Examination of Witnesses (Questions 40-59)
ALAN MILBURN
MP, JACQUI SMITH
MP, MR RICHARD
DOUGLAS, MR
GILES DENHAM
AND MR
NEIL MCKAY
WEDNESDAY 17 OCTOBER 2001
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.
Chairman
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.
Chairman
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!
|
