Examination of witnesses (Questions 80 - 99)
WEDNESDAY 15 JULY
MR C REEVES,
MR A BARTON
and MR R DOUGLAS
80. No; sorry. It focuses on
four national targets, not four major targets. We had an assurance
that the other targets, one being pregnancy rates and sexual disease—I
cannot remember what some of the other ones are—were as
important but they were more relevant to set local targets for
outcomes. I cannot see that being reflected in your presentation
to us. Perhaps it is a question for Ministers.
(Mr Barton) It is the case that the Healthier Nation
green paper was a consultation document and we got a lot of comments
in, including on the local targets. Ministers are still considering
those comments, along with some further inputs.
81. I shall refresh myself by looking at Hansard
before we meet the Minister next week because he was quite specific
and it was a Government commitment that no matter what they would
continue to monitor what was going on.
(Mr Reeves) And to monitor locally.
Dr Brand: No, to monitor nationally how the
local targets were being met and he said they will not be soft
and sloppy targets, they will be tough targets.
Mr Gunnell
82. A separate matter which relates to local
authority spending. The figures you have given us show very clearly
that there has been a very considerable increase between local
authority budgeted expenditure on social services and the SSA.
The gap is in general that local authorities spend considerably
more than the SSA. I should like to ask why the gap has increased
so dramatically since 1993-94? What is being done in order to
reduce the gap and is this being taken into account in the changes
which are being made and the consultation which is taking place
on the standard spending assessment itself? I come from an authority
which certainly when I was chair of social services was always
spending at above the standard spending assessment. It continued
to spend at above the standard spending assessment and judging
by the social services settlement which it received for 1997-98
and the general reaction there has been to that local rate since
they were very disappointed in the settlement, they will obviously
spend considerably more than the SSA. The figures you have given
show that that gap is indeed continuing to increase. Could you
give us some information?
(Mr Barton) I expect many members of the Committee
know that the SSAs are not hypothecated right across services
and within limits authorities can choose whether they spend more
or less from their SSAs. Over all services they tend to spend
above them. For 1998-99 they are likely to be spending about six
per cent above their SSAs on all services. For the personal social
services we expect the figure in 1998-99 to be about nine per
cent which is about the same as it was in 1997-98. It does appear
that for 1998-99 the personal social services budget above SSA
has reached a plateau. It had been going up previously. That suggests
that some level of spending above SSA by authorities is not a
matter for too much concern but in the personal social services
the rise from 1993-94 to 1997-98 was quite noticeable. It went
up from about 4.7 per cent above in 1993-94 to nine per cent in
1997-98 and again in 1998-99. That does suggest that local authorities
were finding the settlements over that period to be very tight.
83. It would also suggest, would it not, that
it is difficult for us to complain from a Department of Health
point of view, that social services authorities are not spending
the money on social services which the Department would wish them
to spend if they are spending considerably above SSA. They may
not be spending it in examining the way they are spending it,
but they are certainly continuing to spend the money on what they
see as the social care priorities. It may be somewhat different
from your own.
(Mr Barton) That is certainly the judgement that they
have made. Obviously this information is something which was taken
into account in the comprehensive spending review and you will
have seen in yesterday's announcement that the intention is to
increase PSS resources by an average of 3.1 per cent a year in
real terms over the next three years. There is really quite a
substantial amount of extra resource going in over that period.
84. Presumably you would anticipate that during
those three years there will also be an increase in direction
as to how the Department would wish it to be spent.
(Mr Barton) Yes. The White Paper does talk about what
the Government's expectations are.
85. Is this the White Paper attached to the
comprehensive spending review.
(Mr Barton) The comprehensive spending review White
Paper does point out that the Government's expectation is that
in return for putting substantial extra resources into the personal
social services, there will be very much clearer setting of objectives
for outcomes and standards that the Government expects social
services to achieve. It will be expecting social services authorities
to make a step improvement in the use of resources and be looking
for new sets of performance measures consistent with best value
initiative.
