Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 40-59)


  40. That is very encouraging. You will, no doubt, realise the disappointments many of us have had. In my own case Mr Milburn promised 35 GP beds and we assumed those would be funded, and the health authority said they can only fund 20, so to know that this is really new beds is great.
  (Jacqui Smith) You will have no disappointments in me. I think your constituents have done quite well under this Government.

Mr Burnham

  41. I would like to hone in on the issue of private nursing homes because I think it is very much linked to the question of the intermediate care bed policy. It is anecdotal evidence from bitter personal experience, I get the feeling that the quality of care in some independent private nursing homes is very, very poor and it is of such a low standard that it is becoming a risk to the people in the homes. I do not know whether that is backed up by any evidence. How concerned are you about the private and independent nursing home sector, do you think it is impacting on the NHS? Do you think it is making the NHS a more difficult job? You have looked at the inspections regime, do you have any plans to change it?
  (Jacqui Smith) Firstly, I do not think it would be fair to suggest that the sort of care that is routinely provided in independent care homes and residential nursing homes care is substandard.

  42. I am not saying across the board, there are patches that have very poor practice.
  (Jacqui Smith) We need to make sure that wherever you receive your residential care or your domiciliary care, care provided for you in your home by domiciliary agencies, for example, or other services provided in the social care field, that wherever you receive it is of a uniformly high standard. That, of course, is the reasoning behind the publication earlier this year in the case of older people, of national minimum standards in relation to care homes for older people. It is also the reasoning for bringing in as from next April the National Care Standards Commission to ensure that we do have a coherent inspection and regulation regime across those social care services. If you are suggesting it was not coherent before I agree with you, it was not, and that is the reason for making the changes that we are going to be making to the inspection and regulation regime. Although, as Richard suggested, there have been some concerns from care homes about how they implement those standards there have also been a lot of welcome of those standards precisely because I think care homes realise that, 1) if everyone is confident they will get a good standard of care and 2) if that stand area of care is regulated in a consistent way it actually helps.

  43. I do not think there is a problem at all with the standards, it is problem in some ways with the operators and the nature of the operators that are involved in the sector, some with no track record in providing care becoming involved and taking over homes.
  (Jacqui Smith) I would be very happy to send you details of the standards. That is why in the standards some of it is about physical environment but probably, much more importantly, it is also about the qualifications of the management, it is about the qualifications of the staff, it is about the type of complaints procedure, all of those things which help people to feel confident that the care they are getting, which ever sector it is in, is of a high quality and covered in those standards.

  44. Can I broaden it out to social services funding generally and what I see as the growing disparity between NHS funding on the one hand, core NHS funding, and the funding that local authorities are allocating to the social services budget. Is there any evidence to suggest that some local authorities may be cutting back social services funding because they are aware of the money in the health service and they think that the health service will be picking up the slack that local authorities might be leaving, particularly as they see intermediate care beds coming on stream there is an opportunity to pull back from some of the services they are providing. If that is so, if there is evidence to suggest that, do we need to look at more ring-fencing, more protection of the social services budget?
  (Jacqui Smith) No, I do not believe there is evidence to show that. What I think we need to do is to promote in a way that the agreement I referred to you before does, in a way that government legislation has, the sort of joint working, pooled budget, partnership arrangements between health and social care at a local level that actually means that we get away from these arguments about is it health money or is it social services money because, quite frankly, if you are an old person in hospital and you are waiting to get out of hospital you are not fussed which budget it comes out of, what you are concerned about is that there is support for you when you get home, there is an intermediate care bed you can go to for rehabilitation. It is beginning to the happen but what we need to promote even further is the pooling of that money, is better joint working, because where we see that we see evidence that we can address problems like bed blocking, we can make sure people do not end up going into hospital. We are seeing some evidence of the flexibilities that are now available being used. We have referred to us, and there may be more than this, 61 projects spending £800 million, not all those for older people, but those are projects where pooled arrangements between health and social services are improving services for the people that are using them.
  (Mr Milburn) May I add one thing, it is very, very important, in my view, that both the local NHS and the local social services get out of their ghettos, they have to understand that they sink or swim depending on the strength of the other. You can see that around the whole delayed discharge problem. What you cannot do is provide the optimum levels of emergency care or shorter waiting times in hospital unless outside the hospital you have a social care system that is operating more effectively and in cooperation with the local health service. Sometimes, sadly, those relationships are not as durable or as strong as they should be. It is very, very important on both parts that there is a will to make cooperation happen. What we have provided is the means to make cooperation happen. When we legislated a couple of years ago we legislated precisely for what local authorities and parts of the health service wanted, which was the ability to cooperate, pool their budget, introduce lead commissioning arrangements, and so on. There is some of that but I think we will want to look very, very carefully about how best we can speed the further development of the pooling of resources. I think you have a point, incidentally, on your first question, which is about the relationship between social services funding and health service funding, social services funding against the historic trend is rising quite fast, however there are very big pressures on budgets, not just for care of the elderly, but care of children, particularly for the most vulnerable members of the community. What we have to start looking at is this idea that over here you have an NHS budget and over here you have a social services budget. We should have, as Jacqui says, one care system effectively with one care budget. The way that you get to that is through the pooled budgets and the partnership arrangements we set out. So far that has been a matter of voluntary endeavour and we would prefer for it to remain as a matter of voluntary endeavour. We will also look very, very carefully to ensure that patients and users in all parts of the country are getting the benefit that some are getting in some parts of the country at the moment.


