Select Committee on Health Memoranda


MEMORANDUM

Memorandum by the Department of Health











  2.3  Expenditure on Community Care

    Could the Department provide a table showing, by service, net expenditure in real terms by central and local government on community care, broken down by residential and non-residential care (taking into account relevant service pay and price increases), over the most recent five year period for which such are available? Could this data include Social Security and Housing expenditures contributing to Community Care objectives? Could it also show this data in graphical form?

  1.  Table 2.3.1 provides details of central and local government net expenditure on services for community care in England, for 1993-94 to 1997-98, the latest year for which information is available. All figures have been adjusted to 1997-98 prices using the latest Gross Domestic Product deflator. The reason for using the GDP deflator is that there is no single service pay and price index that would be appropriate for all sectors.

  2.  Community care expenditure is taken to mean expenditure on non-residential and residential care provided or arranged by local authorities for adults; community health services provided by the NHS for adults; certain social security benefits which support community care objectives; and certain expenditure on housing. Calculation of local authority expenditure by client group involves a degree of estimation.

  3. The data in the table are set out in graphical form in figure 2.3.1. The graph illustrates the real spending each year since 1993-94, with the figures for 1993-94 indexed to 100. DSS payments in support of community care, and local authority expenditure on non-residential care, have both grown steadily and significantly in real terms over the period. Expenditure on residential care, which includes people supported by local authorities and by DSS, has grown more slowly and actually fell slightly in real terms in 1997-98. In contrast, changes in real expenditure on community health services have fluctuated from year to year, but at the end of the five-year period, real expenditure stood some 10 per cent higher than in 1993-94. Real expenditure on housing associated with community care showed the widest annual fluctuations and actually fell over the period by about 15 per cent.

  4.  Part B, Community Health has been amended to provide HCHS gross expenditure on adult community services using all community categories. In addition, a new table 2.3.2 provides alternative information on HCHS gross expenditure in cash terms for adult community services. This is consistent with the methodology used for the alternative programme budget in response to Question 2.2.





Table 2.3.1

NET EXPENDITURE ON SERVICES FOR COMMUNITY CARE (1997-98 PRICES) ENGLAND

£ million

1993-94
1994-95
1995-96
1996-97
1997-98

A.Local Authority Non Residential Care (1)

Home Care/ Home Helps
740
934
998
1,052
1,102
Meals at Home
47
45
44
47
47
Disability Equipment and Adaptations
72
60
75
76
74
Day Care for Elderly People
139
210
237
225
239
Day Care for Other Adults
402
519
548
555
563
Care Assessment, Management and Administration (2)
1,276
1,142
1,221
1,267
1,289
   
Total A
2,678
2,911
3,125
3,223
3,314

B.Community Health (3)(4)(5)(6)(7)(8)(9)

Chiropody
103
102
108
85
82
Family Planning
65
68
72
57
55
Immunisation and Surveillance
1
1
1
1
1
Screening
75
64
69
53
53
Professional Advice and Support
116
113
116
97
92
General Patient Care
957
889
912
942
915
Community Mental Illness
291
334
378
454
504
Community Learning Disability Nursing
219
315
317
362
414
Health Promotion
66
66
71
51
47
Services to GPs Under Open Access
228
235
264
191
188
Other Community Health Services
268
298
335
271
258
   
Total B
2,389
2,486
2,642
2,564
2,609
   
Total A plus B
5,067
5,397
5,766
5,787
5,923

C.Local Authority Residential Care for (1) (2)

Elderly People
960
1,303
1,508
1,713
1,774
Younger Physically Disabled People
66
106
116
133
138
People with Learning Disabilities
298
376
424
478
508
Mentally Ill People
62
85
103
124
138
Administration and Other
219
272
283
299
316
    
