Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 700 - 719)



  700. Even though they perhaps might need a district nurse going in every day and you could argue that there was an NHS component?
  (Jacqui Smith) This is where the discharge plan helps us to determine what the overall needs are, where that person is going and what the responsibilities are, but it is also where we need the sort of assessment that you can do through the single assessment process in order to determine what that older person needs.

  701. So what would tip the balance? Would that be a clinical decision as to whether the responsibility was mostly NHS or mostly social care?
  (Jacqui Smith) Clearly there are situations where what we are talking about is NHS continuing care, where the responsibility quite rightly lies with the NHS. There are situations where an important component of care is NHS care. So the situation there would be that if you have got that balance that we are talking about, between you need a district nurse, but you also need a package of care to enable you to live at home, if what we are talking about is the point at which the charging kicks in, clearly it would not kick in until the NHS provision was in place, because there clearly it would not be reasonable to charge a social services department for something which is not their responsibility.

  702. To clarify that, to quote an example I had recently, I had an old lady who was in hospital for a year nearly longer than she needed to be, simply because the family wanted to look after her at home, all they needed were two assistants to come in morning and night to move her, and Hampshire County Council could not find, in leafy Chandlers Ford, two assistants to come in, at the rate they were prepared to pay. In that case, where the clinicians are quite happy for that to happen, social services want it to happen but just will not fund the travelling expenses, that would then become an onus on the social services department and they would pay or pick up the tab, which hopefully would exercise minds towards upping the rate for help?
  (Jacqui Smith) It is difficult for me to comment on individual cases, but I would have thought, as you described it, that that sounds to me like a social services responsibility. That is a perfect example of where what we need in the system is an incentive that prevents the sort of buck-passing that prevents an older person from coming out of hospital.

  703. So in those cases, will the departments be charged for an individual person who is not transferred as quickly as possible, or will they be charged on a bed-days-lost basis?
  (Jacqui Smith) One of the other things we were talking about earlier was that I was suggesting that where we see a successful approach to tackling delayed discharge is where we see people focussing on individuals, what their needs are, when they are ready to be discharged, who has got responsibility for it, and making sure that they get where they need to be and that the services are in place. On that basis I think that we should be developing a scheme that focuses on individuals and the number of days, if you like, that individuals are delayed because of the inability to put in place alternatives.

  704. So you focus on individuals, but linked to the number of days a particular individual was, shall we say, being delayed?
  (Jacqui Smith) Yes.

  Sandra Gidley: I just wanted to clarify that. Ultimately you are charging social services departments. Most people would regard those departments as being underfunded. Do you really believe that ultimately that will improve the outcomes for people experiencing delayed discharge? You are robbing Peter to pay Paul.

  Chairman: I think we have covered this already, though you were not here, and I appreciate that. I think that if you look at the record you will see that the Minister has answered that in some detail. It may not have been to everybody's satisfaction, but it was answered.

  Sandra Gidley: I asked because I was told that it had not been satisfactorily answered.

Mr Burns

  705. Neither was mine, Sandra, nor was my question satisfactorily answered.
  (Jacqui Smith) And I thought we were getting on so well!

John Austin

  706. Jim Dowd put some questions about the impact on social services that were not able to provide. When Wanless made his recommendation that the merits of this should be examined, I think one of the criticisms was that the Government appears to have jumped straight in and adopted it. In examining the merits, did you examine the comparative levels of spending in Scandinavia on social services compared with here? I can see a way in which it might work if there is a sufficiency of resources, but in a climate where certainly in many of the London boroughs the social service budget is under such pressure, I think there may be a difference between a well-resourced system and an underfunded system.
  (Jacqui Smith) On the point about how quickly we have responded to Wanless, I think when Alan gave evidence he talked about the extent to which he had the ability to consider this before we got to the Delivering the NHS Plan stage. I think we are partly coming back to an issue that we have addressed previously, and that is, is this a policy that can operate if we do not increase funding to social services departments in order to allow them to put in place the alternatives? No, I do not think it is, which is why we are introducing it alongside the considerable extra investment that is going into social services departments. This is quite an important way, moving on from a situation where we have put extra money into social services departments. We have been very directive, to be honest with you, about how it is spent and what it is spent on, but where we have seen the beginnings of development of the sort of capacity that will be necessary to make a success of tackling delayed discharge, we are now moving on to a logical next step. So part of what I am arguing is that I do not see this as being the first step. What I saw as being the first step was the £300 million investment that has gone into local authorities, that has started the development of alternative provision and has prompted quite a lot of focus on the issue of delayed discharge, better joint working, better processes. What is now logical is that we move to a system where alongside the considerable extra investment that is going in, we design a system which at a local level puts in place the sort of incentives that will allow us to continue looking at the problem in the way that we want to do.