  45. There is another position, one common organisation.
  (Mr Milburn) There is never a Health Select Committee hearing where that option is not raised, usually by you, Chairman.

Mr Burnham

  46. The aims of Government are that the targets you have and the aims that you have might be seen by local councils as not being spent appropriately on social services, that is something out of your control in many ways. Is there any way round that? Is that something they will have to be accountable for, to look at people, stand up and take decisions and expect to take the wrap if it is a difficult one.
  (Jacqui Smith) You are right that local authorities will make decisions about their social services budget but, for example, I think increasingly we will expect to see in the case of older people, let us say, in the terms of the extra money we allocated through the agreement, we will expect to see for that additional money results in terms of beds unblocked and delayed discharges reduced, particularly in those areas where we are focusing the money. However, in the end, you are right, local authorities will need to make decisions about their social services funding but I hope they do that in the light of looking at the sort of needs of their local communities. It is quite clear that unless you prioritise and work with health services in the way that we have suggested and, as Alan has said, positively facilitated you will not provide the service to your local people they deserve and should have.

Dr Naysmith

  47. This area has been pretty well explored, I just want to say I agree with what the chair said at the beginning, it is a good thing to be moving away from too much reliance on being in residential homes and moving towards supporting people in their own homes. Nevertheless, we still have at the moment some real problems, referred to very loosely as bed blocking, which covers a lot of different situations, it is really quite important. You were talking about local authorities recognising the needs in their areas and responding to them and funding them properly. There is a lot of evidence, particularly in the South-West of England and Bristol, where I am Member of Parliament, historically there has been under-funding for social services and the problems may be worse by the fact that people tend to retire to the South-West of England, that the disparity between social services funding will grow over the next few years, and the National Health Service funding is quite great. How are you really going to make sure that the needs of the local population are taken into account when it is done on historical funding, and so on? It is no good saying, Secretary of State, if they can do it in one place they can do it in another, that is true of many things but not true of everything, it is certainly not true of this.
  (Mr Milburn) There is a means of these two quite big pots of cash coming together. If you compare, I know there are real pressures on social services budgets, which is why we announced last week the extra £300 million.

  48. Which is very welcome.
  (Mr Milburn) That is very exciting. That takes the social services average growth up to around 3.7 per cent. A few years ago it was rising at an annual rate of 0.1 per cent. There are big pressures, really very big pressures, indeed, out there. We have to look very, very carefully in the future at how we ensure that the rate of growth for social services, in terms of its funding, and the rate of growth for the National Health Service is compatible with what we want to achieve, which is improvements at the interface, the health service and social services working in cooperation, these problems around delayed discharge being dealt with and for certain services, and learning disability is a good example of this, where frankly the two organisations and, indeed, the voluntary independent sector should be throwing in their lot. For people with learning disabilities they rely as much on the support of the NHS and not just social care. What is quite heartening about the partnership arrangements that Jacqui alludes to, the pooled budgets arrangements, is that very many of them are for people with learning disabilities, and that is good. What we have to do is make sure that applies to adults and particularly to elderly people too. I note the point. We are very well aware of the pressures. I also think it is important that both local social services and the local health service recognise they have some institutional means to solve some of these problems, we provided that for them through the partnership arrangements. Last winter we put money out for the NHS and a good proportion of it ended up being spent by social services, why, because they were tackling the same issue. Finally, we have a means actually, if there is the will there on the ground for the two to really get together through the Care Cross model for social services and the health services not just to pool their budgets but to pool their management arrangements, their administration so in the future when it comes to care of the elderly there is one organisation and not what we sometimes see as two competing organisations vying for how they provide services to people.

