Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 280 - 299)



  280. I do not want to make an argument out of this. I just want a clear steer from you that you are not going to cap the costs on individual patient's care which I understand and that is clear cut. Logically that does mean that the budget for patient care in this field is going to be unlimited to keep that commitment. I just want to check that is the right assessment.
  (Mr Hutton) There is another dimension to this argument, Mr Burns, that I do not think you are considering which perhaps I should suggest to the Committee and essentially it might help you. What we have been trying to develop, as the Secretary of State has been saying, is for the first time a clear National Assessment Procedure which will allow a nurse led assessment of the person's nursing needs to take place in a proper framework. If the result of that assessment is somebody needs, say, for example ten hours of registered nurse time taken in a nursing care home every week, that is the package of care and that will be resourced. That is what we have made very clear. The other dimension to this, which might help you a little bit, is that of course on top of that and running in parallel to that, as you will be aware, as the Committee will be aware, we have the review currently taking place about continuing care guidelines themselves and, of course, there will be cases, around about eight to ten per cent of cases currently at the moment, whose needs are so heavy, whose nursing and other medical needs are so intensive that they need full-time care and support from the NHS funded by the NHS sometimes within an NHS facility but, more often than not, in a private nursing care home too. Of course that is the mechanism by which we deal, I think, with the kind of case that you are indicating there about a person whose needs might be very, very intensive. There are resources there, there always have been, to fund those types of care packages and that is an NHS responsibility. Of course that means we pick up the tab, Chairman, for the whole package of care that person needs, including their living costs, their food, their personal care, their nursing care costs as well. I am sure the Committee would like to be reassured about that.

  281. On the question of your assessment, will the patient or the family of patients who may have responsibility for them have a right of appeal against an assessment if they do not agree with it?
  (Mr Hutton) Yes, they will. Of course that will be a feature of the proposals.

  282. How will it work?
  (Mr Hutton) I think it will work through the way that the appeal system currently works. Of course there is, as you know, an established Social Services Complaints Procedure, there is an NHS Complaints Procedure. We will make sure that if there is a dispute around the assessment that people will have a proper opportunity to exercise a right of appeal. That is fundamental, that is how we want to be treated by the NHS and social care. Those appeal mechanisms will be in place for this assessment process as well.

  283. May I ask you a question that I asked your officials last week, which I think they suggested would be better to ask you, which is this. There is anecdotal evidence—I suspect all around the country, certainly in my constituency—that when the social service budget or the health budget is under strain for other reasons, that there is a tendency on the patient to assess an individual for residential care when, strictly speaking, they should properly be in nursing care because, of course, residential care is relatively less expensive than nursing care. Providing you accept that this probably does go on in this country, how will your proposals get round that problem or minimise it?
  (Mr Hutton) I think you are probably right. I think we have all picked out cases in our own constituencies where we think that might be going on. I accept the point you are making. That may be an aspect of how the current system works. Of course, the key to challenging that will be the new assessment procedure that we put in place, which will for the first time give us a proper framework right across the country, led by nurses, delivered by nurses, so that we can properly assess nursing care needs. So dealing with the problems of cost-shunting, which I think is right to refer to, is something that we will have to address and the new assessment process will allow us to do that. The full budgeting arrangements that the Royal Commission were very keen on, in supporting integrated care for services for other people, which we certainly endorse and embrace, are taken forward in the NHS Plan through the new care trust system that we want to see up and running, together with that flexibility which we introduced last year, I think that will help us to overcome some of those problems. Certainly, as I said earlier, it is not our intention in introducing what I think is quite a fundamental reform, bringing great fairness to the long-term care system, that as a result of that we somehow build into the system some other anomaly, some other disincentive to get the system working properly. We are not going to do that. The key to that is to have a new assessment protocol, but we do not have that at the moment. That may be in part why the anecdotal evidence that you have drawn to the attention of the Committee may be surfacing because we do not have that proper assessment procedure in place. Through all of those many and different ways we will get to a position where I hope the Committee and yourself will be satisfied that we have not put in place the type of arrangements that facilitate that type of inappropriate assessment which we have identified.

  284. Do you think it is a lost opportunity, having gone through the whole procedure of a Royal Commission on long-term care and aroused a lot of both interest and expectations from that, that at the end of it all, apart from the proposals to raise the savings levels, which undoubtedly will be welcome, nothing else, to the best of my knowledge, is being done on helping people, with regard to residential care and the costs of that, which will continue to see a situation where individuals or families on their behalf have to sell their homes?
  (Mr Hutton) It is completely wrong. There are a number of other changes that we are proposing, which we identified in the NHS Plan. For example, a three-month disregard. The new arrangements for home loan schemes which we will resource local authorities to provide in future, which will prevent that type of scenario coming out at the end of the day. The response we have made is a pretty full response. We have certainly accepted the vast majority of the Royal Commission's recommendations. It is clear that we did not accept the recommendations about personal care but let me be absolutely clear to the Committee. Of course, we have a choice about that. Of course, we have. We could have spent the billion pounds that we have available on providing free personal care but we would not have been able to address the sort of criticisms that our constituents are always addressing to us about the deficiencies that we have in the care services for older people. Not enough choice. Not enough individually tailored services. Not enough intermediate care. Not enough home based care packages to keep people independent at home where they want to be. The choice we have to make is a very difficult choice. Of course, it is. But we have chosen to make the resources that we have available: £1.4 billion investment in this area to try to address the key deficiencies in the fairness agenda about how long-term care is brought in; and also addressing what I think are the most serious problems facing the development of long-term care for the elderly. It is a choice we have made. We are very confident that it is the right choice. Had we done it differently, we would have simply locked in place the present totally unsatisfactory range of care services for older people. We would not have moved on that agenda at all. We would still be here two years from now dealing with the same criticisms that our constituents are raising about flexibility, availability, the quality of care services to meet their needs. We would not have moved on that agenda at all. So we have tried to do the two things together: to improve the care services across the range for older people, as well as addressing the glaring unfairness of the arrangements about funding long-term care. We have drawn the line where we have drawn it. I think it is in exactly the right place.

