Examination of Witnesses (Questions 746
- 759)
THURSDAY 29 OCTOBER 1998
MR TOM
LUCE CB, MISS
HEATHER GWYNN,
MRS ELIZABETH
WOLSTENHOLME AND
MR MARK
DAVIES
Chairman
746. Colleagues, may I welcome you to
what is the final session of this inquiry and may I particularly
welcome our witnesses. May I ask you, Mr Luce, if you would introduce
yourself and your colleagues to the Committee.
(Mr Luce)
Thank you very much, Chairman. I am Tom Luce, Head of Social Care
Policy and one of the Joint Heads of the Social Care Group in
the Department of Health along with Denise Platt, our newly appointed
Chief Inspector of Social Services. Elizabeth Wolstenholme is
in the Health Services division of the Department with a special
interest in issues around the interface between social services
and health. Mr Mark Davies works in a social care branch which
shares Mrs Wolstenholme's interest in these interface issues,
and Heather Gwynn is from the White Paper Implementation team.
Perhaps I could take this opportunity of saying, Chairman, since
it is a new development since you last saw people from the Department
in connection with this inquiry, that we have had a modest but
interesting evolution of our own internal structure in that we
have created a new joint unit that bridges the social care and
health service sides of the Department to be responsible in particular
for key strategic issues on the interface between the two sets
of services and will also as necessary deal with public health
matters.
747. Thank you very much. May I begin by
referring to the fact that since we last met as a Committee formally
taking evidence the Partnership in Action document has been introduced
which gives us a basis for a number of our questions today. I
would like to begin by raising a general point about the introductory
philosophy that is set out in paragraph 1.5. The clear message
is that major structural change is not the answer, no intention
to establish new statutory health/social service authorities and
a suggestion that this would involve new bureaucracy and would
be expensive and disruptive to introduce. My difficulty in looking
at how the proposals would work in practice is a concern that
we will have different structures in different parts of the country
which would cause some confusion. I am not arguing against flexibility.
I think this Committee has picked up in this inquiry the importance
of flexibility. How would you as a Department address the fact
that there will be by the nature of what you are proposing some
markedly different arrangements in different parts of the country?
(Mr Luce) I think that when the new flexibility powers
become available after the necessary legislation it is inevitable
that the nature of the arrangements between health and social
service authorities will be somewhat different among different
parts of the country but they will be using, if I may be permitted
the phrase, well known brands of structural flexibility. There
are three particular structural flexibilities that are outlined
in Partnership in Action. Where the new flexibilities are used
they will correspond always to one or more of the different types
and they should be readily identifiable as such. There is of course
already under the existing arrangements a great deal of flexibility.
There is a great deal of difference between the arrangements that
exist between health and local authorities and I think in some
ways it is difficult now to capture exactly what they are. There
are joint commissioning teams in many places but not in others,
there are joint commissioning teams for some services but not
others, and there is a variety of less formal, less easy to capture
and describe arrangements for working between the two sets of
authorities. I would expect that the new flexibilities when they
come in will be at least as clearly recognisable as time passes
to all concerned as the existing arrangements are and in some
ways there might be a greater clarity of structures and greater
ease of identifying what the particular structures are.
748. You clearly have ruled out any possibility
of going back to a structure not dissimilar to that which applied
right up to 1974. You experienced that structure as I did and
that structure to me simplified a good deal that is complicated
by the documents that we have before us. Why was that structure
ruled out as being a non-starter from your point of view? I know
that the Secretary of State has responded on this previously but
when I look at HIPs, HAZs and so on and all the various arrangements
that are in here, we seem to be making a dog's breakfast of some
fairly simple issues. We had a straightforward structure that
addressed all this pre-1974 with all these complications since
then. It might be part of my mid life crisis but we seem to have
lost it really and we are complicating a fairly easy solution.