Julia Drown

  49. Can I follow up the chairman's point of view about capacity. There are differing views round the table about if we can ever get to the point of no nursing homes. I hope you would say it is an informed choice that is important for the individuals and their families. Do you have a view at the moment about the informed choice of people of home care services and other things? Do you think there is over capacity or under capacity in terms of nursing or residential home? Furthermore, does that mean you then have a policy that if you want people to have a choice about nursing or residential homes that either means that you need to plan to have a vacancy factor and does your practice guideline say you should be expecting there to be a vacancy factor in your home or is part of the policy accepting there are delayed discharges, and always will be because people have to wait for a space in their home of choice before they can move to it?
  (Jacqui Smith) No. For example in the care home sector at the moment the occupancy rate nationally is about 90 per cent, that differs in different parts of the country, that is part of the challenge of what needs to happen and it is also the reason for the agreement because in response to your question it will differ. Providing a choice for an older person, which I agree with you is absolutely fundamental and, if you like, the mind set that solves this problem is that you put the older person's needs at the centre of your decision making then you work out what part care pathway that older person needs, what choices they want to be able to make, what range of services they are going to need and then you provide those in the most effective way, you do not get high bound by whether that is coming from the social services budget or the health budget. In order to be able to do that you have to, in terms of commissioning at a local level, have a much better system than has existed in a lot of areas. One of the reasons, I suspect, why it has not happened is the suggestion that Doug made, people have thought the answer is to safeguard their budget, well it is not, the answer is to plan much better together. One of the things that we will expect in the agreement that we published, which had buy-in from the Health Service, from local government and from the independent sector is that at a local level there ought to be a three year plan that brought together the partners to look at the type of services that should be available locally, whether or not that is residential or non-residential services, and compare that with the sort of capacity that there was locally, then to plan together what they need to do to invest and to change the nature of the services to ensure that that choice that you talked about is there.

  50. You expect there to be a vacancy rate, do you have any idea what that should be to have an informed choice?
  (Jacqui Smith) No, because I think it depends on what your local circumstances are, what your balance of provision is, what the sort of preferences are that users locally have expressed.

Mr Burns

  51. There is the problem that with the closing of residential homes there is no even pattern throughout the country and one is getting areas of the country where there is a severe shortage, whereas in other parts of the country there may be a surplus. Given you are dealing with elderly people, you cannot move the people to fit the places. In my own area of Mid-Essex we are having a problem where it has been decided through assessment the most suitable place for some people to be is in residential care rather than in a domiciliary care faculty at home, and they are now finding because there are not enough beds that they are having to move from the familiarity of an area where they may have lived all their lives, where their immediate family still are, 30, 40 miles away, which to us may not be very far but to them the upheaval is tremendous. Or you have a problem where all the efforts are being made and the additional money to reduce delay discharge from hospitals is being thrown out of sync because of this problem. What can be done realistically, if anything, to try to overcome this problem, short of just building more homes, which is an option?
  (Jacqui Smith) It is because we recognise the particular problems in Essex, of course, that Essex have got £2½ million out of the announcement.

  52. All right.
  (Mr Milburn) He is pleased!

  53. I approve.
  (Mr Milburn) I am glad we have got that on the record.

  54. Sorry, let me just pick that up. That is great, I am certainly not complaining and I do not suppose anyone else is, but how is that going to directly help the problem I have posed to you?
  (Jacqui Smith) Because one of the things which might happen is that it may be necessary for Essex Council to sit down with its private nursing home providers and talk with them about the sort of fee levels which would be necessary to ensure that the supply to provide the sort of choice you are talking about is there in the future. It may be what is necessary is to look at some of the NHS provision which is in Essex in order perhaps to promote more into the intermediate care services which will enable people not to have to go into long-term care. There is not a necessary inevitability that if you break your hip, for example, you end up having to go into a care home. It may be that people have tended to think they need to and there has been a culture around that but, quite often, people do not need to. But, you are right, it is not a good thing for people to have to travel 40 miles for there to be the sort of care they need. That is precisely why we need that much better commissioning at a local level than there has been.