  285. Why is it then that most people do not share your view on residential care and think you have it wrong?
  (Mr Hutton) We have an obvious argument to make and can have a discussion about that. But we should not lose sight of the fact—I tried to slip this into the argument earlier and I will try to slip it in again, it might help—the argument is often presented as a choice between free personal care or personal care that everyone has to pay for. In fact, as I said—

  286. It does not have to be.
  (Mr Hutton) It is. As I said, 7 out 10 people in residential nursing homes get all or most of their nursing and personal care costs already funded by the state. That is the issue about personal care. We have 30 per cent who get no help at all with their personal care costs. Now we have to make a choice. We have made a choice about whether we invest one billion regardless of a person's needs to deal with that issue. If we do that, we make no further changes to the quality of older care services or we make the investment in those services. That is what we have done.

  287. I think I heard you right. You said basically that 70 per cent of people in residential care have their bills paid for by the state. Of that 70 per cent, what proportion is people who did not start having their bills paid for by the state, but after selling their houses and their incomes have dropped to 16,000 and have tapered down to 10,000 are now being paid for? Because if that is the case, it is slightly misleading to try and suggest that 70 per cent may factually be having it paid now, if you forget that for a lot of those 70 per cent they are only having it paid for by the state because they have exhausted their own funds through selling their home or whatever else, or using up their savings to the threshold.
  (Mr Hutton) Clearly some of those who are getting some or all of their care costs will be people in that category. I do not know, Mr Burns, precisely what the figures are. If those figures are available, which allow us to bottom that out, we will make them available to the Committee.

  288. The way you put that figure is slightly, or seemed to be, slightly misleading.
  (Mr Milburn) There is quite an important point here. As you know yourself, there are always choices and decisions to make about how best to take forward public policy and how best to deploy public resources. That was one point of agreement between the Minority and Majority Report of the Royal Commission on free nursing care. The way we have defined nursing care has been drawn rather more broadly than the Royal Commission suggested. Far from suggesting that has not been welcomed—

  289. I was not suggesting, for one minute, that it has not been widely welcomed.
  (Mr Milburn) Let me finish this. It has been widely welcomed. It has been widely welcomed in particular by the 35,000 people or thereabouts who will pay on average £5,000 a year. They will welcome it and so will their families. I believe that people will also welcome the other measures that John has indicated that the Government will be taking. We are increasing the capital limits. They have been frozen for very many years. We were not responsible for that.

  290. Hang on, Secretary of State. Factually, "very many years" is a suitably vague term that does not bear reality. If you remember, Secretary of State, it was the last Chancellor in the last Government who increased those levels. I did not want to bring this in, but if you also remember, Secretary of State, it was a Labour council in the north west who refused to accept the will of this House and those levels, and proceeded to charge elderly people for their residential care. This went to the High Court and the Department held with great relief when they won the case in the end. So I think it is a little unfair to say that.
  (Mr Milburn) Regardless, the levels have not been increased and now they have been increased. Free nursing care had not been provided and now it is going to be provided. That is true, is it not? It is also true that we are enabling councils, because we provide more resources to them, to take charges on people's homes on the point they go into care; so at the point they go into care, by and large they will not have to sell their home. That will be happening now. It did not happen in the past but there is a big choice to be made about how best we take forward the improvement in nursing care services. In the end I think it is quite straight forward, either we can spend roughly a billion pounds as the Royal Commission suggested to us in the majority report, although not in the minority report, providing personal care for free for everybody. That will not provide a penny piece worth of extra care for anybody, for any other elderly person, and it will certainly do nothing to improve the standards of care or the provision of services that elderly people need. That does not make it any easier a choice but I think the right choice has been to do what the minority and majority report agreed on, free nursing care, and the other changes that we will introduce—the increase in capital limits and so on and so forth—and at the same time to dramatically expand both the range of services that are available for people. We have spent a lot of time talking about intermediate care today, and we will be investing a lot of money in intermediate care and by 2004 there will be around about an extra £900 million going into intermediate care services which had not been available in the past. We all know from our own constituents, those elderly people who write to us and contact us, that the shortage in particular of rehabilitation and recovery services is a real blight on their lives and on their family's lives. In the end, although it is a difficult choice, and although you ask about whether it was a waste of time having a Royal Commission, of course it was not, because the Royal Commission came up—

  291. I did not say it was a waste of time.
  (Mr Milburn) No, you asked the question about whether or not we regretted going through the whole exercise.

