Examination of Witnesses (Questions 800
- 819)
THURSDAY 29 OCTOBER 1998
MR TOM
LUCE CB, MISS
HEATHER GWYNN,
MRS ELIZABETH
WOLSTENHOLME AND
MR MARK
DAVIES
800. What sort of action would you expect
local authorities to take when this impact happens? Could you
think of examples as to how they would respond?
(Mrs Wolstenholme) At a very practical level I would
see them making sure that they were playing a full role in the
discussions around workforce planning at the level of the consortia.
I would also see them needing to have discussions with professional
leaders locally to make sure that they understood exactly what
the professional regulatory mechanisms were and how they would
be delivered in a different arrangement to make sure that professional
standards were maintained.
801. And the trade unions, would you involve
them?
(Mrs Wolstenholme) I am sure at a local level any
structural change that affected the workforce would need to involve
the relevant unions.
802. Does the Department have a view on
the need for any new generic roles bridging the health and social
care divide?
(Mrs Wolstenholme) We hear people say that perhaps
for the future we do need to look at skill mix and the nature
of the person and the skills that are needed, but we have not
taken a view centrally of whether that is right or wrong. I think
that is one of the issues which may evolve as Partnership in Action
is implemented.
803. Is there any consultation document
being prepared or any work being done on the generic work at the
moment?
(Mrs Wolstenholme) Not that I am aware of.
(Mr Luce) The two new national training organisations
that have been set up, one of which covers, broadly speaking,
healthcare and the other of which covers social care, Ministers
did give particular attention to these issues on training when
they were approved and the Secretary of State has it agreed between
their two chairs that they will define a forward programme for
working jointly on these issues and will satisfy him periodically
that that joint work is actually being done. I think I am right
in saying that they have actually, the chairs of these two bodies,
agreed a first joint programme between them and reported that
to the Secretary of State. If I am wrong about that, I am sorry
and we will correct it, but that is my understanding. I think
that that would be one of the processes through which issues of
skill mix were addressed, though it would not necessarily be the
only one.
Chairman: I think we might want to come back
to training in a moment or two, but on the performance issue I
think Julia wants to ask one or two more questions.
Julia Drown
804. I was pleased to hear from Mr Davies
of the one set of performance indicators, not two lots of inspection
and processes both doing the same or similar things. The Committee
would be interested if you could give us any more details of when
the performance indicators would be published or indeed how far
you have got in what sort of things you can look at to see how
effective the collaboration is on the ground. I would be particularly
interested to know whether you think we are going to end up with
league tables of various areas, and I am not advocating that,
but is that in the Department's mind at all? I suppose what is
behind the question is the wish which I know is in the wishes
of the Secretary of State as well as mine to ensure that good
practice is disseminated across the service.So I would also be
interested in your comments on how you will ensure that good practice
is disseminated across the service.
(Mr Davies) Well, I have to say that I am not aware
of whether any performance indicators are going to be published,
so I cannot really help you on that. In terms of good practice,
it is quite clear that because of the way that we are introducing
these proposals, ie, in a very sort of measured way rather than
in a piecemeal way, we will want to make sure that good practice
is disseminated. Some of the preparatory work we are doing at
the moment, for example, we are working with the first wave of
health action zones to consider how they, as standard-bearers,
if you like, of the new developments, might make use of the flexibilities
and we are working very closely with them in order to help prepare
them to use the new flexibilities. That will inevitably, I think,
lead to good practice and dissemination of good practice and I
think we would expect future applications for approvals of use
of a flexibility to be in line with what we have recognised and
identified as good practice, so I think we are hoping that things
will move forward in a coherent way based on best practice that
we have identified from the field.
805. But you say the health action zones
will lead inevitably to good practice being passed around the
service, but I think what we have seen around this Committee time
and time again is that good practice has not been disseminated,
but it tends to stay in one area, so where is this inevitability?
(Mr Davies) Well, I think that with the performance
monitoring framework, we will be looking at issues across the
interface where we perhaps disseminate good practice and expect
people to use it and have a way of measuring it where they are
using it and achieving the outcomes that we expect, so it is a
sort of framework rather than just disseminating and letting it
go out there and leaving it for people to decide what to do with
it. We have a way of monitoring or we will have a way of monitoring
how the performance of authorities and the services provided for
the clients and users is improved.
(Miss Gwynn) Just to pick up a little further on that
because I think it is something that Ministers have been very
concerned about, that the health service has perhaps been rather
bad in the past as to shareing in good practice rather than leaving
each party to re-invent the wheel. Certainly among the Health
Action Zones, as a first step, there is very strong networking
to ensure that they learn from each other, that they come together
and that they share experience. Equally, I think then within regions
and beyond that there will be similar arrangements to share that
good practice out. There are very close links between the health
and social service approach and the health improvement programme
approach and we need to make sure that those fertilise each other.