  John Austin: Doug Naysmith was talking about the growing disparity between the increased expenditure in the NHS and Social Services. Can I refer you to Table 5.2.1, which is the outturn and budget compared to an SSA. I know Darlington is an exception to the rule—

  Chairman: It always is!

Mr Burns

  55. And so is Sedgefield as well.
  (Mr Milburn) And of course Mid-Essex with its £2.5 million which you were so grateful for just a moment ago.

John Austin

  56. I cannot believe the disparity and the spending above SSA for most of the local authorities here; the vast majority of local authorities' social services departments spend way beyond their SSA. Is this not clearly an indication that there is something wrong in the calculation of the SSA formula, particularly in relation to social services?
  (Jacqui Smith) It is right that local authorities make decisions about how they are going to allocate their money, and in relation to that table it is interesting to note that spending well above your social services' SSA is something which has happened throughout the whole of the 1990s, and there is no evidence, for example, in the last year that that has gone higher above the SSA. But if what you are saying is, do we need to have more money going to social services departments, then the answer is yes we do, and that is why more is being invested into social services departments.
  (Mr Milburn) Let me say one other thing. It is absolutely true, and Jacqui can be the dove and I can be the hawk on this, there should be more money and we are putting more money in. As we look through these tables, there were interesting questions the Committee asked about the variation in performance between social services departments, not just on outcomes but on inputs too. We know from study after study that, for example, residential care provided by local authorities tends to be more expensive than residential care provided by the independent sector, and yet, maybe for good reasons but sometimes for bad, local authorities continue to commission the most expensive form of care, and that is not getting the optimum result for the taxpayer or indeed for the user. What we have to do is two or three things here. One, we have to get the investment right. Two, we have to take a long, hard look at how we get maximum efficiency for the investment we are putting in, including through the best value regime, and none of us should be frightened of doing that, we should not be frightened of comparing what the costs are between different authorities and different services. Thirdly, as Jacqui has been indicating, we have to stabilise the care home market. That is very, very important. The truth is for 15 or 20 years there has been a market out there which has just operated as a market, and the National Health Service has assumed it can just get on with its business and not worry about what is going on. By and large for a lot of those 15 or 20 years, people did very well out of it; large profits were made. That, to be truthful, has not been the case over the course of the last few years. In part that is in the South East, Mr Burns' area, the consequence of economic prosperity. Property prices have risen quite markedly in many parts of London and the South East and people have taken a hard look in a market way at where they can best get a return, and many people have concluded that with local authority fees rising by 2.9 per cent on average when property prices are rising far faster, the most sensible thing to do in commonsense terms is to get out of the market. That causes a problem for us in some parts of the country. What I think is so important about what we did last week is not actually the £300 million, to tell you the truth, it is the fact that we published an agreement between local authorities, the Government, the National Health Service and the independent voluntary sector which basically said, "We sink or swim together." Unless we can get stability in the market, and in some parts of the country get additional capacity into the market, then the National Health Service will not be able to do what it needs to do. There are two things which flow from that. One, we have to get all the players around the table in future when it comes to planning the local care system, and by that I mean the independent sector as well as the statutory sector. Secondly, we have to be entering into longer term agreements between the statutory and independent sector rather than just spot-purchasing shorter term contracts. Unless you get longer term stability in the market, people will assume they cannot get the returns they need. I agree with you about investment but it is like many of these public services, the answer is not just putting more and more cash in, we have to make sure we get a return for the cash.