  292. No, I did not.
  (Mr Milburn) It was neither a waste of time nor a waste of opportunity.

  293. I did not say it was a waste of time.
  (Mr Milburn) It was not either. I am telling you I do not think it was a waste of time or a wasted opportunity. Actually we have actioned the overwhelming majority of the Royal Commission's recommendations and on top of that we have in addition invested, and are investing, a huge sum of money in more services for elderly people and in improvements in the standards of care which they receive. Now, arguably, that should have happened many years ago, it did not and we are now getting on with the job.

  294. One final question. You do not think though, on the residential care side, there could have been a third way which was to look at some form of insurance policy to help elderly people protect their capital asset, which from your point of view and the Treasury's point of view would not have involved the massive amounts of public expenditure if you had paid for the whole bills of those people?
  (Mr Hutton) We are generally in favour of the third way as you know, Chairman.


  295. I noticed.
  (Mr Hutton) You may not be. If you look at Chapter 5 of the Royal Commission Report, Mr Burns, I think you will see the Royal Commission themselves addressed this issue and felt that some of the proposals, that the Government of which you were a member of had put forward, these issues would not work, they were not practical, and it did not seem to be clear to the Royal Commission who would benefit. We are not going down that route. We do not think that is the solution to the problems in the way you have described but we are currently looking at the whole issue of long term care insurance products and the market for long term care insurance. The Treasury, who have responsibility, of course, for this work, I understand are shortly to consult on a range of proposals in this area.

John Austin

  296. Can I turn to the PFI. Some people argue the new hospitals are being built without any regard to how they may fit in with other resources.
  (Mr Milburn) Yes.

  297. You have allowed PFI schemes to proceed in advance of developing a national strategy for health care need. Was that wise?
  (Mr Milburn) I think when we came to office we were faced with a choice, and that was pretty straight forward. The hospital building programme had stalled. PFI had stalled as an initiative, as you will recall. There had been no hospitals built although there had been rather a lot of money spent by the previous Government on consultants and on lawyers and by and large it is a good thing to spend money on patients. I get lots of legal advice and sometimes it is helpful, sometimes it is not. We had to get the hospital building programme started. If you like, in some sense, in truth, we had to create a market in PFI because there was not a market, there was not capacity and there was not expertise out there. Now we have got that going and, of course, there will be lessons to learn, of course there will. I think the most important lesson for us is this: if in future we are building, as we will be, more acute sector hospitals, more new hospitals because heaven knows the National Health Service needs them, we have a stock of buildings which by and large are pretty ancient—I cannot remember the figures but Colin will probably be able to tell me the proportion of our infrastructure that is 50 or more years old and some of it dates back to Victorian times or before then—clearly we have to modernise and we have to get new hospitals built but I think the important thing is this, that as we are building new hospitals in future what I will be looking for, whether they are procured, whether they are bought either by Exchequer capital through the traditional public procurement route or through the private finance initiative route, is what we are terming technically as whole health economy PFI deals. In other words, we will only sign a deal in future where we are able to demonstrate firstly that the needs of the rest of the local health service have been fully taken into account before the acute sector hospital is built, the impact it will have upon GP services, community services and, indeed, social services and, secondly, particularly in the next tranche of major PFI deals that we will be announcing before too long, we will want to encourage more deals that encompass not just the new hospital but new health community infrastructure, primary care infrastructure and, where it is possible, social care infrastructure too. So, if you like, some of the concerns that have been expressed in the past about the adverse impact that building a new hospital in isolation from planning the rest of the local health economy, we can deal with some of these concerns through this route.

  298. Is there a danger with some of the schemes we have got we may be faced with outdated hospitals which do not fit in?
  (Mr Milburn) That is true, frankly, whether you buy through the private sector route or the public sector route, of course it is a danger. At least in the PFI route, with respect, we can walk away from it at the end of the term, whether it is 30 years or 40 years. If we do not want to continue with the concession at the end of that period the National Health Service can either walk away or the asset can return to it at the end of that period.

  299. Is there not a problem that you need to adapt to change in the mean time because you are locked into a contract?
  (Mr Milburn) No, and let me give you a good example of where we have been able to vary a PFI contract in the shape of the Norfolk and Norwich Hospital, for example. I know that concerns were expressed there that in the original outline business case and then in the full business case, and indeed when the hospital started I think its building work, that sufficient provision had not been made for general and acute beds, the number of beds in the hospital. We varied that, we changed it, and I think we increased the number of beds in that particular case by 144, if you like, during the building phase of the thing. The other important issue is if you go around and talk to some of the people who are responsible for designing these new hospitals, they are acutely aware, as indeed they should be, that health technology and health needs are changing so fast that whether in the future frankly we build a hospital through private finance or through Exchequer capital, we are going to have to have flexibility built into the very structures of the building. We will have to have that in the future.

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