(Mr Luce) I should just say that my own professional
experience of that structure started only in 1972 when I joined
the Department of Health, at which time there were not many interests
in the Department or indeed outside of it who seemed keen to defend
the pre-1974 structure. On the key point there is not a lot I
can add to what the Secretary of State said, that he was absolutely
determined to avoid major structural alteration that would mean
that the health and social services spent a year or two waiting
for legislation that was going to change the face of the map in
their services, and then spent another year or two in the implementation
process, all the business of defining jobs, defining new authorities,
perhaps competing for jobs that people already held. Ministers
have made it absolutely clear that they did not want to go down
that route. Given the nature of our reference perhaps I could
add a couple of points. One is that though I think many people
would regard the 1974 structures as having a good deal going for
them in an overall sense—
749. The pre-1974 structure?
(Mr Luce) Well, I mean the post-1974 structures, in
the sense that they did bring the responsibility for health service
provision under one authority and they did put the responsibility
for social services provision under another authority so that
those two blocks of services could be planned out as coherent
entities. One of the lessons that have been learned over the years
is that that structural reform, the 1974 structural reform, which
had a very heavy emphasis on macro structural change, delivered
some but not all of the objectives that had been hoped from it.
750. I am not disagreeing with you. It was
the pre-1974 structure that I was referring to where we had a
coherent health policy in local government which avoided the need
for all sorts of initiatives, trying to get people from different
agencies working together, because they were all in the same agency,
including the community health services.
(Mr Luce) One of the purposes of the 1974 changes
was to bring the community health services and the hospital services
under one agency, particularly at a time when it was expected
that there would be, as there has been, a big shift away from
hospital to community services and, in particular in mental health
and kindred areas, quite a lot of hospital closures. Whatever
the merits of these past structures I think that one of the lessons
that the Department has learned is that behavioural issues in
these interface areas and incentives are just as important as
the macro structures and the purpose of Partnership in Action
is to give people a wider range of structures through which they
can work to achieve the objectives of close working together.
Ministers have been absolutely clear that that was the route that
they wanted to go down and Partnership in Action is one of a considerable
number of follow-up initiatives or new initiatives that have been
taken since the Secretary of State was last here.
751. Taking account of the point you have
just made about the coherent entities that you referred to in
relation to health and social services, the one very clear message
we have received in evidence is that those coherent entities in
practical terms do not exist in local areas. No-one can separate
those entities and, as you are well aware, I put to the Secretary
of State a question about how he separated the social care/health
divide. He was very honest in his answer and said that you cannot
offer, as he put it, a definitive definition. You cannot do it,
and yet within this document we retain quite clearly means tested
social care services and free health services. That to me is a
fundamental issue that the Government appears to have ducked out
of addressing and it is a fundamental issue in relation to working
together. As long as that means tested barrier exists there will
not be the fluid movement of the kind that is talked about in
this document because as we found in our evidence, in our visits,
the means testing arrangements act as a barrier to joint working.
Various people have come up with some very innovative ways of
getting round the barrier, I suspect in some instances quite illegally,
and I would not wish to embarrass them by telling you which authorities
are doing what, but we commended the fact that they were doing
this because they were giving a service to people by virtue of
finding a way round this current difficulty. This consultation
document re-states the fact that there will be means tested social
care alongside free health care, so we still have not addressed
the fact that that is the fundamental barrier to working together
as far as we can see at a local level and a disincentive to community
care in some instances.
(Mr Luce) You did have a discussion on this with the
Secretary of State also when he was here. I do not think there
is a great deal that I can add by way of general comment to what
he said. It is of course the case that this situation has existed
in principle since 1948. The Government set up a Long Term Care
Royal Commission to look at this amongst other issues in the long
term care field. What our reading of this situation would be is
that in spite of this difference, which is clearly a significant
matter, no-one could deny it, there has been, even under the present
structures, a good deal of successful collaborative work which
does involve having joint teams, it does involve having joint
assessments, it does involve having joint commissioning, and the
purpose of the Partnership in Action proposals is to allow the
structures to develop so that that kind of working can continue
to be developed and indeed given a new lease of life. The charging
issue is without doubt a significant issue, it is an awkwardness,
but it has not inhibited proper joint planning and provision where
there is a will to do it, and we do not think that there is any
good reason why it should in the future. Nor do we think that
the existence of the charging issue will subvert the intentions
of the Partnership in Action proposals. There is as I say already
evidence from the collaborative work that has occurred under the
present structures, inhibiting (structurally speaking) though
they are, to suggest that it can be overcome, and we think that
it will be overcome under the new structures and that it will
not mean that the benefits of the new structures are significantly
subverted or prevented from happening. There is in Partnership
in Action, as I know the Committee is well aware, a commitment
to draw up guidance on charging. I am talking particularly here
of domiciliary charging once the Royal Commission has reported
so that at the very least, whatever the situation then is and
whatever that guidance exactly says, people will not have to spend
a whole lot of valuable time in each locality re-inventing locally
a charging policy. I think we do recognise that the absence of
any clear guidance, for example on what types of income should
be brought within local charges, is something that quite a number
of local authorities and others find problematic, and I think
it is the Government's intention to address that once the Royal
Commission has reported and its recommendations on this point,
whatever they turn out to be, can be properly considered and taken
account of.
