Examination of Witnesses(Questions 220-239)
RT HON
ALAN MILBURN
MP AND JACQUI
SMITH
TUESDAY 5 NOVEMBER 2002
Chairman
220. I do not want to dwell on the issue of
Birmingham because I do not know Birmingham as well as Mr Burns
or yourself, Minister, but why has the Government not trumpeted
the successes of developing alternatives to care home capacity,
because it strikes me in the numerous exchanges we have had downstairs
about this issue that we are bogged down in this debate about
whether it is 19,000 or 50,000, now revised to 60,000 by the Conservatives.
We estimated it was 31,000 delayed discharges. Surely we ought
to recognise that there is some degree of success when we move
away from the dependence upon care home capacity and the number
of beds. Why is the Government not trumpeting that as a success
and why are you being so defensive about the reduction?
(Mr Milburn) We are not being defensive about it.
You said we were being defensive! It is like a lot of these things—inevitably,
like throwing more beds at the health service—people get
terribly focused about the acute sector and not primary care.
It is true that care home places are a very, very important element
of the spectrum of care that should be available for elderly people.
I have said on many occasions downstairs and in Committee that
for very many people and very many families a residential care
home or a nursing home would be an appropriate choice for that
family or for that individual. But, equally, we cannot have a
situation where the only choice on offer to people is care homes.
Care homes do a good job of work and so on, however, they are
not the be-all-and-end-all of elderly care, and what we know from
every single survey that either we have conducted or anybody else
has conducted of elderly people themselves, their number one choice
is to be as independent as possible for as long as possible. That
is what we all want. It is what we want in our lives and it is
what older people want as well. What we have got to do with the
Government, with the private sector and with the local government
organisations and so on is to foster a greater choice of provision
for people. When I made a statement in the House a few months
ago, that is precisely what it was about; it was about stabilising
the care home market and, Simon is right, there are problems in
particular parts of the country, largely driven by increases in
property prices and so on, and if the local authorities can use
some of the extra resources where it is necessary to stabilise
the market to increase fees, that is a matter for them to determine.
We cannot determine that centrally. It would be quite wrong for
us to do so because Birmingham is very different from Darlington,
Wakefield or London. Equally, we have got to open up more choices
and that means more extra care housing, more supported housing,
more home-based care, more free community equipment and more elderly
people, in time, having a greater choice over how they decide
for themselves how care is purchased. The package of measures
I was able to announce means that at the end of the period 2005-06
we will have more old people cared for where they want to be cared
for which is at home. People always want to do an either/or about
this. When I go and speak at a primary care conference, I always
get people there slagging off the hospitals. If you go and speak
to an audience of hospitals they say the problem is with primary
care. We can all give out if, frankly, it is either/or; we have
got to have both and crucially we have got to have a spectrum
of services in each and every area that allows older people and
their families to make the appropriate choice for them, and that
is what we are trying to do.
221. Do you foresee a time when a Secretary
of State—and figures come up where we have lost 25,000 beds—will
feel able to stand up and say that is an achievement rather than
a problem?
(Mr Milburn) You have got an ageing population. You
have not just got an ageing population but you have got more people
being more acutely dependent towards the end of their lives in
very old age, 85 plus. You only have to go to any nursing home
to realise the demographic make-up of a nursing home.
222. The Minister and I had an exchange when
she was last before us on this issue. I pointed out that other
countries had a similar proportion of elderly people who do not
have any form of institutional care. Do you see a time when we
may move towards that?
(Mr Milburn) That is why we have got to get the spectrum
and the balance right. As I said in my statement, we have got
to move towards a situation where more and more elderly people
have the choice of being cared for as long as possible in their
own home rather than facing only one choice which is care in a
care home. What we will do, with more intensive packages of support
and the gamut of things and more levels of support, too, over
these next few years is we will allow a greater proportion of
elderly people to be cared for where they want to be cared for,
outside an institutionalised setting, and long may that trend
continue.
Julia Drown
223. Many members of the Committee would welcome
your target by 2005 of twice as many people receiving intensive
help at home, but the data supplied to us for this public expenditure
inquiry shows there is more intensive help going to fewer people,
so how are you going to achieve this turnaround which the Committee
have pursued on a number of occasions, and the idea that low-level
help may be really effective, preventative help. We have not got
the concrete evidence to show that to be true but all the anecdotal
evidence would suggest that to be true. How are you actually going
to achieve that turnaround?