Also there is now the Beacon Initiative which was announced in
September which will be another way of highlighting good practice,
not just to identify those beacons in themselves, but to have
as an integral part of that initiative that they should share
their good practice and disseminate it probably both by going
out and bringing people in, so there is a real drive to make that
happen.
(Mr Luce) I wonder if I could just add a quick point
on performance indicators. Since the Secretary of State last gave
evidence to this Committee in this inquiry, there has been published
the National Priorities Guidance to health and local authorities
which we consider to be an extremely important sort of part of
the preparations for improved interface workings and there are
stated some joint performance indicators, including monitoring
of emergency admissions to hospital of people aged over 75 and
there are other indicators there too and of course it is relevant
to one of the Committee's other inquiries, covering children as
well as social services and there are a variety of those, so we
made a clear start on that and there are other things of this
kind in the draft NHS Performance Framework which has already
come out and they will be picked up in comparable material for
social services on which we are working.
806. If I could follow you up on that, in
the National Priorities Guidance there have been some concerns
raised about some of the individual targets, one of which was
that no more than 16 per cent of looked-after children should
have three or more moves per year. Now, that 16 per cent seems
to me to be an arbitrary figure. Can you give us some background
about how those targets were arrived at and maybe use that one
as an example?
(Mr Luce) Yes. I think inevitably when one is setting
performance targets and indicators of this kind, first of all,
it is very important that no one makes black and white, open and
shut judgments on the figures that are brought forward and there
needs to be an assessment of what the figures actually mean. One
of the purposes of the performance indicators in that sort of
area is to get local authorities to address the very high rate
of change of placement that has been characteristic of the care
system for some while and which is regarded by all concerned and
not least, if I may say so, the Committee as a grave defect in
the arrangements. There can be legitimate reasons for children
changing placements, even relatively frequently, and some of these
things that show up for changes of placement are in the nature
of respite care arrangements. Children can be hard to assess and
hard to place, so inevitably no one would want to condemn a child
into a placement permanently if the child was not comfortable
or the placement was not working, so it is really a benchmark
against which to form a series of judgments, and it is not an
inflexible rule so that if it is 15 per cent, you are necessarily
okay, or if it is 17 per cent, you are necessarily not okay.
807. So how did the Department arrive at
16 per cent being a reasonable number?
(Mr Luce) Well, we looked at the material we had,
which was itself not perfect, on what was happening and how that
was expressed statistically and we took account of some of the
issues that I have just mentioned. The purpose of the indicator
is to send a clear signal that the amount of placement instability
in the care system and placement change should be reduced, and
putting it at 16 per cent was the way in which we expressed that
intention.
808. But you would understand that in some
places there would have to be different targets because of local
situations?
(Mr Luce) Yes.
809. In terms of creating those guidelines,
obviously you have got your own research. What I would be interested
to know is how much users of the service themselves, and particularly
carers, are consulted in arriving at those priorities.
(Mr Luce) Well, I think that the National Priorities
Guidance was a first, within living memory at any rate, covering
health and social services. As a document, that was not subject
to deep or long consultation with users and carers in the NHS,
but the Department did draw on its very extensive dealings with
users and carers and their organisations and tried to import that
dimension into the guidelines, the statistical bits of the guidelines
as well as the rest. That said, that is by no means the end of
the story so far as users and carers are concerned and we do recognise
that in future exercises of this kind, they will be able to comment
on what they think of the present version. The most important
thing is that when these priorities guidelines are responded to
locally, and in particular setting out health improvement programmes,
the user and carer dimension should be brought very fully into
that process locally so that if users and carers locally feel
that a particular objective is less important than another objective
or should be expressed differently or should, if quantified, be
quantified in their own local circumstances somewhat differently,
it is one of the purposes of health improvement programmes to
bring that dimension fully in.
810. It seems that with this document, a
lot of the moves which the Department is making are to get more
of the national back into the National Health Service—making
sure that performance is at the same high standard across the
country, giving guidance on charges and looking at performance
indicators across the board. Will there similarly be guidance
on eligibility criteria for services, for both health and social
services?
(Mr Luce) I think it is certainly true that the Government's
objectives are to modernise services and to make them more reliable
and that is the absolutely explicit purpose of government policy
and I think, if I may say so, that your examples are, broadly
speaking, correct. There is still quite a number of commitments
on which we are still working. In the six months since the Secretary
of State for Health gave evidence to this inquiry, we have done
a very large number of things: the National Priorities Guidance;
the Comprehensive Spending Review outcome, and the actions have
been discussed; guidance on health improvement programmes; the
issue of the important document on policy in the NHS called The
First-Class Service; the second wave of health action zones
has also been agreed; the Local Government White Paper, which
is highly relevant to all this in its wider corporate dimension,
has come out; and, though it again touches on another of the Committee's
inquiries, the Quality Protects Programme for improving standards
in children's social services has been launched. There are still
quite a number of things to come, such as the Social Services
White Paper, the legislation to give effect to some of these things
which we have already discussed, the Long-Term Care Royal Commission.
