Examination of Witnesses (Questions 600
WEDNESDAY 8 MAY 2002
MR J RANSFORD
600. So there might be a bias in the system
for local authorities to prefer residential care, to continue
to rely heavily on residential care.
(Mr Ransford) Absolutely and your Chairman is quite
right: historically that has been the system. Right back to the
Poor Law you can see a line through to institutions. We have moved
away from it in mental health, we have moved away from it for
younger people with learning disabilities, moving to a much more
community based system of care. For older people the situation
has changed greatly. Far, far more people with intensive needs
are now cared for in their own homes and community than were five
years ago, let alone 15 years ago. That trend is changing but
that does not mean that immediately we do not need high quality
responsive residential care for the right people. It is a balance.
It is a mixture. Commissioning is about providing the right services
in sufficient capacity for the range of needs you are dealing
(Mr Leadbetter) Yes, it was a fair criticism; it is
less so. What is needed is a partnership between primary care
trusts, social services departments, strategic health authorities
and the independent sector around local forums where all the partners
feel equal. It is very interesting in this country that two of
the major providers said to us when the ADSS organised a meeting
that they would need us for another five or seven years, then
the 1960 baby-boomers will start coming through and they will
pay for themselves. I thought that was an interesting perspective.
601. In Essex how have you broken down the "them
and us" atmosphere which certainly tended to exist a decade
ago between your department and the residential care home area?
How have you brought them together to make them feel that they
are an integral part of the discussions on a more or less equal
(Mr Leadbetter) We have fielded a stronger team. Ten
years ago we did not prioritise it enough, so we did not field
a strong enough team and to be quite frank some of the private
sector were operating in a different league than some of the players
we fielded. That was a mistake. We got the politicians on board,
so the politicians were willing to engage with the private sector;
that was cross-party. Now the traditional "private sector
is good, public sector is bad" is going we broke down that
barrier. We had full and frank debates.
602. Only some politicians of course.
(Mr Leadbetter) Some politicians of all parties. We
had full and frank debates with the private sector about their
need to be responsible and not come to meetings with individual
cases and make a meal of individual cases but raise those outside
the meetings and try to help them lift their play to look at the
strategic issues and not just difficult one-offs. We demonstrated
our commitment, we engaged with the private sector and got some
funds from Europe to train staff in the private sector. We put
in an equivalence of staff time to match fund. We did lots of
creative things but crucially it was a change of heart and mind
amongst staff and politicians alike. The private sector are the
major players. Unless we properly but robustly engage with them,
we are not going to be able to manage this market.
603. I certainly agree with what you said, from
my own experience in the county. However, I was chairing a long-term
care conference ten days ago with people from all sectors, including
social services, and one of the most significant complaints, certainly
from the residential care sector present there, was that they
still felt that too many local authorities around the country
did treat them very much as second class citizens, did dictate
to them either through their bulk purchasing power or through
dealing with their concerns. In your role in the ADSS what are
you doing, what are the ADSS doing, to try to spread what is obviously
good practice in Essex to other social service departments, to
break down far more this feeling? Even if it is an outdated perception
in some areas, in other areas it will not be an outdated perception
and it will still be going on.
(Mr Leadbetter) We are leading the debate. We have
had one meeting and we are planning a second with the Department
of Health as observers, including the Local Government Association,
to engage with private, residential and nursing home care sectors
to have that debate about what is a fair price, about whether
there can be even closer co-operation and then through the mechanism
of the ADSS raising that awareness. It is a tricky issue. I described
it before as a careful dance and it is, because we work in a political
environment, there are 150 different local authorities and different
perceptions from directors and elected members. My sense is that
there is very much a sea change and has been in the last three
or four years.
604. Dr Morgan, in your submission you refer
to a survey which found out that two out of three health authorities
made cash transfers in the 2000-2001 financial year to local authorities
and the average transfer was something over £600,000. Can
we multiply that out and get the total? Did you keep any control
over how that money was spent? Did it actually have an impact
on delayed discharges?
(Dr Morgan) Yes, that money was spent willingly at
local level because communities identified this as a shared problem.
What this was about was how local communities solve their own
problems. If there is a big issue with delayed discharges, and
a whole nest of things around them, health authorities and communities
made a decision this was the best way to resolve it. Certainly
in the communities where this happened, some very tight agreements
were raised about where the money went and how the money would
go through because it was actually solving a common problem.
