Examination of Witnesses (Questions 780
- 799)
THURSDAY 29 OCTOBER 1998
MR TOM
LUCE CB, MISS
HEATHER GWYNN,
MRS ELIZABETH
WOLSTENHOLME AND
MR MARK
DAVIES
780. So there is going to be accountability
to the Secretary of State presumably through regional health authorities
or regional outposts?
(Mr Luce) It remains to be seen how the legislation
will tie this point down in detail and it remains also to be seen
whether there are issues raised on it in the consultation but,
subject to that, I think that what would normally happen. The
classic way of doing these things, would be for the Secretary
of State to require that a health authority and a local authority
wishing to use one or another of these flexibilities for a particular
service should get an approval from him. The way in which that
would be done, I imagine, is that he would get the regional structure
of the Department, that is to say the regional offices of the
National Health Service Executive and the regional offices of
the Social Care Group and Social Services Inspectorate to provide
advice on whether what is proposed seems in harmony with the policies
underlying the scheme.
781. Adds a slightly greater confusion,
of course, by having the regional structure not being co-terminous
for local authorities and health authorities but I do not think
that is for this morning. What sort of mechanism will there be
once in principle pooled arrangements are made and once you have
pooled arrangements with lead agencies, you have joint working?
It might be very difficult to unscramble them at short notice.
Are there going to be any arrangements to make sure that the contribution
to the pool remains equitable? Are there plans to set up some
form of arbitration service as to what is reasonable in contributions
because clearly local authorities have different funding arrangements
from health authorities. Quite often they have differential rates
of increased funding or indeed decreased funding.
(Mr Luce) The consultation document does not hold
out I think the possibility of an arbitration service or the use
of arbitration with either a capital "A" or a small
"a" in this sort of situation. One of the reasons I
think why ministers are keen to have an approval process, at least
initially, is to reduce the risks that anyone would want to unpick
arrangements of this kind in a hurry. Clearly the issue about
the future contribution of participants, each participant authority,
would need to be tied down in the agreement between them. There
are issues about the way in which the two sets of authorities
are financed, not least of course the bulk of the finance for
local authority social services comes from the Revenue Support
Grant in relation to which local authorities have discretion as
to how they allocate that within their overall responsibility.
One would hope that the authorities, either health or local authorities,
would not engage in structural commitments of this kind without
thinking through their forward financial consequences. I think
it is fair also to say that although significant amounts of money
would flow through these structures it is unlikely that they would
be in any given case so large as to deprive a local authority
altogether of any discretion or flexibility about the disposition
of its total budget or even its total social services budget.
In the case where for example one of these flexibilities was used
in relation to services for learning disabled people, a very important
service and significant amounts of funds are involved in its delivery
but nevertheless as a totality, as a proportion of the total money
available to health authorities and to local authorities, it is
relatively small. Certainly there are issues about forward financial
commitments, that is an absolutely fair point and a very important
one but they do not seem to us to be of a kind that if the thing
was properly handled would subvert the purpose of these flexibilities.
Dr Brand: You have great faith.
Mr Amess
782. There is so much about all this, I
will be honest, I do not understand at all. I am drawn to the
press release of 16 September when the Department talks about
ending the Berlin Wall. The Berlin Wall has gone so it would be
marvellous if you can achieve this in the areas we are discussing.
Although I cannot draw on the Chairman's history, the first thing
I want to ask, is this a new idea, what we are talking about,
the idea of a pooled budget?
(Mr Luce) I think the answer to that is yes in terms
of the structures that are available to health and social services
authorities to use. They can go a certain distance now in joint
commissioning and some of them go a little bit further than others,
evidently having satisfied their auditors that they are acting
properly. What they cannot do is basically put blocks of their
own money into management arrangements that have these characteristics.
Local authorities cannot give bits of their money to health authorities
to run a jointly commissioned or jointly provided service. There
are limits to what they can do financially, particularly on joint
commissioning. They cannot, as the paper says, create a pool of
money all of which can be spent on either health or social care
by people who may be health authority employees or local authority
employees, they need a new flexibility in order to be able to
do that. The general idea of joint commissioning of local and
health authorities getting closer and closer together in the way
in which they plan and commission and manage services is an idea
that has been gathering force over a certain period of time but
the proposal in this document to create the structural flexibilities
in the law that governs the way in which these bodies can use
their funds is a new idea. It is a new idea in particular to offer
this kind of range of flexibilities.
