Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 160 - 179)



  160. You were very clear before that you did not think there should be any flexibility with the grant because it might be offset or vired into another budget. Surely there is a case for slightly more flexibility, particularly where you have authorities who have done good work and are funding good services at the moment? Why should they have to go and find new things to do when they are doing good things already?
  (Mr Gilroy) The grant is not just a means of bringing the numbers of delayed transfers down in the National Health Service, it is about better services for people, particularly older people. We are putting quite a chunk of this grant behind the implementation of the National Service Framework for Older People which Ian Philp has been talking about. Improving the profile and quality of services for older people is a challenge which all councils face.

  161. It is much easier for a council where they have not invested in intermediate care or they do not provide very extensive services at home now to go and pay for those services with your money. It is easy for them to go out and use the new money to pay for these things they have never paid for before. What about the council which already has them or has already done it?
  (Ms Platt) We do not know of any council which has the range of resources which is necessary to support the National Service Framework for Older People. Everyone got an allocation of the building capacity grant. Those councils which were not identified as a hot spot got their grant and freedom to look at how they were going to develop their response to the National Service Framework for Older People. The 55 hot spots have got to know us rather well because there are much more stringent conditions and monitoring of the 55 hot spots and there has been a very light touch on the councils which were not hot spots.

  162. We are not a hot spot yet there are these conditions.

  (Ms Platt) Exactly. You do not have as stringent conditions as the hot spots have. The conditions are about additional capacity over and above what you are currently providing. I really do not think there is any council which is providing the adequate, in-balance level of resources for all older people in their area to respond to the National Service Framework.
  (Mr Gilroy) We have not encountered any—not directly anyway; you may be telling us otherwise now, in which case we need to hear this—councils who have said they do not want the grant or that they will bank the grant but they would like to spend it on services for children or improving education services or whatever. We have had an awful lot of councils saying they would sooner be hot spots and have all of the heavy breathing that the hot spots are getting from us around improvement programmes and targets and so on. We have not had the other.

John Austin

  163. Do we know to what extent, if any, the building capacity money may be being used to increase fees to care homes?
  (Mr Gilroy) We think about 20 per cent of it this year is going to go in that direction. There is a big health warning about that. We got to that figure from an analysis of the 55 plans we asked the 55 hot spots to send us when we were doing the targets for them. An analysis of those suggests an intention to commit 20 per cent. If you extrapolate up that is £20 million but there is a health warning in that.

  164. Winter funding was a specific allocation for a specific purpose. We know that in the NHS Plan there is a proposal for an additional 5,000 intermediate care beds in the Government policy which we all welcome to expand intermediate care significantly. Whilst you refer in your memorandum to the £405 million earmarked resources for intermediate care, it was quite clear from a Parliamentary Question which I put to the Secretary of State that that money is not ring-fenced. It may be earmarked but it is not ring-fenced. Are we sure that it is going to go for the purposes for which it has been allocated?
  (Ms Edwards) We can be fairly confident. Firstly, there is very little difference in terms of the differential between ring-fencing and earmarking. What we have said when that money has gone out is that that is what we expect them to spend that money on. Earlier in the discussion this afternoon, we have talked about outcomes and measuring outcomes not inputs and we are moving more and more to measuring the outputs. In addition to saying this is what we expect you to invest in, we have put in very strong criteria about what we expect in return for that money. We have asked every single strategic health authority, on behalf of each of their PCTs to co-ordinate a capacity planning exercise and that capacity planning exercise will require them to state how the money they are getting this year will impact in terms of reducing the number of delayed discharges and increasing capacity in intermediate care. We probably have a tighter mechanism than we have ever had before for measuring, not them being able to tick in the box, which is quite easy to do, that they have put the money in, but what we are getting for it and being confident that we are actually getting the outputs we want. We are going to build that back up into a whole national picture when we get all the data back from each of the franchise plans that the strategic health authorities are doing. We have a very tight handle on it and we are going to control that quite closely.

Dr Naysmith

  165. Resources are also being redirected to local government through the personal social services SSA. Does this not mean that resources are not ring-fenced and might be used for other purposes? Do you think that is possible or likely?
  (Ms Platt) It is possible because anything is, but similarly we are trying to monitor this through the outcomes for the money rather than the inputs for the money. To take a step back from this, when we are looking at new monies for new services, there is an important issue for us to try to get the planning systems of health and social care into synch so they are actually going together and so that they can look at the planning across health and social care together. Part of the problem we have sometime which does inhibit local authority spending money on what might be joint priorities is that their budget cycle starts before the Health Service budget setting and SAFF round starts. One of the things we are actively and consciously trying to do is to bring it into synch so that when we have joint objectives and joint outcomes we are facilitating the joint working and the investment we want to see.

