Local Government
Association and others around this very issue because, as you
know, the current joint planning and decision-making arrangements
that exist between health and local authorities involving also
the voluntary sector are stronger in some areas than in others,
and deliver more in some areas than in others, and we want to
make sure that we get it right. But that duty of partnership is
there and in place anyway. So far as ring fencing is concerned,
it is early days yet to talk in those terms but undoubtedly one
of the ways in which one meets concerns that money should be applied
in this area in ways which will benefit community care and the
delivery of our priorities, is to look to the example we have
sought to set in the community care special transitional grants
conditions for this year, where as I say for the first time a
secondary condition exists in relation to make sure funds are
invested in services with the objective of improving joint procedures
for needs assessment and the like. So there are ways of using
conditional funding to drive this process.
(Mr Dobson) In addition to the point Paul has just
made, which I think shows that at every opportunity we are pressing
those involved in the system to get together and to work together,
when we were looking at how to reduce the winter pressures on
hospitals, which is what the winter initiative was about really,
we could have put some of the money into the Health Service and
some of it we could have given to local councils from the Department
of Health, but had we done that I could not have guaranteed it
would be spent on the things we wanted. Putting it through the
National Health Service meant the National Health Service locally
could then come to a joint agreement which required the local
council to do what we wanted with that money. Had I not been able
to do that, I do not think I would have been able to convince
the Chancellor of the Exchequer and the Prime Minister that the
money was going to be properly spent.
Julia Drown
694. Even where we have seen best practice in
terms of using winter pressures money people have said there are
still legal barriers to them carrying it forward, and I think
there would be a huge welcome for the idea of pooled budgeting
being developed. I wonder if you could give the Committee an idea
of the timescale on the grounds there would be more ability for
people to pool budgets and how that relates to the other work
being done on charging for long-term care? There is clearly an
issue here in that if new services are provided through a pooled
budget, is it something which would be charged for or not? The
other anxiety we have had raised about pooled budgets is that
it could just lead to fewer services being provided free of charge.
(Mr Dobson) If I may attempt to answer those in reverse
order. We have established a Royal Commission on long-term care
of the elderly but also looking at the same time at the long-term
care of other people, and we will not come to any decisions on
charging until we have got the outcome of their deliberations.
They are expected to complete their deliberations by the end of
this year, which would be a remarkable achievement if they bring
it about; a Royal Commission which has done a substantial job
of work and done it within a year. In the long-term, that is what
we will be looking at, their proposals. I cannot tell you, therefore,
what our timescale will be for the introduction of pooled budgets.
At this moment I cannot tell you whether we would be putting it
in the National Health Service Bill, which ought to be coming
up next session, or whether it will be later than that. But I
want to come back to the point that I am sure, even if we have
got pooled budgets, some council's lawyers will manage to convince
some councillors and some officers that even with the change in
the law there are restrictions on what they ought to be doing
because they do not want to do it. Coming back to my point, we
are in favour of pooled budgets because it will make it easier
for the people who want to do the job properly to do it properly,
but it will not guarantee they do it properly. It will be a necessary
but not sufficient contribution.
695. So you are saying you have to wait for
the results of the long-term commission before you would be prepared
to legislate on pooled budgets?
(Mr Dobson) Not necessarily, no.
(Mr Boateng) The important thing to stress is that
even in the absence of pooled budgets, there is a great deal practically
which can be done now.
696. Accepted.
(Mr Boateng) We do not intend to put this issue on
the back-burner pending primary legislation on pooled budgets,
pending any findings of the Royal Commission on long-term care.
We issued in October of last year, together with colleagues in
the DETR, Making Partnerships Work, which is about practical
advice and assistance for front-line managers and practitioners
enabling them to work that much better together. So we will be
going on driving that in terms of the way we seek to performance-manage
the NHS and performance-manage social care.
Mr Austin
697. One of the arguments put forward against
a changed structure of a unified health and social service is
that it merely creates a boundary elsewhere—on housing,
leisure or education. I certainly see the role of pooled budgets,
not as a pooling between social services and health but the local
authority and health, and I was very pleased that the chair of
the Royal Commission shares my view on the importance of continuing
with adult education, which in many areas is a very important
health promotion aspect particularly for elderly people. So when
we are talking about pooled budgets, I hope we are talking about
the totality of local authority provision in terms of leisure,
education, housing as well as just the social services.
