Select Committee on Health Minutes of Evidence


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.


 
previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries

© Parliamentary copyright 1999
Prepared 21 January 1999