There is also a commitment to having the Long-Term Care Charter
on which the Department has already started to consult with focus
groups, and that will have the purpose, amongst other things,
of creating a greater reliability of expectation so that it will
not be a nationally uniform set of standards, but it will enable
people to know in their own localities what the eligibility thresholds
are and what they can rely on having if they need it.
811. I think you are saying in that long
list of things, the Royal Commission and other things, that there
might be some areas where the Department will say, "This
is what the eligibility should be", but there is not a separate
piece of work on that so that most of it will still be at local
level that eligibility will be decided upon.
(Mr Luce) Well, I am sorry about the long list. The
Long-Term Care Charter, which is a Government commitment in the
Manifesto, will be addressing questions of eligibility and the
reliability of expectations that people have.
812. For long-term care?
(Mr Luce) For long-term care. It will not be, as we
conceive it, saying that everywhere in the country for all time
there should be uniform eligibility thresholds, but what it will
be doing will be encouraging health and local authorities through
these processes that this inquiry is concerned with to define
locally what their own eligibility thresholds are so that people
can see what they are and people can influence them if they do
not agree with them.
Dr Brand
813. Chairman, can I very briefly go back
to performance indicators? Obviously there are two purposes of
having performance indicators. One is to do the job better and
if you have got local ones which are owned locally and shared
locally, they are a very good tool for actually achieving things,
but there is another purpose which is for committees like this
one to come back to you in five years' time and say, "What
have you been measuring to show that what you set out to do has
actually been achieved?" Did I hear it right that Mr Davies
said that you are not going to publish the performance indicators
of the Department?
(Mr Davies) I did not say that. I said I did not know
whether we were going to publish them.
814. I thought that was slightly surprising.
I think at this stage where we are setting off on some rather
radical changes, it would be very helpful for this Committee to
have a very early sight of the departmental performance indicators
you are going to use to see whether we achieve the new objectives
that you have set out and I think that would help us because we
might be able to think of other things that we would like to know
about or things which to us are not terribly important. We get
overwhelmed by bits of paper and figures, but they are not always
as relevant as we would like them to be.
(Mr Luce) There are already some of those indicators
set out in the National Priorities Guidance which came out in
September and there are performance indicators, as I was saying,
relevant to emergency readmissions and things like that and some
in the children's field. It is certainly not the intention to
have covert performance indicators.
815. No, I am sure.
(Mr Luce) And we will be making those available.
Chairman
816. Can I come back, before Audrey Wise
comes in on the broader training issues, to an issue that we touched
on that I wanted to explore more. It comes into the context of
training. I have forgotten who raised it but it is the issue of
the actual professional roles that we need to be gearing people
towards in the future. I get the impression that there has been
a distinct change within recent times, certainly within a government,
that with this document we are talking about, Partnership in
Action, the Government is largely responding to much of what
is being already explored at a local level. In many ways I would
welcome that. I think the Committee has recognised in its inquiry
that there are some commendable initiatives already taking place
and is addressing some of the problems that we have traditionally
difficulty coming to terms with. One of the areas that worries
me, the lest a thousand flowers grow approach used in another
context, is that we appear to be failing to anticipate where this
will lead us in relation to professional developments in the here
and now and certainly in years to come. I recognise that there
have been marked changes in the work that people have been expected
to do at a local level for which they have not been properly trained.
The best example, which we touched on to some extent with the
bathing issue, is in relation to the provision of home care where
the home help in my era in social services—some considerable
time ago—is now replaced by a home carer who is required
to have skills that were previously the skills of a district nurse.
It does strike me very strongly that the Department in a sense
has been left behind with these developments and perhaps ought
to be anticipating far more the direction in which the grass roots
developments are taking the professions. We should not be so stuck
to the strict definitions that we have had which will relate probably
to the questions that Audrey will ask about professional training.
The scene at local level has profoundly changed and yet we have
not reflected that in the professional roles and professional
training. I would come back to the point that surely the Department
must be looking ahead in conjunction with the agencies concerned
at training to anticipate the fact that already now, never mind
the near future, the tasks are fundamentally different and people
are not prepared for those tasks and the roles that we had traditionally
are not appropriate to the picture that Partnership in Action
is geared to. I am not sure who that question is geared to, it
might be Mrs Wolstenholme. It might be a general remark rather
than a question.