(Mr Boateng) The response of this Government at every
level—in relation to health action zones, where obviously
we as a department have taken the lead, the youth offender teams,
where the Home Office takes the lead but where we have an active
input—indicates the emphasis we put on the corporate role
of the local authority. So it is the chief executive who convenes
the YOT, it is the chief executive who is envisaging having a
particularly important role to play in terms of the NHS-local
authority developing relationship as envisaged in the NHS White
Paper. So it is the local authority as a corporate body exercising
the role of corporate leadership.
(Mr Dobson) That is why we are proposing that in future
the chief executive of the local authority should attend the meetings
of the appropriate health authority, so that there is a feed both
ways between the local authority and the health authority, but
that it is done at a council-wide level and not just the social
services department. We did receive representations saying it
ought to be the social services director but we felt it was quite
fundamental that it had to be the chief executive and not someone
from a particular department.
Audrey Wise
698. I would like to explore a little further,
Secretary of State, the problem that you have touched on about
how Government money actually gets into the field. You mentioned
specific grants or ring-fencing, to use the modern jargon. I remember
when the change from specific grants to block grants was fiercely
resisted by all Labour councillors throughout the country—and
I can see you remember it too—on the grounds that this was
simply a device by which governments could pass the buck. I have
never ever adjusted to the hostility to specific grants, which
I think have a lot of advantages for both sides. However, the
way now in which money for health-related issues, as we agreed
social services often are, and in any case under the policy direction
of the Department of Health, the way the money comes is via another
department. Now, do you see this as in any way a problem and do
you feel that you can share with the Committee the mechanisms
which exist for the Department of Health to influence, for instance,
the setting of standard spending assessments in order to pursue
the Department of Health's policy objective in the local government
and joint health field?
(Mr Dobson) Well, it is certainly the case that in
the last settlement, we had a substantial hand in deciding what
the standard spending assessment for social services should be
for local authorities in the allocation round that is now under
way. I can remember taking part in those discussions and I broadly
approved, needless to say, of the outcome of those discussions
because it is only right, I think, that people at government level
have to look at not just the part of the budget for which they
have some responsibility, as we do for social services, but also
the relationship of that to other services, so I do not want to
talk too much out of turn or out of turn at all, I suppose, but
we were looking at things like whether we needed to put more money
into the Fire Service, and it seems to me a legitimate consideration
for the Secretary of State for Health to take part in that discussion
and decide with colleagues that the Fire Service, even in terms
of health, is very important and needed some more extra money
than some other services did in the coming year. In fairness to
local authorities, they have been spending well over, on average,
not all of them, but, on average, they have been spending well
over the standard spending assessment for social services for
a long time now and most particularly in relation to children's
services where in the last year they spent 23 per cent, or 22.9
per cent, to be precise, more than the standing spending assessment
for children's services because they chose to do so.
699. I can take your point about issues like
the Fire Service and of course housing and education as well have
a health bearing and certainly it is difficult to be healthy if
you have been burnt to a cinder, so I can see the relationships
there, but does not what you are saying expose the inadequacy
of the concept of standard spending assessments? I remember my
astonishment as a new or retreaded MP in the 1980s to find that
this did not actually involve any assessment of needs or costs
of providing the particular services. Do you think that in fact
it should be possible to introduce more genuine assessment of
requirements into the decisions which are made about the amount
of money which goes into local government? I am sure that you
do it that way far more with the direct funding of the Health
Service and can you ever see a rational system of local government
funding without some considerable change?
(Mr Dobson) Well, I do not want to get into the higher
theology of local government funding, partly because I do not
understand it and partly because I should not, but there is always
a problem if you try either in the allocation mechanism for the
grant to local authorities or the allocation mechanism to the
National Health Service to think that you can come up with some
all-embracing formula which will cover, adequately and fairly
cover, the circumstances prevailing in every part of the country
and I think that that is just statistical folly de grandeur
and so one of the reasons why I was saying I tend towards certain
specific grants to local authorities and also why we are looking
at the allocation mechanisms within the National Health Service
is to ensure that they are going to the areas most, in that case,
in health need. There is also of course the question as to whether
the basic statistics from each area, from the Census and things
like that, are themselves adequate or accurate.
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