Examination of Witnesses (Questions 760
- 779)
THURSDAY 29 OCTOBER 1998
MR TOM
LUCE CB, MISS
HEATHER GWYNN,
MRS ELIZABETH
WOLSTENHOLME AND
MR MARK
DAVIES
760. So can you give the Committee any idea
of what that guidance can then cover? The other thing is that
it would seem wrong to have a session without mentioning the bath.
Will the guidance similarly look at the other great anomaly we
have at the moment,where if you are given a bath by a nurse in
the community it is free, but, if the bath is given by a social
services worker, it is charged for? That seems to most people
not to be fair and will the guidance look at that?
(Mr Luce) I think that in all the circumstances and
given the symbolic as well as practical importance of the bath,
it is inconceivable that the Department of Health could produce
guidance on this subject that was not in some way addressed to
the issue of the bath. What exactly it will say, for the reason
I have given I cannot give any undertakings about, but the Committee's
previous exchanges, in particular those with Sir Herbert Laming,
did identify one principle which is that it is not who gives it;
it is what the need is and the nature of the need that is important.
I do not think that there is anything that I can helpfully add.
Mrs Wolstenholme may be able to add something. It is a little
difficult for us to say very much more about this subject than
two things. First of all the inclusion of the reference to guidance
on charging in the Partnership in Action document is a recognition
that certainly by perception the charging issue can be a handicap
to collaboration and what we would at the very least want to do
is, whatever the policy turns out to be when the Royal Commission
has reported and the Government has considered its report and
any other relevant material such as work that the Audit Commission
have in hand, that there should be some guidance which minimises
the dangers to proper collaboration from the charging issue so
far as that can be done.
Dr Brand
761. May I go back to domiciliary care rather
than allowing you to avoid an answer because we are awaiting a
Royal Commission (and I appreciate that) on the long term care
side of things. I am really quite astonished at your answer that
no work has been done on looking at the impact of charges on other
agencies within your Department, social services charges impacting
on the health service. You have just had a wonderful experiment
last winter with the winter pressures payment which I thought
had actually shown that the expenditure of that money and the
way it was spent in service delivery actually took a lot of pressure
off the NHS and therefore presumably saved a great deal of money
somewhere, or allowed work to carry on that could not otherwise
have been done. Surely that in itself is something that you should
be evaluating to see whether it was the extra money or the way
the extra money that was used had made it so successful, because
the evidence that we have got, going round the country,—in
Glasgow for instance it was quite clear that because the packages
could be put in at very short notice there was not this need for
an immediate means testing assessment so that hospital admissions
were avoided, hospital discharges were very much expedited. If
I can put a slight subsidiary to that, if we are going to have
pooled budgets and pooled responsibilities for service delivery
but we are going to have a lead agency, for instance if your primary
care trust is going to be delivering what may be traditionally
social services work, will they be obliged to charge? In my experience
as a GP it is extraordinarily difficult to get domiciliary input
any time after five o'clock at night or any time after two o'clock
on Friday afternoon. If you look at the pattern of admission to
hospitals, they tend to occur outside those hours. I would submit
that if I could put in £30 worth of domiciliary support sometimes
it could avoid an admission that might cost a thousand pounds
or more.
(Mr Luce) Perhaps Mrs Wolstenholme might say something
about the winter pressures, and it was certainly was a highly
successful exercise. I have to say that obviously Ministers will
look at all these points in the light of the outcome of this consultation
which is nearly but not quite complete now, and in particular
at the recommendations, whatever they turn out to be, of the Royal
Commission and it is quite difficult for me to say anything very
much in advance of that. Just taking things in terms of the present
situation, the flexibilities that are suggested in this document,
if the present policy on charging were to continue, the charging
policies have some flexibilities going with them anyway and people
are not obliged to charge. They can tailor their charging arrangements
within quite a broad discretionary power.
762. I am sorry, Mr Luce, but if you are
being underfunded by nine per cent to deliver a service on the
assumption that you are making up that money through charges,
it is really not much of a discretion.
(Mr Luce) It is a discretion in the hands of the individual
local authority and their charging practices are very different.
763. I think they all try to make their
nine per cent.
(Mr Luce) Not all of them do make their nine per cent.
Some of them make a good deal more and some of them make a good
deal less.
764. Go on.
(Mr Luce) I do not know whether Mrs Wolstenholme has
anything to say on the winter pressures.
