Examination of Witnesses (Questions 180
- 193)
WEDNESDAY 22 JULY 1998
RT HON
FRANK DOBSON
MP, TESSA JOWELL
MP, MR ALAN
MILBURN MP, MR
PAUL BOATENG
MP, AND MR
COLIN REEVES
180. I welcome that response. Do you believe
that the development of the primary care groups will actually
lead to an increase in the proportion of salaried GPs?
(Mr Milburn) I think that will be a matter for GPs
to decide. One of the questions posed by the BMA and GMC was whether
or not the advent of primary care groups was somehow a threat
to the independent contractor status of general practitioners.
The answer to that is no, the advent of PCGs is not. Actually
independent contractor status has served the NHS rather well if
you think about the great achievements that primary care has managed
to bring to the NHS and to the population over the last 50 years
and we want to see it have a healthy future. We also accept that
the world out there is changing and young doctors going into practice
nowadays are much more likely to want to marry their family responsibilities
and their leisure opportunities with their work responsibilities
and many of them will opt not to go into a partnership. Some of
them will want to opt for the salaried route and what we have
done is provide some choice for people but that will be a matter
for the individual GP to decide.
181. Can I come on to the management boards
of primary care groups and ask if you could look into your crystal
ball and tell us what the fully fledged boards will look like.
I think the Secretary of State denied there was a Berlin wall
between health and social services, but I think we would all agree
that there is a series of hurdles and an open ditch perhaps. What
will be the relationship between the local authorities and primary
care groups? Will elected councillors or officers of local authorities
be members of primary care boards? I am in a dangerous position
here sitting between two GPs but in opposition I was arguing for
a primary care-led National Health Service, as I believe you were.
I was not arguing for a GP-led NHS. How would you redress the
very real and genuine concerns felt by other professionals such
as the nurses as to their role within the primary care groups?
(Mr Dobson) Two points I would like to make. Again
Alan has been dealing with the detail of this and will give you
a more thorough answer but there are one or two general points
I would like to make, the first being that it is not just with
primary care groups that we want to build up more of a teamwork
approach and an involvement of other agencies. Health authorities
will be obliged to draw up a health improvement programme for
their area. They will have to do that in consultation with primary
care groups, trusts, with any other parts of National Health Service,
with voluntary organisations and with their local authority or
authorities and to facilitate that we are providing for the chief
executive of the local authority or even in some cases each local
authority to attend or take part in but not vote at the meetings
of the health authority. As far as primary care groups are concerned
then again there will be in this case a social services representative
on the board of each primary care group.
Chairman
182. This is a practitioner we are talking about,
not a social services councillor?
(Mr Dobson) Not a councillor, an official, and there
will also be at least one community nurse on the board as well.
There have been some expressions of disappointment that the proportion
of GPs to the rest in some people's opinion is too high but I
think it is greatly to the credit of the medical profession and
those representing people in primary care that they have for the
first time ever conceded the concept that they will not be the
sole determinants of policy and practice in primary care. They
have agreed to share it. It is a very big step for the medical
profession to agree to that and they should be applauded for it
and we want to encourage it. Certainly several people have come
up to me and said, "What's happening? Why are there not more
community nurses?" The only community nurse who has actually
come up to me who is directly involved in this came up to me in
Sandwell and said, "I want to talk to you about community
nurses and primary care groups." I expected some criticism
but she said, "It's brilliant. They are listening to what
I have got to say. We are having a say for the very first time
and it really is going to make a very big difference." I
do emphasise that it is greatly to the credit of the medical profession
that they have accepted this.
Mr Austin
183. I welcome your comments about the social
services and community nurse representation. I assume that will
be in essence a minimum requirement. To what degree will there
be local flexibility beyond that by agreement in terms of the
management board for inclusion for other patient group or pharmacists?
(Mr Milburn) There are two things I think briefly.
One is that the PCG boards will have the ability to co-opt. If
they want to co-opt that will be a matter for them. We are not
going to tell them what to do. These people on the ground are
going to be getting on with the business of improving primary
care, doing the commissioning, making sure they have the right
relationships in order to improve the health of the local population.