(Jacqui Smith) The first thing to say is the Chairman
accuses ourselves of not trumpeting our success. You are right—it
is a success that we have a 38 per cent increase in those people
receiving intensive packages of care in their own homes since
1997 and that we have got more hours of home care being provided
in home since 1997. The problem, I think, comes when you define
low-level care as only being about the hours that somebody comes
in and visits you in your home. My argument would be that in the
past sometimes what local authorities have done is to send in
a home help for perhaps sometimes as little as 15 minutes a day
for something which is really not appropriate for the older person.
That goes on for a long period of time and it assumes that no
effort is being made to ensure that that older person is enabled
to be independent. Some of the other things are not included in
that figure of home care, like community equipment services, like
the use of occupational therapists, like people going out to day
care and receiving support there, like housing adaptations, where
we are also with the Office of the Deputy Prime Minister investing
more. Those things in terms of low-level support are more effective
in providing the sort of care that people need to be independent
and, in fact, if you look at those figures, in the last year there
is a figure of something like 1.3 million people who have been
supported through that variety of low-level care. Perhaps the
accusation is we do not record that information properly and I
think that that would be a fair accusation. I do not think we
do. I do not think our data collection has kept up with the new
ways in which we need to provide support for older people, all
the various different elements of it.
John Austin
224. On the ability to support and maintain
someone at home rather than in an institution, whether it is high-level
care or low-level care, there are many more people, in my view,
who could be cared for at home if their home were suitable, but
of course the provision of suitable homes, ie sheltered housing,
is not your department's responsibility, so in terms of planning
for the future and in terms of what level of capacity we need,
how does the Department of Health tie in with the other providers
of bricks and mortar to provide say sheltered housing whether
it be local authorities or housing associations?
(Mr Milburn) I think there are two things there. I
think there is what can be done to better help people stay in
their existing homes. You must find it, I find it in my constituency
that one of the most frustrating things for older people, and
largely their families who come along to surgeries, is about the
delay that they face in getting some pretty simple, bog-standard
community equipment that makes all the difference as far as maintaining
independence is concerned—rails, ramps, showers, and all
that sort of stuff. That is a real problem and local authority
performance is extremely variable, it has to be said, and of course
presently, although we will change this before too long, there
is a charge for that fairly low level but pretty vital community
equipment. The stuff of handrails and hoists is never going to
make the newspapers, with respect, but it is hugely important
for lots and lots of elderly people. If we could provide more
of it, first of all, and, secondly, if we could provide more for
free, which is what we want to do and, thirdly, provide it more
quickly which is why we have set some pretty demanding objectives
for local authorities, I think that, in Julie's words, is a very
simple, good, cost-effective measure that will prevent people
necessarily having to go into hospital and indeed remain independent
when they want to remain independent. That is point one. Point
two is what can we then do for those people who do need an increase
in intensive help and support, but outside of the Chairman's institutionalised
setting, outside of a care home—extra supported housing
and so on and so forth. There are some fantastic and very innovative
schemes. I visited one in Leeds in the last year which they put
together with one of the housing associations—I do not know
which one—which is very good and we would like to encourage.
So we are in discussions in terms of what our responsibility as
a department is with other government departments and we have
been in discussions with housing associations to see if we can
migrate them into this market. There are a number of housing associations
potentially interested.
225. But the supply of that will have a profound
impact on the numbers of residential care beds that are required.
(Mr Milburn) I think in the short-term given the capacity
constraints that exist, particularly in some parts of the country
(and, crudely, the further south you go, the worst the position
becomes) then I think we need to see a modest increase in care
homes places for the interim period, but we need to see quite
a big expansion over and above that of intensive home care support,
low-level, home-based support. I said in the Commons that we want
to see a 50 per cent increase over the course of the next three
or four years in this form of extra services and care enhancement,
precisely because it works. It both affords people dignity and
independence and yet provides support for people. It seems to
me to be a good model and one where we are trying to actively
encourage, not just local authorities but housing associations
and potentially other players to get involved. There is no reason
in theory, for example, why local primary care trusts or the National
Health Service should not get engaged in this. If there is a problem
with hospitalisation rates or readmission rates, the problem of
people being in hospital who need not be in hospital, this is
a perfect reasonable thing for PCTs to think about their role
in this. Very often when you go into one of these places like
the place in Leeds what you find is that the building is one thing
but there is a huge focus of different services all providing
services there, whether it is leisure or the Health Service with
occupational therapy and so on and so forth. There are some models
on which we can build.