  707. Have you looked at the comparative levels of spending in Scandinavia? Are there significant differences?
  (Jacqui Smith) I have not looked at comparative levels. What I am concerned about and the Department is concerned about, as we made our bids to the Spending Review, is what we thought was necessary to provide those alternatives to enable social services to take on the responsibility for people coming out of hospital into alternative community provision, and that is what we focussed on. Earlier on I gave you some examples of the sort of provision that we think the extra spending could provide in the community.

Dr Naysmith

  708. Minister, you will realise that I have been studying carefully the document Delivering the NHS Plan. In there, in paragraph 8.12, it is stated that the relationship between health and social services will be kept under review, and that if more radical change is needed you will introduce it. Does that suggest some kind of implicit threat that some more radical restructuring might take place if some unspecified event takes place or does not take place? It is a little reminiscent of the bit in the Bill which fell before the last election, which talked about compulsory merging. I was on the committee stage of that Bill and it talked about the compulsory merging of social services and health services, coming from either side, if things did not work properly. Is that an implicit threat that you will reintroduce that?
  (Jacqui Smith) No, I do not think it is about threat, what I think it is about saying is that all of us have to put at the centre of our thinking not the sensitivities of those people who are in particular agencies at the moment, whether or not that is local authorities, or primary care trusts or acute trusts. What we have to put at the centre of our reckoning is what is the most appropriate way to deliver better services, in this case for older people, for making sure that they get out of hospital when they need to, for making sure that they have got the services in the community, the alternative in terms of long-term care that they get. We will do what is necessary to make sure that those older people get the services that they need. As I suggested earlier, where partnership delivers that, that is good. I am less concerned about people wanting to maintain their set of boundaries than I am about what we need to do to get the services for older people that are necessary. Now that is not a threat, that is just a statement.

  709. It was seen as a threat in the original Bill before the election, certainly by local authorities. I just wondered why that was removed. Obviously it was removed because the Bill had to be got through before the election took place, but why that particular bit of the Bill?
  (Jacqui Smith) Partly, of course, you are right, new legislation depends on its process through Parliament and the way in which we listen to what is being said to us. If you are saying to me, does the Government now not think that much better joint working, use of health flexibilities, care trusts where appropriate, are a good thing, the answer is that we do and we will give further consideration to what incentives we need to put in place to develop that further. That is not about threat, that is about saying all of us can work together to make sure that there are better arrangements in place where they are going to deliver for older people.

  710. A question was asked about the joint budget, and would not one budget be better than trying to form a partnership? The question arises again, is it not best to get rid of this and have one budget and one service?
  (Jacqui Smith) In many areas I think it is very good to have a budget or a care price for older people, and that is why in many areas people are moving towards it and why, as I suggested earlier, people are already bargaining on the £300 million spending being spent to improve healthcare flexibilities. The way in which we get there depends, I think, on our judgement and the local authorities' and healthcare communities' judgement of what is going to deliver the best services for people. What we do not have truck with are people who would be in a situation where what was at the top of those people's minds is "maintaining our barriers simply because we've always had those barriers". I am not saying that because I think that necessarily exists. I think that, as we have already seen, there is a lot of good movement towards developing those partnerships. I think that everything that we are planning for the future will promote that even further, and it will promote it because it is by having partnerships, or by having pooled budgets where that is appropriate, that you actually get better services and better response.


  711. Is not the entire policy to move towards one common system? When I talk to people such as home carers and district nurses, their work is coming closer and closer to care. In my own area we have professional carers who are now doing very clearly nursing tasks in relation to stoma care and a whole range of areas that would not previously have been a social care provision. It is only ten years ago that the other party had as a compulsory option the integration of the health and social care system. Have we gradually come back in that direction which was seen as so radical by many people? When you talk about buck-passing, you would need to buck-pass if you were in the same organisation and had the same budget. You would need to fine one element of the department if you were actually under the same authority. It just seems to me so obvious. Have I missed something here? I cannot understand why on earth we do not take the most logical step possible, which is what Doug has just said.
  (Jacqui Smith) This is obviously the second area of policy today which has emanated from your work ten years ago.