783. I stand corrected, Chairman, I thought
that I had heard or read about it before but if it is a new idea
that is wonderful. I am sure it works extremely well if you are
all singing the same song from the same script. I am a little
bit confused as to how this will work in practical terms. The
next thing I want to explore, again in the press release, which
seems to be the main signal for this, it talks about local agreement
for single agencies to take the lead on health and social care,
and at the end of the day I suppose MPs are very concerned about
bed blocking and that is where they want the effectiveness to
take place but what work is the Department doing? It might have
happened when I was out of the room. What are the savings that
we are talking about? The bottom line to me is we are talking
about the year 2000. We have a huge legislative process. Assuming
we are going to continue as a democracy we will want to scrutinise
all these matters very carefully. We have heard already complaints
about six weeks' consultation period but I assume that you are
taking orders from ministers. I do not understand how any of this
can be delivered by the year 2000. It seems a little bit impractical
to me.
(Mr Luce) My reply has to be subject to the timing
of legislation. I cannot say any more than I said before. If there
was to be legislation in the forthcoming session and the new powers
were on the statute book next summer or autumn that would basically
give all concerned, whatever it was, six to ten months to make
a start on using them. One of the reasons that ministers have
for preferring to avoid massive uniform blue print change is to
give people the time to make their own assessments of what structural
development would be helpful to them and give people time and
space to work it out properly and do it progressively over a period
of time. So there is most unlikely to be any question of on 1
April 2000 or 1 April 2001 that these new structures, these development
structures would be springing up comprehensively across the scene.
The whole purpose of it is to enable health authorities and local
authorities to make a careful assessment of what structure would
best suit their needs, what provisions of their joint health improvement
plans,and health improvement programmes would be best served by
using these new structural flexibilities and go purposively and
carefully about the business of setting them in place. Of course,
between now and whenever it is that the new powers become available
to health and local authorities the Department will be working
very carefully with the health and social services worlds and
indeed with the wider corporate element in local government in
other agencies and for example through health action zones to
make sure that everybody understands what is available and what
its purposes are and to generate discussion of what is good practice
and how best to deliver the potential of these new structures.
So that by the time the new powers, subject to Parliament, get
on the statute book people could make a well informed and determined
start of the new arrangements rather than sitting around doing
nothing for quite a long time.
784. I am very grateful, Chairman, for the
replies. The only answer I did not get was the savings, single
agency.
(Mr Luce) Both the health service and local authority
social services have efficiency and effectiveness improvement
targets but there is no particular bit of that arithmetic that
depends exclusively or directly on using new powers of this kind.
Audrey Wise
785. The report envisages circumstances
when it might make sense for authorities to get together and across
the health and social services fields for one to delegate commissioning
to another to act on behalf of both or presumably even more than
before. Could you elaborate a little bit on this for us? The delegating
authority would remain responsible for the services which it was
delegating to a lead commissioner. How do you envisage that the
delegating partner will ensure that the commissioning is effective?
(Mr Luce) I think there would be a variety of mechanisms.
First of all, one would expect that the objectives for the service
concerned would have been clearly and jointly agreed between the
two sets of authorities in their health improvement programme.
Indeed a wider range of influences should have been brought to
bear on the service as well, the user and voluntary body influences,
so that there was a clear agreed objective in the health improvement
programme to act as a starting point. Secondly, although the document
does not go into details about this kind of thing, and it is the
sort of issue that we would be covering in guidance or good practice
material that would follow the legislation, there clearly would
need to be a clear and detailed agreement between the two authorities
as to what the commissioning authority was actually going to commission
and monitor and deliver. If issues arose on how that was going
or how for example it might need to be adapted to changed circumstances,
if unexpectedly the pattern of need of the locality changed, it
would obviously be something for resolution between them.
786. I presume when you talk about clear
objectives that would have to be put into a written form?