(Mrs Wolstenholme) Only that I think it supports very
much the thinking that was behind Mrs Wise's question as well,
in that it was one of the first initiatives where we really were
requiring people to look across the whole health and social care
system and see where money here and service here might help capacity
there, and it does appear to have worked.
765. Yes, but that is why I am so astonished
that Mr Luce said that no work had been done in the last eight
years on what the impact of the spending money or not charging
in one part of the Department's responsibilities is on another
part of the Department. You have just done an enormous experiment
which I would have thought would have demonstrated that quite
clearly if you worked that through.
(Mr Luce) I would just like to say that I did not
quite say what you have attributed to me. I did not say that work
had been done. I said that it had been reviewed from time to time
and that we have not during that period found evidence of serious
distortion in the take-up of the cross-sector services. I think
that would be a fair way to put it. I did emphasise that these
were not reviews in depth and I also said that one of the reasons
that the Government set up the Long Term Care Royal Commission
to look at long term care and its funding is that these issues
are extremely complex and they do justify a serious look in depth
with the kind of authority that a Royal Commission has. We were
certainly extremely pleased by the results of the winter pressures
money, which was used through existing systems, including (where
they exist) charges. We thought that it was a very successful
exercise and that what it showed was that even within existing
structures giving people incentives and giving people money in
fact to improve work at the interface is a very well worthwhile
thing to do. The purpose of the main proposals in Partnership
in Action is basically to take that further forward to provide
new flexibilities in the structure to achieve those objectives.
The document does recognise that there is an issue about charging
which obviously we cannot resolve in detail this side of the report
of the Royal Commission and the Government's consideration of
it and the consideration of it by others.
766. It may be very useful if the Department
could do some work on whether the charging regime was different
in the winter pressure initiative than it was normally because
my understanding is that there was a great deal more flexibility
about putting services in and charges only being levied much later
than they would normally be. It would be helpful I think to the
Committee if we could have a note from the Department on that.
(Mr Luce) Fine.
Dr Brand: It was innovative and that is why
it worked.
Audrey Wise
767. Can I be sure what the answer to my
question was because I thought I was sure and now I am not? You
said on the point which I made, has there been a study of the
impact of charges in social services on other aspects, especially
the NHS, that there have been reviews from time to time and then
when I pressed you for when was there a substantial study you
said not for eight or 10 years. It is possible to have reviews
which are quite quick and apparently superficial, providing they
are picking up on a body of evidence which has at some stage been
collected. You do not have to start and do everything from square
one every time you look at an issue. What I was trying to find
was when was there the initial study which then you are reviewing
from time to time to see changes and so on. When, if ever, has
there been a proper study of the interaction of charges in the
way that we are exploring?
(Mr Luce) First of all I think I should say that the
issue of charging was very carefully gone into when the last Government
was producing its community care White Paper in 1989. It was also
gone into in the work that preceded that, the report by Roy Griffiths
and other work that led to that. If I may use the phrase, the
turf around charging issues was good and proper dug over at that
time.
768. "Dug over" and such like
colloquialisms are not really what I am after. Was there a quantitative
style of study which produced facts and figures which should be
in your files? You went in eight years ago and you should be able
to pick up on the information if there has been this study. I
do not mean dug over in general ways. I mean really looking at
does it prevent proper use of NHS resources because there is for
instance resistance built up in service users? What is the actual
effect? That is what I am after. I am not after has it been chewed
over in the Department or dug around. That is a different thing
altogether, but actual facts and figures, figures in particular.
I do not believe anything about money questions unless somebody
somewhere has got some figures.
(Mr Luce) Certainly the issues were on my understanding
carefully gone into around the time that I mentioned when the
last Government was producing its community care policy. I do
not have all that material in my head. There was extensive study
leading to that policy and I am sure that the issue of charging
was very carefully considered. Basically that settled the policy
of the last Government up to and following the 1993 community
care reforms.
Chairman
769. Would it be fair to say, if I may intervene,
that there was criticism at that stage within the social security
budget, rather than within the health budget, in relation to the
mess that had arisen?