The second thing that we emphasise very strongly that we will
shortly be emphasising in guidance to go out to the embryonic
PCGs and indeed the health authorities is that we expect to see
that the boards are not the end of the matter. We get terribly
fixated thinking if we get exactly the right representative structure
then everything will be fine. Life is not like that. What we want
to see is PCG boards engage with the full range of professional
expertise that is out there. If the PCG in Darlington is going
to think about improving maternity services I would expect to
see the PCG board and the PCG going out and talking to midwives.
Who is better placed to advise about how good practice can be
built upon and how bad practice can be eliminated? Midwives. Similarly
if they are going to improve district nursing services or chiropody
services, then the obvious people to go and talk to are the patients
obviously who are receiving the services but also the staff who
provide them. We have emphasised very strongly indeed that there
should be a process of regular engagement with the various professional
organisations and groups who do provide the services on the ground
and that is below the level of the PCG board. So far as social
services is concerned and relationships there what we want to
encourage is not just one official on the PCG board but a much
closer working relationship in the future than there has ever
been in the past between the NHS and social services. Paul and
I have been working for example on producing a discussion document
about how we can improve flexibility between the health and social
care interface, looking at issues like pooling of budgets, lead
commissioner arrangements and so on because this is what the people
need on the ground. The staff want that and the patients want
that as well. They do not want to be shunted backwards and forwards
between different organisations. They want to feel that they are
beneficiaries of an integrated system of care.
(Mr Dobson) Just following up on that very briefly.
One interesting development has been that the consultants side
of the BMA is now expressing an interest in some degree of representation
or involvement with primary care groups trying to lock things
in better than they are at present.
Chairman
184. I was going to tease out in advance of
the social care White Paper your thinking in respect of a social
services presence within primary care. I am reliving my youth
in policy terms. If you are around long enough it goes in a circle.
(Mr Dobson) What goes around comes around!
185. Are you flagging up in serious terms the
idea of GP-attached social workers or are we talking here specifically
just about the management role at this stage? I would like to
ask another question on the public health side. Mr Boateng, do
you want to respond to that?
(Mr Boateng) I think we have a real opportunity in
terms of the relationship between social care and health and primary
care group and the work that will be done around health improvement
plans provides a window of opportunity to actually get a whole
range of professionals in working together in meeting health and
social care needs in a holistic way.
186. Within PCGs?
(Mr Boateng) Within PCGs, working closely with PCGs
because I do again think that it is very important to take on
board, let me give you an example: if you are talking about the
mental health of children and adolescents your concern is to make
sure that the health visitor, the community psychiatric nurse,
the social worker and the GP are all working together centred
around the needs of that child or young person. Now that does
not necessarily require in fact the social worker to be attached
to the GP but it does require them to have developed working procedures
and protocols that enable that holistic approach and I think PCGs
and health improvement plans and the work that we are doing, as
Alan Milburn has indicated, around pooled budgets and managing
the flexibilities gives us a real opportunity to make a difference
there.
(Mr Milburn) The issue here really is what PCGs do
particularly by getting that direct relationship at an operational
level between primary care and social services which has never
really been there and applied is that it gives an opportunity
for professionals concerned (after consultation with local patients
and the public and so on and so forth) to shape services that
best meet local needs. That will be a matter for determination
between the PCG and the local authorities. Let me give you another
instance of this. In Darlington on Friday I was chatting to a
GP who was complaining they had a problem with salaried locums.
They were desperate for a salaried locum. I said, "Raise
that in your embryonic PCG and that may be something the primary
care group wants to think about funding out of its allocation."
The point is an illustrative one. We will be placing the responsibility
of costs on the PCGs but we will also be giving them literately
the tools to do the job. They will have the resources at their
disposal to decide how best to shape local patient services across
the piece. That is going to be an enormous boon. I do not pretend
it is going to be easy, it is going to be hard work, but the prize
on offer is an immense one.