  166. This is fascinating. How are you doing it? It is obviously something you know is a constant problem if you have been in local government at all and been involved with the National Health Service.
  (Ms Platt) The planning cycles.

  167. Getting budgets into synch and knowing that there is money there to do joint funding.
  (Ms Platt) Part of that equation is within the Department of Health's bailiwick to do. We can influence the timescale whereby we require the NHS to do its financial planning. The local government budget cycle has particular statutory dates in it, but we are actively looking at how we might do that to assist the joint developments which we want to see.

  168. How is it developing? How is the pattern developing, particularly of expenditure or intermediate care services? Can you give some indication?
  (Ms Platt) Yes, we are on target to meet the NHS Plan increases in intermediate care across health and social care and we can send you more detailed information about that if you would like us to.

  169. What types of service have been developed which were not there before? Tell us about innovation.
  (Ms Platt) A whole variety of services. Services in independent sector care, which is rehabilitative, community nursing services which are there to help people stay at home, a whole range of different sorts of schemes. We have particularly been looking at those residential based intermediate care schemes where intensive rehabilitation can take place.

  170. There has been some suggestion that there may be a bit of rebadging going on of existing services. Have you come across that at all?
  (Ms Platt) We have tried to stop that and establish a base line from which we can look at new service developments.

  171. So it has been happening a little bit or people have talked about it.
  (Ms Platt) People have talked about it, but we have scotched it where there has been a rumour.

  Julia Drown

  172. There is certainly an anecdotal feeling and I wonder whether there is any hard evidence, that because home care has become much more concentrated over the last years, there are more hours of home care, it is being concentrated on much more dependent people, therefore what was the old home help service has virtually disappeared and the lower end of home help services not being there has led to crisis management having to come in at a later date, which is obviously costing a lot to the individual in terms of their quality of life but also a cost to society. Do you have any evidence on that? Is there a feeling that taking out that sort of less intensive home care has cost the Health Service, cost social services, more in the long run?
  (Mr Gilroy) The evidence suggests that the trend you describe has happened. It is probably over-exaggerated because if you look at the number of people receiving some form of social care support, it has not dropped all that much. If you take into account day services as well as home care, as well as community support and other forms, the gap narrows.

  173. Except if you went back a few years people got the old style home help, help with cleaning, which hardly anybody gets now.
  (Mr Gilroy) Indeed. The trend is unquestionably there. Whether there is clear evidence that nails the connection between that and inappropriate admissions to hospital, people then having to go into residential care much sooner than they otherwise would have needed or wanted, I am not absolutely sure that has ever been nailed. We buy it anecdotally, but that is so plausible as to be an extremely sensible proposition. We have identified something very heartening. The figures I was just quoting about the expenditure from the building capacity grant suggest that about ten per cent this year is being spent on preventative services. That is just what we are talking about now. We sucked our teeth a bit when we saw that because we wondered whether it would create the speed of impact on delayed transfers that we were hoping to achieve. We decided this was so much in keeping with the implementation of the National Service Framework, getting a better profile into expenditure on social care, that we have stopped sucking our teeth about it. We welcome it.
  (Ms Platt) What we want to see is a balance of care and clearly low level support for some people who are at high risk is a very cost effective way of doing a variety of things, not only maintaining their dignity and independence, but also providing a contact. The issue is that all levels of care which are provided need to be reviewed to see whether they are still adequate or still needed. Some of the problem in the past was that the level of care went in for years and it never changed. If everybody gets the same, then nobody gets anything which quite fits properly.
  (Professor Philp) There is some evidence from the personal social services research unit at the University of Kent that it may be more effective to deploy resource in low level support to a larger number of older people on the health promotion agenda than to purely narrow the focus of that support on those with most intense needs. It is very challenging for service providers in practice to play out what would follow from that evidence. I am sure that Denise Platt is right, that it is about getting the balance right.