86. That presumably is an issue to take up with
the Secretary of State when we see him next week rather than with
yourselves.
(Mr Barton) What this means. Yes.
87. I have a second question which is also about
local authority expenditure. The data in your papers suggest there
is a certain amount which is the average amount spent on supporting
elderly residents in nursing care. The figure given is £245.
That contrasts strongly with the 1997 Community Care Trends Report
which indicates that the weekly costs of nursing home placements
averaged £326 in the counties, £320 in metropolitan
authorities and £408 in London. Could you comment on those
differences?
(Mr Barton) Are you referring to the figures in Table
5.3 of our evidence?
88. Yes.
(Mr Barton) When you look at the unit cost data which
is provided there, it certainly raises questions in one's mind
on the reliability of some of the figures, most notably the fact
that in 1994-95 it appears that the unit costs in nursing homes
are actually lower than the unit costs in residential care which
does not seem a very plausible proposition. A difference is shown
in the later years but there is a question mark over the quality
of some of the data in this table.
89. I was wondering which data you regard as
more suspect. Your own data was reported by whom?
(Mr Barton) To which report were you referring?
90. The other information came to us from what
is called the 1997 Community Care Trends Report. I am not sure
where their data comes from. Maybe somebody here could enlighten
me. It seems to me that if we get different data it may be that
the data supplied by nursing homes as opposed to the data which
is reported to the Department of Health—
(Mr Barton) It probably does come from an independent
source. I am not familiar with the particular report you mention
but we did check before coming here about what the Laing and Buisson
figures show.
Chairman
91. I was going to suggest that was the report
we are referring to here.
(Mr Barton) According to Laing and Buisson in February
1997 the weekly cost of a nursing home place was £336 not
the £274.
92. It is a different report then. I have given
you the wrong information.
(Mr Barton) Our information is based on returns made
by local authorities. There is quite a serious point here, that
is very clear from the things we discussed about the Government's
expectations in performance and measurement of performance in
social care, that we just discussed in relation to the CSR. It
is also clear from the reports of the joint audit commission/SSI
reviews of local authorities that it is important that individual
local authorities collect accurate unit costs and examine these
and consider their performance in comparison to similar authorities.
There is a question mark over the quality of some of the information
which they are providing at the moment. It is our view that it
is very important information. It is information that ought to
be used both by authorities themselves and by the department in
assessing performance. One of our expectations is that as we move
into making very much greater use of this information and encourage
authorities to make very much greater use of this information,
the authorities themselves will take steps to improve the quality
of that information.
The Committee suspended from 6.01 p.m. to
6.11 p.m. for a division in the House.
Audrey Wise
93. We have not so far asked any questions about
people with mental health problems or learning disabilities. These
are people who impinge on both social services budgets and on
NHS budgets. I should just like to look at the figures about care
of patients under a mental handicap or learning disability consultant.
I notice that in section 2.4a, paragraph 3 you say the number
of NHS beds in 1986 showed a huge fall in 1997 and its almost
a corresponding increase in beds in private nursing homes and
in staffed residential care. The figures there in private accommodation
have almost doubled. If you put NHS and private together in 1986
it comes to 61,800. If you put them together in 1997 it comes
to 56,900. So the fall is less than 5,000 in people in beds in
either hospitals or nursing homes, excluding small homes. What
analysis do you make about the actual cost impact on respectively
the NHS, social services or people's pockets? There has been a
huge change in the balance but not a big change in the overall
number of people occupying beds. In 1986 the total number of people
with mental learning disabilities in institution type accommodation,
wards, NHS wards and private nursing homes put together was 61,800,
made up of 39,500 in the NHS and 13,000 in private nursing homes.
In 1997, you have it exactly the other way round. Your NHS provision
has gone down to 22,300 and your private accommodation has gone
up to 43,900, which is a huge increase.
(Mr Barton) Which table are we looking at?