(Mr Dobson) The small point I would make in addition
is that the idea of involving the local authority does not stop
at social services. At a practical level we will want PCGs to
looking at relations with the housing department or education
or leisure or whatever, street cleaning in some cases on the grounds
some places need a bit better attention than they are getting.
187. Can I press you further on that. The second
area I was going to come on to is the link with public health.
The mechanism as I see it for this very important link is the
health improvement programme and the Minister of State may want
to comment on this because the real worry I have got in looking
at the structure proposed is that the connections are not that
clear other than the health improvement programme. It worries
me. I have mentioned this previously in some of the sessions of
our Committee. I have got two health authorities in my constituency
as the Minister of State is aware because he knows the area well.
Both areas have excellent public health people, some very progressive
thinking people but in one part there is no connection with primary
care and the GPs do not know the public health people. I find
that astonishing because the GPs are facing the public health
issues at ground level on a day-to-day almost hourly basis. I
cannot see beyond the H.I.P. issue where the connection is. Secretary
of State, you made the point about the local authority connection.
You have got the social services connections quite clearly there.
I am looking for further reassurances about where that public
health connection is going to come. Of all the areas where we
have gone backwards in recent years public health is an area we
need to address. I welcome some of the initiatives the Minister
of State has taken.
(Mr Dobson) A lot of it will revolve around the preparation
and then implementation of the health improvement programme. The
health authorities' major task in future will be in consultation
with primary care groups, in consultation with the trusts, in
consultation with the local authorities, all sorts of local organisations,
voluntary organisations who provide services, neighbourhood groups,
businesses and everybody to identify what are the health needs
of the area, what are the health care needs of the area and how
do we go about addressing both the health needs and the health
care needs and then the people who have been consulted would be
treated as signed up to the organisations once the programme is
there and it will be their job to implement it. In this case the
primary care group, from your point of view Chairman, will be
the eyes and ears of something to do with public health, they
and community nurses and health visitors and practice nurses and
so on. And they will feed into it in terms of formulating policy
but they will also be feeding back whether what they are doing
and what other people are doing is actually changing the situation.
So in many ways you could argue that the introduction of health
improvement programmes is the nub of what we are trying to do
locally and it is something that has never existed before.
(Tessa Jowell) Let me just follow that and begin by
agreeing with you about the extent to which the public health
infrastructure has been run down and one of the consequences of
that both at central Government and at local level has been a
widening in health inequality in the standards of health enjoyed
by the poor as opposed to the considerably higher standards of
health and increased life expectancy enjoyed by the rich. So we
start from a low level. I would like to pick up the very important
point that the Secretary of State made which is that the health
improvement programme is the junction box. It is what holds the
implementation of both the social care, public health and health
care parts of our policy together and will deliver it to local
people. There is also the duty of partnership that will be legislated
for between health and local authority but beyond that there is
also a performance framework at the top of which sit four national
targets, to reduce the rates of heart disease and stroke, accidents,
cancers and mental illness together with the local imperative
that comes from between two and three local targets selected because
they meet particular local health priorities and together those
represent the outcomes, the achievements that the combined health
resources of that health authority comprising the contribution
of trusts and primary care groups must actually deliver. But I
do not underestimate any more than you and other members of the
Committee do the scale of regeneration that is needed in the public
health function and that is why in developing the public health
agenda we have done three things. First of all, the Green Paper
which went out to very extensive consultation which had an enormously
large and warm response is in the process of being translated
into a White Paper which will set both targets and the means by
which those targets will be implemented linking very heavily with
the performance framework that was set out in the NHS White Paper.
But, secondly, there is an exercise which I commissioned the Chief
Medical Officer to undertake which is to review the capacity of
the public health function both at national level and at local
level and the conclusions of that will also feed the content of
the White Paper. The third is the independent review of health
and inequality that we commissioned from the former chief medical
officer, Sir Donald Acheson, which will enable us to deliver policies
which will in turn ensure we achieve our health objectives which
are three-fold. The first is to continue driving up the overall
improved health of the population and, secondly, to extend the
healthy years of life that people enjoy. We do very badly on that
particularly in relation to women compared to other European countries.