Total C
1,604
2,142
2,434
2,746
2,874
    

D.Income Support:—Residential Care,
Nursing

Homes and Residential Allowance
Cases
(10)(11)(12)
2334
2,036
1,804
1,688
1,549
   
Total C plus D
3,938
4,178
4,238
4,434
4,423

E.Other Social Security Benefits

Attendance Allowance (13) (14)
1,676
1,801
1,922
2,030
2,169
Disability Living Allowance (13) (14)
2,460
2,723
3,216
3,587
4,014
Invalid Care Allowance
396
464
529
639
616
Independent Living Fund (15)
106
93
94
95
91
Social Fund Community Care Grants
105
105
101
98
97
Mobility Allowance (14)
61
n/a
n/a
n/a
n/a
    
Total E
4,802
5,187
5,863
6,451
6,987

F.Housing

LA Expenditure on Own Stock; New
Housebuilding for the Elderly and
Disabled (16)
15
10
6
3
3
Housing Corporations; ADP Approvals (17)
160
145
77
116
61
LA Grants; Disabled Facilities Grants (18)
83
99
104
102
100
LA Expenditure on Own Stock;
Adaptations to all LA Dwellings for the Elderly and Disabled (19)
n/a
n/a
79
80
79
LA Expenditure on Own Stock;
Renovation of Specialised Dwellings for the Elderly and Disabled (20)
28
33
n/a
n/a
n/a

Total F
286
286
266
301
243
    
Total E+F
5,088
5,473
6,129
6,752
7,230

Grand Total A to F
14,092
15,048
16,133
16,973
17,576


Footnotes:

Parts A and C

  1.  Local Authority expenditure is obtained from the RO3 current expenditure return.

  2.  Care assessment, management and administration, although included under local authority non-residential care in Part A, also includes expenditure which is relevant to residential care (Part C).

Part B

  3.  As it is not possible to supply net expenditure figures from the HCHS programme budget, figures are gross expenditure and this may mean that they are slightly overstated.

  4.  Figures derived from HCHS programme budget analysis. It has been assumed that approximately 90 per cent of chiropody, 95 per cent of Family Planning, 1 per cent of Immunisation and Surveillance, 100 per cent of screening, 35 per cent of professional advice and support, 95 per cent of total general patient care, 95 per cent of community mental illness nursing, 80 per cent of community learning disability nursing, 70 per cent of Health Promotion and Services to GPs under open access and other community spending is on adults. It has also been assumed that 100 per cent of maternity care is spent on the delivery and no costs are associated with the mother, and 100 per cent of community dental is spent on children.

  5.  The above allocations have been taken from the Expenditure per head of population exercise.

  6.  Administration cost for community health services are not separately identifiable and are not included in the Community Health figures.

  7.  Prior to 1996-97 monies provided for GP fundholders to purchase HCHS was exclusively allocated to General and Acute care. A more realistic allocation of expenditure shows that community services comprised a part of this expenditure. Hence figures for 1996-97 and 1997-98 are not directly comparable with previous years.

  8.  In 1996-97 several categories of the programme budget were affected by the changes to accounting practice and the changing structure of the NHS. Included in these was the need to capitalise redundancy payments and recharges were no longer included.

  9.  Figures for 1997-98 are provisional. 1996-97 figures shown in last year's evidence have been replaced with final versions.

Parts D and E

  10.  Source: Income Support Statistics Quarterly Enquiries May 1993 to February 1998. Based on a 1 per cent sample up to and including February 1994 and a 5 per cent sample thereafter. Estimated Annual Income Support expenditure is based on numbers and average weekly payments in the enquiry week, and is based on a four quarterly average.

  11.  Expenditure is based on Preserved Rights Residential Care and Nursing Home cases, and Residential Allowance cases for England.

  12.  Excludes unemployed claimants who are now provided for by Jobseeker's Allowance.

  13.  Estimated Attendance Allowance and Disability Living Allowance figures are produced by apportioning out-turn figure for England by average payment, in week ending February of the relevant year.