(Mr Luce) Yes.
787. So it was available for reference.
Presumably there would need to be some continuing relationship
scrutinising, updating, monitoring so that the delegating authority
would still have to remain fairly intimately connected with the
process. Is that so?
(Mr Luce) Yes. The statutory responsibility for the
delivery of the service would remain as it is now. So in the case
that it was a social care service the local authority would be
ultimately accountable and answerable for the delivery of that
service. It is absolutely right that the delegating authority
would retain its basic statutory responsibility and it would need
to have arrangements with the other authority that enabled it
to ensure that its responsibilities were being discharged in the
manner that it intended the joint commissioning arrangement to
achieve.
788. Would you envisage this being expressed
in some form of contract?
(Mr Luce) I think there would certainly need to be
an agreement.
789. The monitoring, do you have any views
about how to prevent that from being another layer of bureaucracy?
How to keep it as effective monitoring rather than both running
over the ground twice? Will your guidance be including observations
on this?
(Mr Davies) I think this is some of the detail we
do have to work out the guidance for the next stage. We set out
in the Partnership in Action broad areas we expect an approval
request to cover which would include things like disputes between
partners and evaluating and monitoring progress. In a sense we
have to put some more flesh on those bones. Partly that is one
of the reasons we are consulting with the field because we do
want to make sure that the arrangements put in place are acceptable
to the field and do not create problems which you rightly raise.
790. I can see the sense in this sort of
approach and clearly part of the result should be, one would think,
the development by the lead commissioner of particular expertise
over and above the general run of expertise within the authorities.
(Mr Davies) Yes.
791. Do you see any danger in that case,
where that is a desirable outcome, of there being an undesired
side effect in that the delegated authority becomes a sort of
junior partner?
(Mr Davies) Again that is something we will have to
make sure we think about how we address. What we are not talking
about is generally delegating the whole of your commissioning
skills to the other partner.
792. Right.
(Mr Davies) We are not talking about wholesale takeover
of one partner by the other. We are talking about specific areas
of either client group areas or service areas so there will still
be that general commissioning skill which will have to be retained.
Also this will be taken forward in the context of the health improvement
programme so we are looking at a broad local strategy rather than
the strategy for development of the individual agencies.
793. This is not a new thing because there
are lead commissioners already within the NHS structures anyway.
I suppose the difference is making it cover across the different
kinds of authorities but there can be difficulties, can there
not? The document says that obvious examples where this might
be useful can be found in learning disability or mental health
services. Clearly this is a good idea but those very services,
especially perhaps mental health, present really quite specific
difficulties and unfortunately a lot of opportunity for things
to go wrong. I can think just off the top of my head of an instance
of a delegated power in the mental health field and then there
was a very nasty occurrence and then the delegating authority,
there was a flurry of activity and inquiry as to how this happened
and whose fault was it and possibly in those circumstances you
would have definite tendency to want to pass the buck. Will you
be gathering experiences in the field of lead commissioning and
delegation and trying to warn people of the pitfalls and express
examples of good practice where things have not gone wrong?
(Mrs Wolstenholme) I am sure we will, that is the
way that around the interface we have tried to operate over the
last few years. We know that the experience is out there and we
know that we are moving into areas where people are doing things,
sometimes for the first time. We do need to learn from that and
make sure that both good and bad experiences are shared across
the country. I am sure that Mark and the joint unit see that as
part of their role. As one of the joint owners of the joint unit
I would certainly see that as part of it.
794. Finally—and these are intended
as friendly exploratory question, my questions are not always
of that style, I am reassuring—I can foresee possible problems
in relation to arguments about how much it costs to provide the
service which is required. You can see a relationship between
a commissioner and a provider and that can be sufficiently fraught
with different views about how much needs to be invested in the
service. If it is being done third hand, you have then got another
entry into that, the two bodies on whose behalf the service has
been commissioned, do you envisage problems about deciding on
levels of investment? What if there are disputes, will they then
just say "No, I am not accepting the job of joint commissioner".
Do you see a problem? Have you thought about it?