(Mr Luce) Yes, but the issue of charging in social
services was one of the issues that was looked at. Do not misunderstand
me. I am not speaking for any particular policy or any particular
set of reforms. I am simply trying to answer Mrs Wise's question,
which is that the issue was carefully gone into within the terms
of the previous Government's policy in the changes that led up
to the 1993 reforms and the Department of Health, in monitoring
the effect of those reforms, looked carefully to see what was
the pattern of service development following those reforms, particularly
on the community side. There was a significant increase in community
provision for people needing long term care. Various other patterns
emerged but that was the pattern within the context of the policy
that we were implementing at that time and we did keep a careful
eye to see what were the obstacles to the further development
and the success of that policy including the scale on which community
services were developing and expanding. I think it is well known
what the last Government's attitude towards these charging issues
was and within the context of that policy the Department looked
at that issue amongst others to find out what was affecting the
development of the policy. The conjuncture in which we are working
now is different in the sense that there is this Royal Commission
looking at these matters. We have provided the Royal Commission
with any information that they have requested from us but of course
their trawl of opinion and their trawl of the facts has gone very
well beyond, and rightly beyond, the Department of Health or other
Government Departments. The Partnership in Action document acknowledges
that in effect there are issues about charging which can be relevant
to the way in which good quality work and effective work across
the interface can develop because it is perceived to be a problem
by quite a lot of people, and it gives a signal that, when it
has the Royal Commission's report and has been able to consider
it, the Government will address these issues through guidance
which will come out between the report of the Royal Commission
and the actual availability after legislation of the new flexibilities
with which Partnership in Action is concerned.
Dr Stoate
770. I thought previously that this had
all been looked into and I am quite sure it has, but I am more
confused than ever about what has been decided and I share Mrs
Wise's worries that we seem to have a big black hole. To go on
to my question, Partnership in Action has clearly thrown up lots
of issues, many of which have been discussed this morning and
many of which clearly we do not know the answers to, and indeed
many fundamental issues have been raised by my colleagues this
morning. Why in that case was the consultation period of Partnership
in Action only six weeks long, four weeks of which were in the
parliamentary recess, and most of my colleagues have not even
had sight of? We now have a closing date for comments two days
from now. Yet many people I am sure feel that they have had very
little time in which to study some of the fundamental issues involved.
Can you tell me why only six weeks were allowed and why the timescale
is so short?
(Mr Luce) I think we would acknowledge that it would
have been a good idea if we had been able to give people a little
bit longer. I hope I do not need to say that the Government would
attach very great weight to this Committee's report, whatever
the time of its issue. It is regarded as an extremely important
area of policy and to implement it does need legislation and although
I cannot say exactly what the timing of the legislation will be
(for obvious reasons) we are anxious to get, after consultation,
a settled position on these matters so that if the legislation
were to be early we would be able to incorporate it properly.
It is worth adding one further point, which is that although,
as you say, we are not quite at the end of the consultation period,
on the whole, although a number of people have expressed anxieties
or reservations or in particular have asked for further clarification
of this, that or the other aspect of policy, the document has
had an extremely good response.
771. I am sure it has. Obviously we are
looking into this in some detail now. Can I just ask who has been
consulted because I want to be certain in my own mind that not
just parliamentarians and Select Committees have had a chance
to look at this but that everybody in the field who might have
an interest and might have something useful to say does have a
chance to look at it. Who has been consulted?
(Mr Davies) We sent out something like 25,000 copies
for consultation not only to the whole of the health and local
authority sector, the people who will be using the new flexibilities,
but also to a very wide range of public sector organisations,
of user representative groups, and also every single GP practice
has been consulted, so the whole of the health/social care field
has been consulted as well as local government generally, so chief
executives and chairs of local authorities have had copies too.
772. Can you tell me how many responses
you have had and whether you have had many complaints about the
shortness of the timescale?
(Mr Davies) We have had a number of complaints about
the shortness of the timescale and we are obviously being generous
with their time limits and are not simply drawing down the barrier
on the 31 October. We are having quite a number of responses.
At the last count—clearly it takes some time for people
to put together their responses—we have had somewhere between
60 and 70 written responses at the moment and we know that for
example many local authorities are seeking their members' views
before they respond formally and we know that a great number of
local authorities will be responding within the next week or two
because we have had talks with them. We are also consulting proactively
by going out and talking to people in the field, so we are having
face to face consultation with a very wide range of organisations,
mostly health and local authority organisations, but at different
levels within the organisations. We are talking to people as well
as just expecting written responses.