  14.  Disability Living Allowance replaced Mobility Allowance and Attendance Allowance (for people under 65) in 1992.

  15.  Independent Living Fund figures estimated as 85 per cent of Great Britain figures detailed in the DSS Departmental Report 1999.

Part F

  16.  The majority of new social housing (including for elderly or disabled people) is now provided by Housing Associations rather than Local Authorities.

  17.  Housing Corporation Approved Development Programme (ADP) approvals for schemes by registered social landlords (mostly housing associations) aimed at the elderly and disabled. This covers the Corporation's own programme and joint schemes. They do not cover local authority sponsored Registered Social Landlord schemes. The information about sponsored schemes is not complete, but approvals amounted to £34 million in 1996-97.

  18.  DFG grants are paid to the private sector and to HA and LA tenants. Figures shown are the total of mandatory and discretionary grants paid under the Local Government and Housing Act 1989 and Housing Grants, Construction and Regeneration Act 1996.

  19.  Collection of these figures began in 1995-96.

  20.  Collection of these figures ceased in 1995-96.

Table 2.3.2

HCHS GROSS EXPENDITURE ON ADULT COMMUNITY SERVICES IN CASH TERMS (taken from alternative programme budget)

£ million

Programme
1995-96
1996-97
1997-98

Community mental illness nursing
263
323
355
Community learning disability nursing
71
75
85
Community Nursing G&A
845
1,079
1,093
Health visiting G&A
137
114
119
Professional staff groups G&A
466
493
546
Residential care G&A
98
122
158
Other community expenditure
405
453
502
    
Total
2,354
2,697
2,901


Footnotes:

  1.  It has been assumed that approximately 95 per cent of community mental illness nursing, 80 per cent of community learning disability nursing and 50 per cent of other community expenditure is on adults.

  2.  Figures used to derive the age allocations are taken from the Expenditure per head of population exercise, the latest for which data is available.

  3.  The source of the data is CIC outturn expenditure table 03 part 1 and 2 for 1995-96 to 1997-98.

2.4  Care of Mental Health and Learning Disability Patients

  2.4a  Would the Department update the information given in Tables 2.4 to on patients under the care of a learning disability or mental health consultant, discharges by length of stay, ages and destination, and residential and other places available?

  2.4b  Could the Department provide a table showing:

    (i)  number of people sectioned, by HA and by type of section;

    (ii)  number of people sectioned in proportion to HA population;

    (iii)  number of people sectioned in proportion to number of admissions;

    (iv)  proportion of people who appeal against being sectioned and the outcomes of the appeals.

    Could the Department provide a commentary on the introduction of the new sections (45a & 45b)?

  2.4c  Could the Department provide a table showing, over the last four years, the numbers of people with mental health problems and with learning disabilities who have been in special hospitals, prisons and regional secure units?

  2.4d  Could the Department provide any useful data and knowledge on the survey of the incidence of mental health problems in the prison population (as referred to on p 47 of last year's evidence)?

INTRODUCTION

  1.  Tables 2.4.1 to 2.4.3 present information on in-patients under the care of a mental handicap specialist and table 2.4.4 presents information on beds available in the NHS and private nursing facilities and places in residential care for people with learning disabilities. Tables 2.4.5 to 2.4.8 have similar information for patients in the care of a mental illness specialty. Tables 2.4.1 to 2.4.3 and 2.4.5 to 2.4.7 are derived from the Hospital Episode Statistics (HES) system. The figures in tables 2.4.2, 2.4.3, 2.4.6 and 2.4.7 are estimates and provisional. In tables 2.4.1 and 2.4.5, figures for 1997 are not available and therefore previous years estimates have been used.