Dr Taylor

  57. I am delighted, Secretary of State, you have mentioned best value because very simple arithmetic shows you that the annualised average cost of unblocking a bed is £200,000, and the actual cost of running a general and acute bed is only £110,000 per annum. Would it not be more sensible in the short-term at least to keep open a few more acute hospital beds and thus save some money?
  (Mr Milburn) We can go even further than that, and we are. For the first time in 20 years the number of general and acute beds is actually rising. Actually I think they rose in 1978 by a few but they are rising now by several hundred and they will continue to rise. We have a problem in that in my view for too long in the NHS there has been a philosophy around that somehow beds in hospitals are bad things, and all of our planning assumptions have been about reducing and reducing bed numbers and assuming, rather naively sometimes, we can build up community services and they will cope. When you have average occupancy rates of around 89 per cent, as we have now, in our NHS hospitals—compared incidentally to average occupancy rates of around 55 per cent in private sector hospitals—that causes a problem right through the system. It means you cannot get the waiting times down, it means there are too many delayed discharges, it means that people coming through the front-end, through the emergency services, do not always get the optimum level of treatment they need in the right place in the hospital. So my answer to you, Dr Taylor, is you have to do all these things at once. There is not a magic silver bullet you can fire to solve the capacity problems in the NHS or social care. What you have to do is build capacity across the piece, in intermediate care, yes in the residential and nursing home sector, certainly in domiciliary care for people which we need to see vastly more of, but we also need to take appropriate action to ensure we get the occupancy rates down in NHS hospitals as well.
  (Jacqui Smith) I am sure you are not suggesting, are you, that it would be good for an older person to go back to the sort of situation where long-term geriatric beds in acute hospitals were the solution? That was neither good for the NHS and, most importantly, it was not what older people wanted. It is certainly not what they want to go back to. We need more beds, as Alan said, which is why for example the fact we are delivering more intermediate care beds, some of which are making use of hospital capacity to deliver them, is a good thing not only for the NHS but, most importantly, for the older people we are trying to give a better form of treatment to.

  58. I am quite sure the people of Worcestershire will not see that you are increasing the number of acute and general beds.
  (Jacqui Smith) Well, we are.
  (Mr Milburn) We have to make sure that happens everywhere, with respect, and not just in one town in Worcestershire. We have to make sure it happens across the whole of Worcestershire and across the whole of England.


  59. In relation to care trusts, which I find more attractive than some of the models which have been offered by the Government in relation to collaboration at the local level, is there any comparative work being done in terms of how that impacts on joint working compared to areas where we do not have care trusts? Could I also ask about the issue of joint budgets. We have a situation in my constituency—and the Secretary of State knows Wakefield reasonably well—where in the current financial year the social services departments are having to make a reduction of around £2 million in their budget. Under what circumstances would a health service partner want to come into a pooled budget arrangement with a local authority which is facing immense pressures? All of us refer to our own experiences as constituency MPs but we have a situation where we have to speak about who is responsible for the care of people who are terminally ill, who may have six weeks to live. I have to say that I find it quite obscene that we are having debates about where the funding should come for somebody who is dying. My appeal to you, Secretary of State, and we have debated this long and hard over many, many years, is that we have to come up with some better answers than we have at the present time, otherwise we get into that kind of debate which I think is totally and morally wrong.
  (Mr Milburn) I agree with that. I think you are right, I think the care trust model provides an opportunity for that where both the local authority, on the one side, and the NHS locally through the primary care trust, on the other, could take the decision actively not just to pool their resources but come together as one organisation. Personally, I am very keen on that model. We have not got care trusts up and running at the moment, they are coming into being, there are a limited number. I think we have to test it and make sure it genuinely works and provides the benefits and outcomes both of us think will probably accrue, but I also think you have to accompany it by some changes for the individual. The truth is that structural change for the individual patient does not mean a damn thing. What counts for the individual elderly person or the situation you have described is that in future rather than having the GP, the health visitor, the social worker and the community nurse all coming out to assess the needs of a family, we have a single care assessment done by one individual. I think that is where we can get to. We are going to have a single care assessment process in the future, so we can assess the needs of the individual and their carers and family, and then we can just get on and fund it, regardless of where the money comes from. My own view is that in order to really achieve that, we have to start looking pretty hard at some of the demarcations which exist amongst some of the staff I have just described. I travelled recently with a health visitor on the plane down from Newcastle to London and she was describing to me her frustration about turning up in a pretty deprived community, doing her assessment of a family in need, only to find that the social worker had either turned up the day before or was turning up the day after to do precisely the same assessment. Why? Why does that need to happen? There is no reason. One of the more depressing things I find about some aspects of the care system is that people go along with these things because that is how they have always been done. That is what you have to change.

  Chairman: They have not always been done like that, before 1974 it was all different. They were all in local authorities, as you well know!

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