(Mrs Wolstenholme) We do share your concerns that
the workforce of the future is the workforce that we need to meet
the needs of the people that we are trying to support in their
independence. On objectives like the objectives in the National
Priorities Guidance around promoting independence we have to think
what are the workforce implications of that because, to take your
home care example, and remembering my years in social services,
which was probably equally long ago
817. I do not think so.
(Mrs Wolstenholme) It was very much about doing things
for people rather than supporting them in doing them for themselves
and there were training issues around that as to how you switched
the attitudes towards promoting independence rather than doing
something quickly for someone and moving on to the next person.
We are very conscious that there are some generic issues around
assessment and review that are relevant regardless of the professional
person who is coming into somebody's home and have been meeting
within the Department with our colleagues who work on human resource
issues to see how they might take those issues up on our behalf
in dealings they have with educational establishments and curriculum
design and so on.
818. It may be that Mrs Wise wants to look
at this in more detail but it has struck me on several occasions
from witnesses that the distinction between the social care/social
work element and the nursing element is, like the division between
social care and health care, increasingly difficult to define.
I recall an exchange with a witness I believe from the RCN about
comments that she had made as to the extent of the distinction
of the roles which I felt was far too rigid. I recall putting
a question to her about what would a social worker do when they
were meeting somebody who had soiled themselves, do they leave
them and ring the nurse who might be four hours coming to see
them? Of course they do not, they deal with it, but we know that
training aspects and other aspects are raised by that kind of
scenario. That is a day-to-day issue facing people on the social
care/social work side, that they are increasingly involved in
what has traditionally been nursing. Ann Keen will probably want
to comment on this. Increasingly the nursing side is involved
in what has traditionally been the social care side. It surprises
me that we are way behind in addressing that. I am not sure it
is just the Department of Health I am putting this to, I think
it is a wider issue in looking at professional roles. We seem
to be a long way behind where the reality is at grass roots level.
That is probably a remark rather than a question.
(Mr Luce) These issues were acknowledged as very important
in the NHS White Paper as well as in here. The Department is determined
to address them. I think that significant changes in the curriculum
and so forth as far as professional and occupational groups are
concerned are not things to rush into but they are definitely
on the agenda. I wonder whether Heather might add something. You
said we were getting behind what is happening in the localities,
I think Heather has something to add on that point.
(Miss Gwynn) Just to paint in a bit of the picture
on this and how we hope that locally some of these issues are
going to be addressed. The way we see things happening in the
future is that the health improvement programme will give a framework
bringing all the players together, both the different statutory
organisations and indeed input from the staff to think about what
the objectives are. We are then requiring the health improvement
programme is underpinned by the development of the human resources
strategy, which we want to be looking at the whole health economy
and indeed looking at the boundaries with social care so that
it can pick up the consequences for the workforce and looking
at whether there is the right mix of skills, the right balance
of people to address the aims. So, for example, as people pick
up mental health, which is flagged as an issue to be developed
over the coming 18 months in effect as the national health service
framework emerges, it is ready for the health improvement programmes
in 2000-01. There ought to be the capacity to look at these issues,
to look at whether there are staffing questions, skills questions,
that emerge from the strategy we are now going to deliver and
which can then be played into the local workforce consortia and
local training needs. We are attempting to make the joins and
address these. I am conscious it is very much the local picture
still but that is how we hope that bit of the jigsaw will come
into place.
Chairman: Can I express some sympathy with the
Department on this? I am quite surprised at the evidence that
we have had over a period of time, not just in this inquiry but
in others, at the way that professional witnesses from professional
groups have had some very distinct views on the rigidity of the
roles and are determined to defend their corners, and I appreciate
that has given rise to difficulties in relation to a dialogue
within the Department and the professionals on this issue. Can
I bring in Audrey Wise who may want to touch on this?
Audrey Wise
819. Can I just very briefly revert to an
earlier question first for some extra clarification: the target
on children being moved around? We understand it would be a perfectionist
who would say it should always be done correctly first. The number
of looked after children being moved around three or more times
is one thing but it is quite important whether in the next year
the number of children being moved is a different set of children
or how much overlap there is. Will you be ensuring that information
is looked at along those lines as well, it is not just a global
number? We did come across children and accounts of children who
had been moved an amazing number of times. That is the only thing
that bothers me. Have you got this in mind as well?
(Mr Luce) We would certainly want to make sure that
this performance indicator is not used in any crude statistical
way. We certainly want to help individual local authorities to
assess and improve their situations dynamically over time. That
means some look not just at the numbers but at the characteristics
of the children and the reasons why the numbers are as they are,
the reasons below the numbers, to see whether the numbers throw
any light on whether these services are actually getting closer
to achieving the objectives that they should be achieving. That
is our purpose. We would want to look at the way that the numbers
move dynamically over time and if there has been a change in the
children's population or pattern of need. That would certainly
be something which would be very relevant.
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