752. It certainly struck me, in looking
at the evidence that we have picked up in this inquiry, that the
SSA assumes nine per cent proportion of social services income
comes from charging generally across the board. I cannot give
any figures but anecdotally we have picked up arguments that that
nine per cent really presents such a barrier and that it costs
more by virtue of the barriers presented by the charging that
it is not worth having the nine per cent.In one area we were very
impressed by a care manager working in a GP practice, where the
GPs, carers locally and patients were very happy with the way
in which the care manager from social services, based in a GP
practice, was able to do urgent community care assessments and
get resources for people either in the community or in institutional
care in the community without bedblocking. We were very much aware
of the fact that the social services could not extend that policy
elsewhere because of the cost to social services, despite the
savings to the health service of course. If you are knitting your
own Department together you must be aware of the way in which
this nine per cent assumption, wherever it is in cash terms locally,
is probably costing a lot more in the NHS by the barriers that
are erected by that requirement for charges preventing a flow
of people from hospital or wherever into community care. Is that
not an issue that the Government should have looked at?
(Mr Luce) I do not have all figures in my head but
the overall receipts to social services from charging, if you
include the residential sector, are I think somewhat more than
nine per cent.
Dr Brand: Oh no.
Chairman
753. That is the assumption on SSA calculations;
we understand that.
(Mr Luce) If it were demonstrable that collecting
these charges where they are collected was proving obviously and
demonstrably cost ineffective across the spectrum of services
as a whole, then that would be a significant factor in the development
of future charging policy in the light of the Royal Commission's
recommendations when we have them and know what they are and any
other analysis is done. I think the Audit Commission is doing
some work on charging as well.
Audrey Wise
754. I was going to make the same point
as the Chairman but then the follow-on is, before making any pronouncements
about continuing present policies, has the Department done any
analysis of costs, and it is not necessary either to say across
the board you can quite neatly separate residential and domiciliary,
and I think that we picked up that the income from domiciliary
services is pretty low and yet can have a disproportionate effect.
I wonder: has the Department itself looked at the significance
of the income in relation to the turbulence and resistance it
causes?
(Mr Luce) We have over the years looked at this issue
from time to time. We have not found any evidence that the power
to charge is seriously cost ineffective in its consequences and
of course it is a discretionary power in the hands of local authorities.
If there were to be a situation locally in which it was clear
to the authority that the revenue from domiciliary charges did
not justify the costs of its collection or other adverse consequences
then they would be able not to levy the charges or to levy them
in a different way or at a different level.
755. But that is missing the point. The
saving is not necessarily to the Social Services Department. It
is not necessarily the case that it costs more than you are getting
in. It may be that if you look at the provision in the round that
is the NHS as well, there can be savings. The Social Services
Department is not going to do that on its own. It is going to
look at its own budget but has the Department looked at that kind
of meshing?
(Mr Luce) It was the overall system, the overall effect,
that I commented on in my first reply on this point. What we would
say is apart from the fact that there is a Royal Commission that
is looking at the general issue of charging in the context of
long term care overall and there is other work going on by the
Audit Commission, that these structures in Partnership in Action
would provide a clearer and better context for looking at issues
of that kind locally than now exist. For example, the pooled budget
concept would enable those concerned to address that matter locally
if they thought it was a significant factor.