CARE OF PATIENTS UNDER A MENTAL HANDICAP/LEARNING DISABILITY CONSULTANT

  2.  The estimated number of in-patients under the care of the mental handicap specialty, at the end of each year, fell from more than 34,000 in 1986 to 8,400 in 1998 (Table 2.4.1). This is mainly due to the fall in the number of very long stay patients, from 27,400 to 4,400 over the period. This fall in the number of very long stay patients resulted from the closure of long stay units and resettlement of patients. There has however been a substantial increase in the number of short stay episodes. Provisional estimates show that 76 per cent of patients discharged in 1997-98 had been in hospital for less than a week. This compares to 58 per cent of those discharged in 1986 (Table 2.4.2); this probably reflects an increase in spells of respite care. Table 2.4.3 shows that most patients under 65 discharged after a length of stay of less than a year return to their usual place of residence (97 per cent in 1997-98); the estimate for those aged 65 and over is 68 per cent, with a further 18 per cent transferring to other NHS trusts. Of those under 65 discharged after a stay of a year or more (an estimated 1,200 in 1997-98), 23 per cent returned to their usual place of residence, 38 per cent transferred to another NHS trust and 31 per cent to local authority homes or other non-NHS institutions. Only an estimated 300 patients aged 65 or over were discharged after a stay of a year or more in 1997-98; the estimates of destination on discharge are based on small numbers and are unlikely to be reliable.

  3.  Table 2.4.4 shows that, in NHS facilities, the average daily number of beds on wards for patients with learning disabilities has fallen from 33,400 in 1987-88 to 12,300 in 1997-98. The decrease is mainly due to the closure of long stay beds. In private nursing homes and in staffed residential care (excluding small homes), the number of beds for adults has almost doubled in the ten-year period; at December 1988 there were 23,900 places compared with 45,200 in March 1998. Residential places for children declined from about 2,600 in March 1988 to 1,500 in March 1997, before increasing slightly to 1,800 in March 1998.

  4.  There has been a decrease in the number of in-patients under the care of mental illness specialists, at the end of the year, from 60,000 in 1986 to less than 32,000 at 31 March 1998. Again, this is due mainly to large falls in the number of long stay patients (Table 2.4.5). There has nevertheless been an increase in the number of short stay episodes of in-patient care; there were 116,000 discharges in 1986 with a stay of under one month, compared to an estimated 135,000 in 1997-98 (Table 2.4.6). Most patients discharged after a length of stay of less than a year return to their usual place of residence (an estimated 88 per cent of those aged under 65 and 75 per cent of those aged 65 and over in 1997-98); about 9 per cent of those aged 65 and over went to other NHS Trusts and 12 per cent to local authority homes or other non-NHS institutions (Table 2.4.7). Patients discharged after being in hospital for a year or more (estimated to be 2,900 in 1997-98) are less likely to return to their usual place of residence. Of patients under 65 discharged after being in hospital for more than a year, 49 per cent returned home, 25 per cent went to another NHS provider and 13 per cent went to local authority homes or other non-NHS institutions. Of those aged 65 and over, 30 per cent returned to their usual residence, 37 per cent went to another NHS trust and 25 per cent went to a local authority home or other non-NHS institution.

  5.  There has been a fall in the average daily number of beds available for mentally ill patients in NHS facilities from 67,100 in 1988 to 37,900 in 1997-98 (Table 2.4.8). This is mainly attributable to the fall in the number of long stay facilities. From 1987-88 to 1996-97, the number of beds in private nursing homes and hospitals increased from 4,500 to 28,500, before falling very slightly to 28,300 in 1997-98. Most of the increase was in places for elderly or mentally ill patients. Between March 1988 and March 1998, the number of places in staffed residential care (excluding small homes) for adults increased from 15,200 to 36,000; between March 1996 and March 1997, an additional 10,200 places were recorded bringing the total number of staffed residential places to 34,250. This was due to a large increase in the number of available places recorded in private residential care homes catering primarily for the elderly mentally ill client group. The number of places in the affected homes in 1996-97 was just over 8,000. In addition a change in the method of data collection in 1996-97 may also have had an effect on these figures.


 
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