Life expectancy has increased but people's later years are blighted
by low level disability or by life-limiting illness and a lot
of that can actually be prevented. The third obligation that there
will be on health authorities is to provide evidence on closing
the health gap, the gap between the richest and the poorest, the
best off and the worst off. No Government has ever before set
itself a target of improving the health of the worst off at a
faster rate than the improvement of the health of the population
as a whole. That is what we are setting ourselves to do. We have
set ourselves tough targets against which we will measure our
progress in doing that. We are putting in place a performance
framework that will lock together the three elements of our policy
that will enable us to deliver that.
Mr Gunnell
188. You said in your statement that the extra
personal social services money will provide the money necessary
to improve the quality of care received by children living away
from home. The Utting Report and our own report did suggest that
local authorities should provide sufficient resources to enable
them to have the choice for children in care between residential
home and foster care treatment. We have done the work which we
have presented and it showed that 65 per cent of children now
are in foster care and the question is how do we get to the position
where each local authority can make a choice for their children?
I do not know how you imagine that the money will actually get
to local authorities in such a way that they can use it in this
way because it is a question of whether the money comes to the
local authority directly in some form of specific grant or whether
you provide the capital and it then reverts to the questions we
started with on capital expenditure, and it is also whether you
use it as a means of increasing the standard spending assessment
as a means of getting money to the local authorities. I just wonder
what mechanisms you have to ensure that the money will enable
people to make those choices.
(Mr Dobson) Again Paul has been dealing with this
in more detail than I have but there are a number of basic points
that need to be made. The first one is that the object of this
must be to make sure that children fondly described as "in
care" are really being cared for and preferably that they
have some stability and security in that care as well as being
cared for and while I think most people agree that the higher
proportion of children we can have in foster care the better,
it is not necessarily beneficial to them if they are whirling
from one foster parent to another as occurs to quite a few children
who in some cases have found themselves living in eight different
places in a year which is as unacceptable as living in eight different
children's homes in a year. So we need to provide a high quality
of care and security and stability in their lives because that
is the thing that they most need and we are looking at the moment
at what is the best way to make sure that the funds we intend
making available are spent on what we want them spent on. As you
know I do not shy away from the concept of specific grants for
specific purposes although some people in local Government do
not like the idea. In fairness to people in local Government in
terms of the SSAs they are spending on average well over the children's
SSAs already but some of the money is not being well spent is
the answer and there needs to be a lot more management attention
if first of all suitable people are to be found and then matching
placements that are good for the children concerned and give the
degree of stability that we are looking for. Before Paul comes
in with a greater degree of detailed knowledge on this than I
have the other thing we are looking at very very seriously is
at the moment the obligation on a local authority to look after
the young person ends at 16 and they have got discretionary powers
up to 18. We think that that is wrong. 16 is far too young an
age for somebody to be liable to be chucked out on the street
and the thing I have asked the officials to do, and in fairness
to them they did it, is to try to identify what we got when we
were 16, 17, 18 and 19 out of what you might call normal family
life and try to make sure that the system that is providing for
children in care provides as many of those things that come out
of normal family life as is possible. Some of them probably are
not possible at the margins, the spotty youth who comes home and
manages to touch both mum and dad for a tenner probably would
be quite difficult for a child in care, but the other things like
a shoulder to cry on, a base to go back to when things go wrong,
somewhere to go and get their washing done. They do not sound
important but if we look back on our lives, by God, taken together
they are important and we have got to try to provide those. Paul?
(Mr Boateng) Many of these children and young people
have not even got a base to go back to when things go right. One
of the most alarming pieces of evidence we had on the Utting ministerial
working party that we have working across Government around these
issues is for instance that when you take a child who has been
looked after and has managed to get a place in university a real
issue for that child is what happens during the university holidays
when all our children would, perforce, come back to us at least
before they went on their subsidised travels. These young people
who have managed to get through the system have no one to get
back to. There are also issues around whether or not they will
ever get funding for the individual who has taken an interest
in their career to attend their graduation ceremony. Absurd rules
that say if someone is to come up to visit a young person at a
university from the staff pool of their sending local authority
they have to come up in pairs, they cannot come up individually.