(Mrs Wolstenholme) We talked when I came here before
about joint investment plans which are currently being worked
on as the operational underpinning of the health improvement programmes
in the areas that cross the interface. I suppose I see that mechanism
and that point of agreement, this is joint agreement, which would
still be in place whether it was the lead commissioner or not.
I think those discussions would have happened in the joint investment
planning process.
795. Finally when in a future session of
this Committee we ask questions about how it is all working, will
we be told, as we so often have in fact been told: "It has
all been delegated for local decision making" or will you
be monitoring it and be able to answer questions about how it
is working?
(Mr Luce) I think it would be a very brave person
who gave a guarantee that the Department would always be able
to answer the Committee's questions to its satisfaction but I
think we did touch on this to some extent when Dr Brand was raising
points about how the Secretary of State was going to use his powers.
The document does say that at least initially the Secretary of
State will be giving approvals when these new flexibilities are
used. He will use that power to ensure that they are used for
the purposes that they have been approved, should this turn out
to be so, by Parliament and that they are used to support better
outcomes across the interface between these services. It is beyond
question that the Department will be monitoring carefully how
these powers are used and should be able to show what their effectiveness
has been as a whole across a period of time, bearing in mind that
actual outcomes in these cases can take some time to occur and
are not always particularly easy to assess. I think certainly
it is the intention that these new powers should not be launched
on the waters and lost sight of. Ministers want to make sure that
they do make the contribution that is envisaged for them and they
do lead to better working and better services.
Chairman
796. I know Julia Drown wants to look at
performance indicators in a moment. Before we touch on it can
I look at how performance will be monitored. I am not clear from
the answers that have been given how the structure will adjust
to the new regime. Mr Davies, you head the new group that Mr Luce
described presumably bringing together the key areas within the
Department. Will something of this nature happen similarly at
a local level or will we still have the SSI as the lead agency
with one provider or the Executive as the lead agency with another
one or are we going to bring the two together in some way to reflect
what is happening at national level and to reflect the movement
towards integration at local level?
(Mr Davies) I think we will be moving towards much
more closer working between the two regional structures of the
Department. A draft performance framework has already been issued
for the NHS. I think it is no secret that the Social Services
White Paper will produce something for social services. What we
would aim to do is where the indicator or the performance we wish
to monitor is at the interface of the area we are discussing here
we would want to ensure that the social care regions and the regional
offices of the NHS Executive work together to monitor those. In
fact, we are even now talking about, or considering, what monitoring
arrangements we need to have in place for joint investment plans
which is an early expression of joint working and working together
to achieve joint objectives. That monitoring will be taken forward
by two regional structures collectively and in consultation. I
hope I can assure you there will not be two separate empires looking
at two sides of this question, they will be coming together and
monitoring jointly what happens locally.
797. If someone was to say to you that the
integrated providers, which are suggested in this document, are
perhaps a stepping stone to one single agency at some point, would
that be wrong? Is it possibly something that you might favour
in the longer term? Is it something the Government have looked
at?
(Mr Luce) I think it is not envisaged that the single
provider would necessarily be a stepping stone to the amalgamation
of authorities and that is not one of the purposes envisaged for
it.
798. I do not want to hark back to a discussion
we had some considerable time ago. There has been speculation
for a long time that social care may be moving to health or whatever.
Are you excluding within the short term anything of that nature?
Some people see it as a stepping stone to exactly that kind of
new model?
(Mr Luce) I think these proposals, as they are described
in the discussion document, are seen as fulfilling the purposes
that are attributed to them there, that is to say, to improve
working across the interface, particularly between health and
social services, in a way that is flexible and can be adjusted
according to local need. They are not seen as a precursor to other
major structural change.
Ann Keen
799. Partnership in Action is an
area I want to look at. If we are looking at integrated provision
how will the Secretary of State be able to monitor the impact
on the workforce that could bring about?
(Mrs Wolstenholme) I think that builds on Mark's answer
about how we monitor the change in general. We would have to think
very carefully about what the impact on the workforce would be
of some of those changes and make sure that the connections that
are already there, education consortia for example, are part of
that process so that we are not in any way undermining the education
commissioning process by having social services providing some
elements that at the moment might be in community trusts for example.
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