94. We are looking at paragraph 3, which is
referring to Table 2.4.4. The point I am making is that it seems
from your figures, unless I am totally misreading them, that the
number of people with learning disabilities in hospital-cum-nursing-home
type accommodation was hardly any less in 1997, just under 5,000
fewer, but the private element of that was greatly increased.
Mostly, when we look at reductions in NHS beds in this kind of
field, we are told this is because they are no longer in NHS beds
because they are in the community. But it looks from these figures
as if it is not that they are in the community, it is that they
are in private nursing homes. My question is: what estimate or
work has been done on the cost of that, the effect of that in
relation to the NHS costs, social services costs and the cost
of the individual? The cost of the individual is not going to
be very much because they are not going to be people with resources:
means testing or not is going to make no difference. Is this a
shift? To what extent is this a shift from the expense going on
the NHS to the expense going on social services? It seems to me
at first glance that it must be a colossal reduction for the NHS
and increase for social services.
(Mr Barton) I would just put one gloss on the description
of the position which Mrs Wise has given. This is that the shift
we are seeing, and it is particularly clearly brought out in Table
2.4.4—I am sorry if the text does not quite make this absolutely
clear—as far as people with learning disabilities are concerned,
has been a very substantial shift out of NHS hospitals but not
in general into private nursing homes where the numbers are actually
quite small. The private nursing homes are the second block there.
The shift has actually been into residential places and quite
a lot of them voluntary and some local authority as well as private.
There is quite a mix.
95. I understand that. I am not simply saying
this is public to private. I am really saying it is NHS to social
services. It is not into social services because it is into the
community in the sense of people in their own homes or whatever.
It still is institutional accommodation, in fact it specifically
in the text excludes small homes. What I am asking is what analysis
there is. Where do we look for how much that is costing the NHS
less and how much it is costing social services more?
(Mr Barton) How much it is costing the personal social
services more is shown in another table, in Table 2.3.1, which
demonstrates the very substantial increases there are in local
authority residential care for people with learning disabilities;
the time run is different. These are constant prices figures and
the cost went up for people with learning disabilities. Section
C in Table 2.3.1, the expenditure on residential care for these
people, is shown in constant price figures from 1992-93 to 1996-97
which show a very substantial increase which is the effect of
the community care reforms in 1993, together with a much longer
standing policy that long-term hospital care is not the best form
of provision for most people with learning disabilities who have
long-term care needs but these are much more of a social care
type than of a medical type. That is a policy which goes back
an awful long time as far as I can remember.
96. This increase in cost is there. Where would
I find how the local authorities are going to pay for that? If
you are going to tell me that is transitional payments, then that
is finished.
(Mr Barton) The special transitional grant, which
has been paid each year since 1993-94, is intended to meet the
local authorities cost of providing that care.
Audrey Wise: But it is transitional
Chairman: Is that not part of the SSA?
Audrey Wise
97. It is stopped
(Mr Barton) It is still in existence this year but
it is not like most of the other grants which go on as grants
for ever. With the special transitional grant the grant from one
year is added in to the SSA the next year and then there is a
new STG, extra money. There is a special transitional grant this
year so it has not stopped yet.
98. But it will be stopping.
(Mr Barton) Ministers have not made decisions about
how they are going to deal with the funding of the personal social
services in the light of the CSR settlement yet.
99. This is really important because if it goes
simply into SSA, then the control which the Department of Health
has over that really disappears because it becomes the DETR, does
it not? They deal with that. What handle is the Department of
Health going to have on ensuring that there are sufficient resources
in the personal social services sector to cope with this continuing
huge extra cost?
(Mr Barton) Part of the assessment which was done
as part of the comprehensive spending review was looking at the
sort of upward pressures there are for various demographic reasons
on the personal social services. So that was taken into account
in the settlement which was announced yesterday. The continuing
provision for people with learning disabilities is part of the
3.1 per cent real terms increase each year which is provided for
in the settlement. That is how it has been taken into account.
How this will be managed is something on which further announcements
will be made.
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