773. But that is my point because, as you
rightly say, there are many layers within organisations that have
to be consulted: there are members, there are boards, there are
meetings which may only occur on an occasional basis. There is
every reason therefore to suppose that there will be great numbers
of people who would like to respond but because of the structure
of their organisation they have not been able to consult their
membership. How tight is this deadline? Can you extend it? What
would be the latest you would be prepared to accept a written
or verbal response?
(Mr Davies) To a certain extent, as Mr Luce as explained,
we are bound by what the legislative timetable might be like.
Although we cannot talk about that at the moment, there are clearly
time limits which we are coming up against. Most people we have
spoken to have asked, and we have spoken to a number of local
authorities who have commented on this and all of them have asked,
for an extra week or an extra two weeks, so we are reasonably
flexible because this is a genuine consultation exercise. There
are some issues raised that we are awaiting the views of the field
on in time for comment. We are truly interested in having the
views of the local authorities so we will be as flexible as we
are able to be within the timetable allowed.
774. I am only partly reassured by that,
to be honest with you. If you have had 60 or 70 written responses
that does not even mean one response from every local authority.
(Mr Davies) No, it does not.
775. We have not even got a response from
social services departments, let alone all the other organisations,
the GP practices, primary care groups and trust boards, somebody
who might have a legitimate interest. The 60 to 70 responses from
25,000 papers sent out is pitiful.
(Mr Davies) Yes.
776. If you really are saying that you can
only allow another week or so I am of the opinion that there will
be a very great number of people with a very real interest in
this who cannot simply be ignored and forgotten about because
you have closed the deadline even with a week or so's grace. I
am concerned about that.
(Mr Davies) One of the points we should make is that
the deadline is really about the principles which we hope or propose
will be expressed through the legislation. The further detail,
of which there is a huge amount, we would propose to address through
secondary legislation later in the session and indeed through
guidance and support through the field. We can allow much longer
for that which we have made quite clear. We are saying people
should address the principles now and the detail we can accept
later. Indeed we will be consulting over the next few months about
the detail and what needs to follow on from the proposed legislation.
I hope we can reassure you that we are not just drawing down the
line, the principles we have to resolve very early but the detail
we can resolve over time. There are another 18 months before it
is proposed that these flexibilities will be available.
Chairman: I think Julia Drown wants to pursue
that.
Julia Drown
777. Yes, I might be pushing you in the
other direction. You say in the press release that the new measures
will be able to be implemented early in the year 2000. If that
is the case can we assume that we are going to see the proposed
changes in the new session of Parliament and if not how will it
happen?
(Mr Luce) I think I have to give a slightly unhelpful
answer to that which is that the new legislative programme for
the next session is announced to Parliament at the proper time
and in the proper way, not by civil servants in advance of that
process. We have made clear that we want legislation to convey
these and other changes affecting the health and social services
as soon as Parliamentary timetable allows. Within a month or so
things should be a bit clearer.
Julia Drown: I think that is suitably helpful
really. Thank you.
Dr Brand
778. Can we go back to the pooled budgets
and the arrangements that are going to be set up. It is already
happening in some parts of the country . It appears from the guidance
that you are going to be issuing that this might not be a local
position, this might need permission for this to actually happen.
Could you expand a bit on that?
(Mr Luce) The proposal in Partnership in Action
is, I think it says at least initially, the application of these
flexibilities will be subject to approval by the Secretary of
State. What that represents is a determination by ministers that
these new arrangements should be put to the uses for which they
are intended; the proper audit and accountability processes in
this rather innovative area should be properly in place and perhaps
also, going back to the Chairman's opening question this morning,
so that the Secretary of State can keep an informed and proper
perspective of the overall national scene so that these important
new instruments of flexibility are put to the purposes for which
they are intended and there is not a random or incomprehensible
picture that emerges across the country.
779. In this instance you really want clarity
before we set off rather than seeing what happens when we have
done it? It runs a little counter to many of the papers which
are coming out of the Government's programme at the moment which
seem very aspirational rather than specific.
(Mr Luce) I think the way that I would put it is that
the Secretary of State's intention here is to promote and give
a big incentive to local innovation and in particular the will
to improve the way in which these services work together locally
so that the decision is predominately a local one. The powers
are not compulsory, the document makes that clear. But, he retains
a responsibility or he can discharge his responsibility for assessing
and reporting to Parliament on the overall scene and also for
ensuring that these new powers, which are innovative powers. They
raise quite significant issues about audit and accountability
for large flows of public money. These new powers are being used
properly and safely as well as innovatively and creatively.
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