  174. From what Ms Platt was saying, she was talking about only providing services at the more high risk end. Is the Department at all looking at trying to go back to the days of having that home help service and having what I describe as preventative service?
  (Ms Platt) People can be at high risk because of their loneliness, their isolation, the fact that they have no relatives. That is the sort of risk I was talking about then rather than high risk caused by very complex needs, high levels of disability which need quite a complex package of care. People can be at risk at a much lower level of dependency.
  (Professor Philp) So we are concentrating an aspect of the National Service Framework implementation around promoting health and active life, looking at older people at all levels of disability and what are the most cost effective ways to help prevent future problems. I mentioned earlier the work we are doing on workforce development and talking about the general hospital setting, one of our five priorities this year, but one of the top priorities this year is looking at the roles of care assistants. Whether they work in the independent sector or in social care or for the National Health Service, this is the group which is the substrate of care delivery to older people in health and social care and we want to work with the training organisation for personal social services and with other groups to look at how we can acknowledge the work of that group and make sure that they are recognised or trained appropriately for their work and can do a lot of the things which would help to maintain older people's independence.

  Julia Drown: The other thing I should like to ask about is in your evidence where you talk about the many potential applications for home monitoring, which would allow patients to be seen and cared for at home rather than in hospital. Could you outline a bit more about that and what we might be seeing on the horizon?


  175. I do not know whether the witnesses are aware that before the election our Committee had a session on tele-health, basically to look at what was available because all of us are very much aware that this is a new area of great potential. The picture we got was that there was frustration among the companies that there was no strategy at government level to take advantage of the immense potential. As you may know we certainly intend to look at this during one of the sessions because it is a very important area. Is it fair to say that there is no strategy, that insufficient thought has been given to this?
  (Ms Platt) There is piloting of some projects which are being done within the NHS so that we can test out what is the most appropriate strategy to develop, the remote monitoring of people with obstructive pulmonary disease, remote monitoring of cancer patients, a variety of projects that the NHS is currently involved in, so that we can look at the efficacy of how and in what circumstances such technological invention and innovation might actually be used. The University of Portsmouth has a database of projects on the tele-medicine website. Those sorts of things are clearly important and we need to evaluate and look at what the potential is. There is also a great deal of potential for older people with different sorts of alarm call systems and ways of getting assistance and certainly some of the Smart flat arrangements we have seen in Lewisham for example show that technology can do things which workers have done in the past. The thing which struck me when I visited the Lewisham Smart flat was that older people, who live on the ground floor who cannot get up out of their chair, are very worried about their safety because they cannot close the curtains and the Lewisham Smart flat had a wonderful remote control mechanism which did it from the chair. Those things which can make people feel safe and more confident in their home are being developed which we can look at much more. The Rowntree Foundation similarly has looked at a whole range of ways in which people can be assisted to remain in their own home with a lot more things under their control.

  176. There are also lots of mechanisms for people suffering from dementia where they are being maintained in their own home to monitor their movements, any wandering and so on.
  (Ms Platt) Yes; absolutely. Some of those are in the Lewisham Smart flat.

Jim Dowd

  177. A couple of points which we skated over on cash for change. You mentioned in your evidence sustainable long-term solutions bringing about a step change in managing these services. I am not quite sure how big this step is. In what ways will it require the pursuit of different strategies from those used in the past? How can you ensure that you deal with this problem once and for all and it does not recur?
  (Mr Humphries) The discussion this afternoon has reflected the fact that the nature of the problem is different in different parts of the country. So the step change which is required will vary. For example, it may mean that some health and social care communities have to think very radically about re-designing their services, so they are not in a position of almost total reliance on whatever number of places the local nursing home market has to offer. In other cases it might involve looking at some of the processes which determine whether or not people have a smooth passage through the hospital system. We know that in the assessment, hospital discharge planning, care planning arrangements, there are some examples of first class practice which could help others to improve their performance. So the team will be trying to pick out not just good practice, but best practice which could help achieve a step change if everyone was in a position to apply that. There are also challenges which apply to whole regions and particularly issues around recruitment of key people where we need to look at the problem across the whole region and not just within an individual authority. In many cases here, we are not talking about problem authorities, we are talking about authorities with problems which are not necessarily of their making. There is a whole range of things we can do but the focus will be primarily on two things: one is working with the authorities with the worst problems on their specific situation; the second is to identify the best practice that everyone can learn from and improve in a way that they are managing the delayed discharge issue.

  178. Are you reasonably confident that the processes in place now are significantly different and mean that this problem can be addressed if not once and for all then certainly substantially so?
  (Mr Humphries) The cash for change initiative has helped everyone to focus their minds on the problem, more so than before. There is better joint working now between health and social services, although there is probably some way to go within some of the more difficult areas of problem. Particularly where you have very complex health and social care economies with several different NHS organisations, more than one local authority, not sharing the same boundary, that is a logistical nightmare in trying to get all the services and resources synchronised together. It will vary.

  179. In my experience, cash for just about anything has a way of changing human behaviour.
  (Mr Humphries) Yes, it does concentrate the mind.

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