Julia Drown
226. Going back to where we were, I would not
necessarily want to encourage a lot more data collection, but
I would want to encourage better low-level services to be developed
where that is possible. Given the huge pressure on social services
departments across the country—child protection, the vulnerable
elderly and so on—how will you get those social services
departments to find money to spend on low-level services?
(Mr Milburn) Can I say one thing just to begin with
and then Jacqui can add something. As you know, in a sense one
could say, although it is an unfair charge, that we created a
rod for our own backs, because our commitment is—and I think
it is a right commitment to make—that we will move towards
less and less earmarking of resources for social services generally.
That came up with the Government White Paper published back in
December. I think that is right because in the end I cannot decide
what is right for Birmingham any more than you can. That has got
to be a decision taken locally by local council taxpayers and
by the Government through inspection of the councils' accounts.
So there is a low level of earmarking overall and I think we are
going to reduce earmarking for social services by about 40 or
50 per cent over the course of the next few years. However, within
that what we were very conscious of when we came to look at how
best to use the resources when we came to look at the spending
review was precisely Simon Burns' point that almost inevitably,
because there is a statutory requirement on social services, what
they tend to put first, for perfectly understandable reasons,
is children's services, and there is no argument about that. Life
is always full of difficulties and it is difficult in central
government and it is difficult in local government. What we cannot
have is one set of decisions adversely impacting on other services,
which was why there was quite a high level of earmarking for the
elderly care bit of social services. There is more, it is true
to say, of the elderly care package within social services which
is being specifically earmarked precisely to avoid the situation
that Simon Burns described earlier, which means in some ways we
are saying to local authorities, "Look, these are areas where
you need to spend money."
227. You mentioned there about it being right
for local authorities to dictate the shape of the local market.
Would that be the case even to the extreme that if there were
a complete monopoly, say, by a private provider in a particular
area that you would feel comfortable with that?
(Mr Milburn) I think it is their decision in the end.
What is our concern here? Our concern in central government has
got to be to ensure that the standards that are being set nationally
are being met.
228. Would that be the same if it was all in-house
provision as well?
(Mr Milburn) That is a matter, I think, for local
authorities to determine and they will have to report on both
standards and value for money. In the case of Birmingham, for
example, Simon has raised a perfectly reasonable point, the local
authority will have to explain both locally and nationally whether
for the money it is getting both from central government and the
local council taxpayer it is getting both better outcomes/improved
standards on the one side and decent value for money. In a sentence,
we are not prescribing a model that says it has got to be this.
However, it would be pretty foolish, would it not, if there is
capacity available and organisations which can provide local services
for there not to be a dialogue and partnership approach to provision.
229. Finally on these issues of where is the
right place to take decisions, I know it is historical reasons
that means there is a national system for deciding for charging
for residential care. You had the intention with Fairer Charging
of trying to look at a fairer framework for other types of care—for
care in the home and so on. But what is the reasoning behind there
being ultimately a national approach for charging people when
they are in residential care but a local one when you are charging
for other services which especially in the light of recent discussions
about them being really two alternatives—either being at
home or being in residential care—it is hard to hold on
to the logic for that?
(Jacqui Smith) I think there is a certain amount of
history here, to be honest with you. I think we also need to look
at whether or not that history delivers what it is that we want
to see in relation to both of those two areas. I have no reason
to think that moving away from a national means test with relation
to residential care would benefit us in terms of the sort of objectives
we have been talking about today. In relation to non-residential
care we have not said we want to move to a position of a national
means test, because that is an issue that is, rightly, for decision
at local authority level and, of course, some local authorities,
a very small number, have decided that they do not wish to charge
at all in that particular area. What we have said, and this was
obviously a recommendation that came out of the Royal Commission,
is that where local authorities are charging for non-residential
care that it is right that there is a framework that puts into
operation the sort of principles that most of us would think are
right round how you design a charging system. That was the reasoning
behind issuing the guidance on charging for services. The sort
of principles in there are that we should not be charging people
on very low incomes, that we should be recognising disability
expenditure before we are charging out of disability benefits,
we should be promoting what good authorities already do, to ensure
that their clients are making the most of their benefit entitlement,
which some of them are not, there is a very strong emphasise on
that. Can I say one other thing about how we make sure we get
to where we want to go, we have done a lot of work in terms of
how we performance-manage social services departments—I
touched on star ratings earlier—in relation to older people
we already have Help to Live at Home, a performance indicator
which will be a very important benchmark of the success that local
authorities are having in developing that. We will, given the
emphasis we want to place on community equipment, want to develop
a performance indicator round community equipment as well as an
important output measure of how local authorities are delivering
on this objective of supporting people in the broadest possible
way.