756. You have two points of a triangle and
the point that is being missed out is the interaction with the
service user and the resistances that can be built up in the service
user's approach. We are all very keen on social services and the
NHS getting much cosier together, but that has still got to integrate
with the third point, the service user. Really I think, Mr Luce,
that your answer is that the Department has not actually looked
at the effect of charging on the overall cost effectiveness of
the two services.
(Mr Luce) My answer is not quite that if I may say
so. The Department has not, at any rate not in recent years, done
a large scale survey or study in depth of the consequences of
charging. Certainly so far as the last year or two are concerned,
that is because the Government set up a Royal Commission to look
at long term care funding arrangements generally. What I think
I would say about the user dimension is that there is a good deal
of emphasis in Partnership in Action as in other material from
the Department that is relevant to service users, in particular
the way in which the health improvement programme should be taken
forward in each locality, that the service user interest is seen
as extremely important and through the combination of the Partnership
in Action proposals and the health improvement programme arrangements
we would expect that the voice and interests of the service users
would be brought very well into these arrangements, the new collaboration,
the new interface arrangements, and that if that was one of the
points that emerged from the involvement of service users, then
within these structures and within these new arrangements there
would be a good opportunity to have that point properly taken
account of, properly assessed and given proper weight in the arrangements
that were put together under the Partnership in Action flexibilities.
757. You said, Mr Luce, that there has not
been a substantial examination of this point in recent years.
Has there ever been? Can you give us an idea of how long we have
to go back for such an examination, if it has ever been done?
(Mr Luce) I can only speak for the last eight years
personally. There has not been during that period a substantial
in-depth examination of the charging issue. The Department has
looked at it from time to time, it has looked to see what the
trend of the revenue consequences of the charging powers are,
it has looked to see how far there are differential charging patterns
between different local authorities, but it would be fair to say
that at any rate over the last eight or 10 years the Department
has not done an in-depth examination of the charging issue. We
did for the last Government a good deal of work on the financing
of long term care generally and the last Government did produce
some proposals, the partnership scheme proposals, as a consequence
of work done in the Department of Health and other parts of Government
during that time. They were all published. When the present administration
was formed their commitment was to set up a Royal Commission into
long term care and the funding of long term care and its report
is expected around the turn of the year.
758. I had in my mind very much the domiciliary
aspect when I was questioning you, but there is the other aspect
of nursing homes. In paragraph 4.36, in saying that there are
no barriers to independent sector providers offering both nursing
and social long term care, it goes on to say that a common form
of integrated provider is the independent sector nursing home
whose services span the health and social care interface. We have
on occasion looked quite thoroughly at this. In spanning the health
and social care interface one of the effects is that part of what
is really normally, certainly by service users, regarded as health
care, ie nursing, slips over into being charged for so that nursing
homes are the only areas in which nursing care is charged. It
is free in hospital, it is free at home, it is charged in nursing
homes. It is one way of spanning the interface but it is not a
very good way in my view. In writing that paragraph has any thought
been given to for instance previous recommendations of this Committee
that it is fine to integrate but that that charging effect should
not be one of the results?
(Mr Luce) The Department and its Ministers are very
well aware of this issue. My best answer has to be that it is
one of the issues that is within the terms of reference of the
Royal Commission. What we would feel inhibited from doing I think
on a point of that kind rather than a more general issue of service
development policy is expressing a view or having a policy or
a new policy on that issue in advance of the Royal Commission's
report and its consideration by Government and other parties.
Julia Drown
759. In the Partnership in Action document
you have said how you are preparing guidance for next year to
make sure there is more consistency in charging. Clearly you have
got to wait for the Commission on long term care's to come out.
Am I right in thinking that the Department is going to want in
that guidance to get rid of the rather large anomalies we have
across the country, for example, with domiciliary care where in
some parts of the country people are being charged hundreds of
pounds a week for their domiciliary care, and then in other areas,
such as Northern Ireland where it is free? Is that sort of anomaly
going to be ruled out by the guidance?
(Mr Luce) It is a little difficult for me to answer
the question what the guidance will say because until the Royal
Commission has reported I think we have to be completely open-minded
about what it will say.
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