Absolutely crazy, and we have a job of work to do to make sure
that the new resources that we have found—it is almost £3
billion over three years, it is 3.1 per cent over that period,
this is sustained growth potential for personal social services—are
properly targeted in delivering outcomes to these young people.
Children looked after in terms of their safety as well as their
development and children and young people who are leaving care.
I would just make, Mr Gunnell, three main points in response to
your direct question. In one sense it is all of the above so far
as the various alternatives that you posited in relation to foster
care because if you take the evidence we have submitted to you
in writing the picture that emerges is in fact a fairly mixed
one. Overall a growth in the proportion of children looked after
in foster homes rising from 1986 to 1986 from 52 to 65 per cent
so that general upward trend, but when you come actually to look
at different authorities a variation there, 38 per cent in Trafford,
85 per cent in Norfolk and similarly the proportion of children
looked after in community homes vary; one per cent in Camden,
31 per cent in Trafford so there is considerable variation and
I think what we are concerned to do is to make sure that we have
the mix of available accommodations and choices and that may well
be different local authorities coming together in consortiums
and, yes, as I indicated in my brief intervention on the PFI point,
there will be additional moneys available there and support through
that route for smaller schemes that do have potential so far as
shared arrangement for children looked after and the development
of residential and community homes. It is also making sure, Mr
Gunnell, as your own report points out, that we have an improved
quality and increased choice so far as care placements are concerned
within the foster context. It is important that we spend greater
care and attention on the training and support of foster parents
and that also in terms of the residential sector we continue to
build into that provision improved training for staff. That is
absolutely key because for too long social care workers in the
residential sector have been regarded not so much second class
but third class citizens within the social care spectrum and indeed
the White Paper to come out later in the year will show how the
general social care council can operate in a way to improve and
enhance their status. And the third point I will make, Mr Gunnell,
is about the importance (and I think there is considerable potential
for work in this area which the CSR will underpin for getting
service regulation right) of private fostering which is something
your Committee has shown considerable concern about in the past.
We need to make sure that it is regulated properly. I think these
new resources which are as a result of the PES settlement do give
us an opportunity to address all those issues.
189. You accept from what you have said there
will be some local authorities where the choice of residential
care is hardly there at all and that some children would be very
much better served by residential care at this point.
(Mr Boateng) Then I would encourage those local authorities
to look at the opportunities of collaborating with other local
authorities in order to provide provision for them. There is certainly
scope not least in the bigger urban conurbations to do that and
I very much hope it is done and PFI is one way of taking that
issue forward.
190. So you would imagine that the way in which
resources will need to be directed—and I accept your point
about SSAs that the majority of social services authorities are
spending above it—either through a capital bid perhaps from
a small PFI project, as you suggest, but you would suggest otherwise
you would operate by specific grants?
(Mr Boateng) The Secretary of State has made clear
our position in relation to specific grants. There is good evidence
to show that they have a role to play and certainly in relation
to children's services what we know is it is not simply a question
of making sure that the money is in fact spent on children and
children's services, it is also a question of making sure that
children's services are performance managed in a way that, quite
frankly, they have not been in the past. The lessons we learned
for instance on the report from Ealing, frankly Mr Hinchliffe
the situation there was an absolute disgrace and children looked
after were not even in a position to be able to rely on the fact
that there would be a social worker allocated to them when it
was quite clear that the social services committee had not got
a handle on the numbers of children for whom they were responsible.