Mr Amess
230. I am listening carefully to what is being
said but it seems to me as if ministers are being complacent.
If you have elderly people who need to be looked after and you
cannot do it yourself the manyana attitude is not acceptable.
I have to say that ministers are talking about it being patchy
throughout the country, perhaps we are just unlucky in Essex and
Southend. Certainly in my area we have a lot of people who need
to be looked after. Ministers were warned what would happen about
the Care Standards Act and the impact in our area is very, very
serious indeed. Hardly a week goes by where there is not some
argument between social services and the private sector that someone
wants to be moved out. I know you have the best intentions of
these people at heart, and all members of the Committee applaud
what you want to do, try to look after people at home, but locally
it does not seem to be working. Finally, can we have some guidance
on this? Local government is saying the Government is taking away
more and more of their powers. They give members of Parliament
the impression that there is a limit to what they are able to
do and at the end of day they are looking to central government
for funding. Whilst all of these arguments are going on people
are suffering. I have many elderly people in my area with no relatives
at all, they are just dependent on friends and neighbours, is
there not some mechanism whereby the Government, I know you have
gone out to consultation again, give some immediate help, if you
like, arbitration between these endless arguments—none of
this is new—between what the private provider is given and
what the local authority is given. In my area more and more of
the homes are shutting, and they are basically saying, well we
argued about the room being six inches too small or the lifts
and all of that, we are not going to wait for further consultation
we are closing now. Certainly in our area we have a crisis.
(Jacqui Smith) Firstly I do not want to repeat myself,
this is most certainly not about manyana, this is about recognising
what has already happened in the last five years but also recognising
there is more that we need to do, more money needs to go into
system. You have particularly focused on care homes and it seems
to me you have identified two problems, firstly that care homes
need to have their costs reflected in higher fees. We accept that.
That, of course, was one of the reasons why we introduced the
£300 million building care capacity grant which is already,
today and yesterday, having an effect on fee levels. It is also
part of the reason for the additional extra investment going into
social service departments. Heaven forbid we should get into arguments
here, one of the reasons why social service departments have had
problems keeping up the sort of fee levels they want to maintain
quality is because, frankly, the pathetic levels of funding up
to 1997 that those social service departments were facing. We
are talking about increases from 1992 to 1997 of point 1 per cent
in real terms, from 1997 to 2002 of 3 per cent real terms and
for the next three years of 6 per cent real terms. Yes, we need
more money, we are putting more money into the system. Secondly,
you raise the issue of standards. Let us be clear where we came
from, we came from a situation not where there were no standards
but where there were 250 different authorities imposing a variety
of standards on different care homes. Quite rightly care home
providers said to the Government, they even said it in the time
when Simon was a minister, this was an inconsistent system, they
wanted a level playing field. That was the reason for introducing
the Care Standards Act. We always said we would look very carefully
at the impact that was having on care homes. These standards were
introduced in April, we had already taken action in January to
make clear to the National Care Standards Commission our view
that room sizes, lifts and door sizes should not cause good care
homes to close when there was still concern that that was not
being reflected in what care homes felt about it. As Alan announced
in July we are consulting and we intend to ensure that those good-quality
care homes existing in April 2002 will not face new improved environmental
standards, even those that were not due to come until April 2007.
We recognised even though we have given than long running time
there were some care homes that there were concerns about. That
is all action that has been taken today and yesterday and which
is already beginning to have an impact. Is there more that we
need to do? Yes, there is. We have listened where there are concerns
and we have put in money where it is necessary. That is already
beginning to make a difference.
Mr Burns
231. I just want to ask because possibly, I
know you cannot comment on this at this stage, there is going
to be legislation in the Queen's Speech next week which will presumably,
possibly, implement one of your proposals that you announced in
the House the day after the Budget, I think it was, to take forward
the NHS plan and for the fining of social service departments
if they did not fit the relevant criteria. You have consulted
on that, could you please tell us what your consultations revealed?
Did you have, for example, a 100 per cent consultation saying
what a marvellous idea this was? Did you have people replying
saying they thought there were better ideas and this was not the
best idea to proceed with? Could you share your responses with
the Committee?
(Jacqui Smith) It might not surprise you to know that
we did not have a 100 per cent positive response for these proposals.
