Examination of Witnesses (Questions 160
- 179)
WEDNESDAY 13 FEBRUARY 2002
MS DENISE
PLATT, CBE, MR
DAVID GILROY,
MR RICHARD
HUMPHRIES, MS
MARGARET EDWARDS
AND PROFESSOR
IAN PHILP
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?
Chairman
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.
| 