So there is an enormous amount of work to be done in addressing
some of variations that exist as between local authorities in
using the resources that are available to them and we have to
get them better at using the resources that they have. No one
must go away either from listening to us here today or from the
floor of the House in the belief there is going to be a massive
cornucopia for children's services and all they have got to do
is put their hand out because it is very clear that some local
authorities are not using the resources they do have at the moment
as effectively as they ought to. One of the things we are absolutely
determined to ensure that the new monies that come on tap are
used in a way that adds value to the lives of children, children
looked after and children leaving care who have been failed. I
want to say in conclusion, wanting to get my tuppeny ha'penny's
worth, that is why we are looking at ways of enhancing our capacity
for research and development within the Department around outcomes
about children. We have spent money usefully on research on outcomes
for adults. It is now time for us to devote a similar amount on
looking at what outcomes work for children and making sure we
spread good practice around the country.
(Mr Dobson) There is one additional point I would
like to make and that is in monitoring whether things are done
properly. We are trying to make sure that is improved. We want
to put more information in the hands of councillors so they can
carry out their local monitoring task better than they have done
in the past. I also think it is fair to say that under the leadership
of Herbert Laming the Social Services Inspectorate has considerably
improved its capacity to carry out effective inspection partly
because he introduced the idea of having on the information teams
young people who have been in care which is one of the reasons
why with his help I insisted on having a young woman who had been
in care on our ministerial review group and a salutary presence
she proved to be.
191. Do you anticipate any further public announcements
about the way in which you will be dealing with Utting?
(Mr Dobson) Yes we will be producing a cross-Government
report. I am not quite sure when at the moment. We were hoping
to do it by about now but there is such a deal of work to be done
and I want to get it right so it may be in the early autumn rather
than during the summer.
Mr Gunnell: Thank you.
Audrey Wise
192. Can I first of all briefly encourage you
in your interest in earmarked money. It seems to me that it gives
considerable help in measuring the outcomes in relation to extra
investment and I do not think it interferes with democracy at
all because the democratic elements seem to me to be met by how
the outcomes are delivered which gives a great challenge, but
in looking at efficiency in this particular regard could I get
you to comment on a particular problem which is that choice and
getting an appropriate placement does involve an element of spare
capacity. When placements are made they are often of an emergency
nature or at any rate urgent. If a child is not like a suitcase
to be put on the nearest if not the only shelf there has got to
be some spare capacity. Do you react favourably to that kind of
suggestion?
(Mr Dobson) Yes it is absolutely crucial that there
is spare capacity otherwise, as you say, it is just a hand to
mouth thing. We have got this child, we have got these foster
parents, we have got one place in that home, and off they go because
it is the only place. I think the young woman who serves on the
Ministerial Review Group went to about five secondary schools
during her educational career. She is now at university and did
dramatically well in GCSEs and A-levels but it was despite being
shuffled round from school to school sometimes in different counties
and we just cannot have that sort of thing. There has to be the
spare capacity there or otherwise there is no choice and we then
get into the situation of blaming people for misplacing children,
if I may so describe it, simply because they can do nothing else
than misplace them because there is not a right place to put them.
193. Can I encourage you also in your determination
to get your reply to Utting right even if it takes a little longer,
and encourage the same response to our report, and draw your attention
to the fact that our report in general deals with less dramatic
aspects but they are nonetheless fundamental and hope that when
you do your reply to us that you will be as favourable as you
are in these remarks?
(Mr Dobson) One of the factors that has led to the
likely delay in the publication of our overall response is our
wish to look at those aspects of the Committee's report which
differ from Utting and we want to make a proper judgement on those
as well and incorporate everything we can. I think in many senses,
although obviously as required by the rules of the House we will
provide a Government response to the Committee's report, the more
important response will be our overall policy as set out in the
response to Utting which will I can assure the Committee reflect
our response to what you have said as well.
Audrey Wise: We think that the reports are complementary
and both are very important if it is to be got right.
Chairman: Do any of my colleagues have further
questions? If not, do any of the witnesses have anything to add
or clarify? Can I once again thank you for firstly the written
evidence you and your officials have given, the oral evidence
today and express our appreciation for your co-operation. We look
forward to seeing you in whole or in part in the new session.
The session may be a good deal longer because Mr Amess will have
got his act together by then!
Mr Amess: I have got many questions but I will
keep my powder dry for the next time.
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