However, I think there is a recognition—there was recognition
as I said when I came and talked about delayed discharge in evidence
given to this Committee—that we do need to have a much clearer
idea in the system about where responsibility lies between social
services and health. We do need to ensure that we have the necessary
incentives in place so that when we begin to get even more of
the additional investment into social service departments to provide
the sort of alternatives that we have been talking about today
to hospital care that we are clear that local authorities will
be spending money on those alternatives and we are going to be
able to bear down even further than we have already done on delayed
discharges.
232. That was not exactly the question I asked.
I will rephrase the question to press you further, what proportion
of responses to your consultation, in percentage terms, expressed
support for the Secretary of State's proposal for fines for social
service departments?
(Jacqui Smith) I do not know. I know, as we usually
do with consultation, we will make that consultation public.
233. Let me broaden it a bit, I suspect you
have a rough idea of the answer to this question, I will be amazed
if you do not. Broadly, were the responses more in favour of the
Secretary of State's proposals or more against them?
(Mr Milburn) They were more against them.
234. Thank you. Was it overwhelmingly against?
(Mr Milburn) I have no idea at all.
235. It was more against.
(Mr Milburn) It was more against, so nobody is surprised.
However, there is a funny old thing about being a minister, you
must remember this, you have to do what you think is right. Sure
you go out and consult, you talk to people, so on and so forth,
people have a right to put their view and in the end we have to
decide what we think is right. I will tell you what I think is
wrong, it is fundamentally wrong, in my view, where you have confusion
about responsibility. This Committee under the chairmanship of
Mr Hinchliffe has argued more cogently than anywhere else in this
place that what we need is one care system where people accept
responsibility for what they do, particularly for the elderly
person, not just the elderly person but those with a mental health
problem or learning disability or whatever. Partnership is a really,
really nice idea and it is a very, very cosy word to use and we
are all terribly in favour of it, I am terribly in favour of partnership,
but in the end what it means is that somebody somewhere has to
accept their responsibility because otherwise it does not work.
Despite extra money going in, despite the fact there are a number
of people whose discharge from hospital is needlessly delayed,
as it, it is falling, we have far too many people needlessly in
hospital because somebody somewhere is not accepting their responsibility.
We have to find a way of putting that right. If we do not put
it right what you are doing is condemning individuals to being
in the wrong place in the system at the wrong time and you are
condemning the system to further pressure. I think that is fundamentally
wrong. We have consultation, of course we listen to what people
will say about this but make no mistake about it, we have to find
a structural solution to what is, in my view, a structural problem.
236. Broadly most of what you just said is absolutely
right. If we can get back to the question of fining, given that
you said in your response you want the best system possible for
people to take responsibility to ensure that people are not languishing
in hospital unnecessarily but are getting appropriate care, I
do not think anyone would disagree with that. You also said that
as a responsible person you listen. So you have admitted and accepted
that a majority of the consultations were against your proposal
for fines. You are listening. Presumably these people have not
just written in saying, "we are against. . .", they
have given you a rationale as to why they are against it. As you
are in listening mode can you share with the Committee, are you
going to make any revision to your announced intentions of the
fine system in the light of consultation representations you have
received?
(Mr Milburn) We need to wait and see. I am not going
to prejudge anything that may or may not be. You asked about the
Queen's Speech, I am not going to prejudge anything as far as
that is concerned. I will tell you, I have found while doing this
job, being a minister in general, that very often you are faced
with quite a wealth of decisions that you want to take, that is
because there are difficult decisions to take. What I have to
do, what Jacqui has to do and what we will do is take the right
decisions.
237. Lovely.
(Mr Milburn) We will take the right decision bearing
in mind there is a structural problem that requires a structural
solution. Where partnerships work they are great but where they
do not work it is a disaster.
238. I am glad you mentioned partnerships because
that leads on to my next question, where partnerships are working
well—obviously the whole emphasis has to be encouraging
the development and the working of partnerships to the best possible
levels—what damage do you think is going to be done to them
with the introduction of a fine system?
(Mr Milburn) None. I think it will enhance the partnership,
not diminish it, because everyone will be crystal clear about
their responsibilities.
239. I am not in a position at the moment, because
the system is not in place and if it is introduced we will find
out whether that answer is right or not, it will be extremely
interesting if the system goes ahead, as envisaged, whether partnerships
benefit, because I suspect that it will put unnecessary and undue
strains on partnerships. We will see.
(Jacqui Smith) Can I say, Alan's point was right,
we are all in favour of partnership because it delivers results.
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