605. Another example of partnerships actually
(Dr Morgan) Very much so and fitting in with a view
coming very strongly from members. As we submitted to the Wanless
committee, you have to think of health and social care funding
as a whole. It is no good having it out of balance because decisions
in one sector affect the other. This is really an example of how
the health services try to deal with that perceived imbalance.
606. One of the interesting areas which this
Committee picked up in the last Parliament was the way in which
in certain parts of the country the Health Service was actually
paying the costs, for example of day care, the social care costs,
to the local authority because the individual client/patient could
not afford to pay those charges. Is this a factor from your point
of view? Is this still happening? Is this leading, if it is happening,
to a debate about the logic of charging in such circumstances
and the relationship between the two authorities, the Health Service
and social care provision?
(Dr Morgan) I am not personally aware of people paying
for things where there should be a charge. It would not be the
way most people would do it.
607. We suspected it was illegal, but it was
(Dr Morgan) That is why I am careful. It would probably
be ultra vires to top up for individual patients. What
organisations do is make large transfers for a range of services
which can then be used to support people. You cannot do it around
individual patients. You cannot top up a care package between
health and social care. It is about how you work jointly. One
of the problems when you begin to look at the spend between health
and social care is that people do not look at it in the round.
You have some communities where there is a big expenditure by
health on old people's care, but often they are the same communities,
whereas if you look at the same expenditure for children it is
actually very low and social services pays more. There are so
many interfaces between the two organisations that it is very
difficult to take a single figure and read anything into it because
you have to look at the relationships in the round. What it does
demonstrate is that in the best places people, managers from health
and social care, are getting together to solve their own problems
and that has to be the way to solve this, it has to be at a local
level with enough incentives in there to encourage people to want
to solve it locally.
608. I want to ask Dr James something arising
out of the evidence which was submitted by the NHS Alliance. You
highlight the range of facilities required to allow appropriate
discharges to take place, but then you argue in paragraph 25 of
your submission that primary care organisations "are finding
it impossible to reserve funds for these necessary schemes in
the light of other cost pressures particularly linked to achieving
short-term activity targets". Could you say a little bit
more about that? If you really believe that to be true, what sort
of evidence is there that primary care organisations are having
(Dr James) It is a general comment about people's
wish to modernise and reserve resources and finances to modernise
services, but finding it difficult to modernise services, putting
money into IT or into one workforce or into developing a workforce
to take on new roles. It would mean taking money away from other
services which have targets set on them and the targets are not
allowed to be bridged. This money is shoring up the targets.
609. Is the building capacity funding not meant
to address these kinds of problems?
(Dr James) Primary care trusts are increasingly frustrated
that they hear of money coming in to help primary care and investment
by primary care and then never really see hide or hair of the
investment because it seems to be promised elsewhere before it
even reaches the coffers.
610. Is that happening in this instance?
(Dr James) This is a general comment about modernisation
and wanting to do things differently rather than a particular
comment about delayed discharges. May I twist your question to
make a comment that I was wanting to make? A target for our endoscopy
services, for example, is that GP referrals must be seen within
13 weeks. Because there is a target attached to that, it means
that any other call on those services does not take that priority.
Urgent referrals by consultants to endoscopy services have a waiting
time of eight to nine weeks and their routine ones are about 40
weeks. Then inpatients waiting for an endoscopy, just for endoscopy,
wait for three weeks. They are in that bed for three weeks, so
that is a delayed discharge but it is not counted as a delayed
discharge. It is a waste but the shoring up of our services is
for the targeted service, which is the 13-week wait.
611. I know of some instances where people have
been in hospital for cardiology related things and have been told
"For goodness sake do not get yourself discharged or you
will go the end of the queue. If you stay in for a couple of weeks,
we will get you done".
(Dr James) That is right, that sort of thing.
612. Dr Morgan believes that is happening as
far as building capacity funding is concerned.
(Dr Morgan) There are two sets of money. There is
the building capacity money, which is tightly audited and I have
no doubt is being spent where it should be; no problem. The issue
you have here is one of the biggest problems facing primary care
organisations. It is about how you develop a whole range of new
services and whilst we are on the treadmill of spending money
in the acute sector it is hard to release money. What this is
about is that primary care organisations want to spend more money
on this area and that is the bit they find very difficult to do.
The money which comes with a tight label comes with a tight label
and is audited to death.
613. Basically the building capacity funding
is not enough in some situations.
(Dr Morgan) It is not enough and if you talk to the
health community, what they will tell you is that the way to change
the nature of the Health Service to make it truly sustainable
and be the sort of service we would all feel proud to use every
day is to invest more in the community sector and less in the
acute sector, making the acute sector really intensively looking
after people who need high technology. The issue, once you have
your money in there, is how to get it out to develop these new
alternatives. You need the new alternatives before you can get
rid of the beds in the acute sector. You are back on this continual
cycle of how to find the space and capacity to double one to allow
you to get off the petard you are hoist on.
(Dr James) Thee is a great concern about building
capacity just for capacity's sake, because we need it, without
really acknowledging that delayed discharges are a social care
problem. They have been through the potential for medical care
improvement, they may have got there because of inappropriate
medicalisation. Rather than getting into the treadmill of being
medicalised, being in hospital, being institutionalised maybe,
then requiring residential care, we really need to be looking
at the alternative referral destinations, alternative treatments,
treatments from home, keeping these people out of hospital so
they are not in this situation. Rather than building capacity
with the inherent dangers of warehousing and elderly patients
because it is a tidy solution to a crisis, we need to be building
individual care plans to keep them independent and hopefully well
in the future.
614. That is what people are supposed to get,
is it not: individual care plans?
(Dr James) Mm.
615. Looking at intermediate care and rehabilitation,
my questions initially are to Mr Leadbetter. I want to look at
your survey of last spring, 12 months ago, where you welcomed
the new investment in intermediate care. Who would not? Of the
returns, a number specified lack of transparency in tracking compared
with what we have just heard about the additional funding, but
also the negative incentives which appear to exist in the way
the money was being allocated, inasmuch as it rewarded poor practice
rather than advocated and advanced good practice. Could you comment
(Mr Leadbetter) Much of this has been referred to
previously in the response colleagues made. Paying additional
money to people who are struggling with capacity, on the one hand
is fine, but many directors said to us that it was not fair, they
had invested extra money in this (building capacity) and they
were being penalised. Others countered by sayingand I am
thinking particularly of the Kent, Sussex and Southern and South
East authoritiesthey had done everything possible and they
simply needed more money to pay more to the private sector. There
are two views on this, both have equal validity and it is a difficult
choice. I would probably err on the side of giving more money
to those authorities providing it is properly audited. I would
probably part company slightly from health colleagues on the question
of additional money. The phrase we use in social services is that
some of that additional money which was intended to be targeted
for intermediate care appeared to have sticky sides. It seemed
to go in different places. There was the tranche of intermediate
care money, £250 million, a couple of years ago. We did a
survey amongst authorities and lots of authorities said they had
not seen the evidence of how that was spent. Remember, it can
be spent on pre-admission planning as well as post-admission planning.
616. Have you seen who was spending it?
(Mr Leadbetter) I have not seen it spent and targeted
on what we thought it should have been, which was creative use
of it to improve intermediate care, to stop people going into
hospital, creative day care, discharge planning, hospital at home
schemes. Bristol, for example, have used the £200 million
to create a team where people who are not well enough to stay
at home but not acutely ill enough to go into hospital, go somewhere
separate. That was done with the money targeted at social services,
not with the money targeted at health some years previously.
617. The negative incentive you identified was
actually not rewarding those who really made the effort, merely
bringing up those who were the slowest.
(Mr Leadbetter) Yes.
618. So what is the message for the future?
Do not bother doing anything because the Government will bail
you out ultimately.
(Mr Leadbetter) That could be a perception.
619. It would not be the only area where that
is the perception either. Looking at the winter pressures, your
survey identifies the expanded home care packages as the most
beneficial element of the additional funds. What does this say
about where we target any additional or further expenditure in
(Mr Leadbetter) Two views on this. The LGA would argue,
and Mr Ransford can represent that view, that the money should
come to local government with few strings and we will spend it
wisely. There is evidence of that in that the money which came,
the £100 million and £200 million, was spent wisely.
We did have a target of reducing people waiting by 1,000 and we
achieved this. The ADSS would take a slightly different position
in that not all authorities are as kind (given appropriate regulation)
to social services as the majority, so targeting some of the money
on specific schemes with ring-fencing or hypothecating makes sure
it goes to where it is needed.