  712. I did not say "new policy", but you guessed it.
  (Jacqui Smith) I am not sure there is much more I can add to what I said about my view and the Government's view about partnership. Clearly we think there are significant benefits in pooled budgets and in care trusts, otherwise we would not have legislated to enable them to happen. How we get to a situation where the partnership that is right in those particular circumstances develops I think does differ from area to area, and it is important that people go forward and make that partnership in the most effective way, because it is quite complex, is it not? For example, if you look at the four care trusts that currently exist, one of them commissions and provides services for older people, the other three are around mental health services. So there are a whole range of considerations that I know are actively happening at a local level, supported by Richard's team and supported by the thrust of government policy, about how we get to much better joint working. I would not necessarily go all the way down the track that you are suggesting as the objective, but we do have a clear objective that we have legislated for and that we have put in place the policy levers for to develop much better partnership working.

  Chairman: If I can look at my own area and elsewhere where I deal with officials who are doing a broadly similar job, in two distinct chunks, much of their time is taken up in trying to determine who does what. If those barriers were removed, you would not need two officials in a similar capacity, you would only need one. However, that is something the Committee can look at. Now we want to talk about care home capacity.

Mr Burns

  713. Before we do, it is rather interesting listening to what you are saying to the last three of my colleagues who questioned you, where you rightly placed a great deal of stress on working together, partnership, to push forward the policy, which is absolutely correct, but working together involves social service departments, local health trusts and the Department of Health. Why do you think it is, in the spirit of working together, that on the proposal which has aroused a great deal of controversy in its own field for these financial penalties on delayed discharges, you did not consult before announcing what you were going to do?
  (Jacqui Smith) I think, Simon, that you understand, do you not, about budgets and the sort of consultation that goes on as you come up to budgets. I think there is a difference between stating, as we did, what our clear objective is, which was completely in line with everything else that we have said about the NHS, which is that we need to develop a system where there are incentives in place alongside the investment to tackle, in this case, the problem of delayed discharges. There is nothing that is out of kilter with what we have said across the whole of the system. So in terms of saying that that was what we want to legislate to put in place, I think we are very clearly in line with other things that we have said. The point now is that I think that we already have worked with, and we certainly will continue to work with, a whole range of stakeholders to talk about the details of how we deliver that incentive system, but I do think it is right that Government, in setting down the way in which the system should work, should state clearly how they think it should work and then should work with stakeholders in order to make sure it delivers what I think is probably a shared objective.

  714. On care home capacity, there is, of course, one problem. You were talking about the extra money, which no one can dispute, but if you talk to the other side, particularly social services departments, they will say that what they actually need, to stand still, is another £1 billion, and that with the problems of the closing of capacity in the care home sector, where often it does not reflect where there is the least need for care homes, more often than not because it is not spread thinly and evenly over the country, you are having a problem in certain parts of the country—not all by any means—where there just are not the beds for residential care, which is causing problems, where people are either having to be placed far away from where they have lived and been brought up or are having to be put into inappropriate or less appropriate care. So I am not convinced that your thesis has reached the stage yet. You said about extra money, which is why you can now move ahead with the correct policy, but I think that might be a bit premature. If you talk about the capacity, why do you think there are such variations in the number of places claimed to have been lost in the last five years? If you look at it, if you see the independent analysis, what it will say is about 50,000 beds. If you listen to the Prime Minister it is either 26,000 beds or 19,000 beds, depending on which day of the week he is answering the question. The Secretary of State is somewhere inbetween those two figures. Why are there all these different figures being bandied around, which one do you think is the correct one and why do you think it is the correct one?
  (Jacqui Smith) The Department's analysis suggests—and these are our figures for England—that between March 2000-2001 there was a reduction in residential care places of 4,700, there was a reduction in general nursing and mental nursing home places of 6,500. That is 11,200, 2 per cent of capacity, but that is for the last year. The 50,000 figure which you are very keen on using, Simon—

  715. We would like independent figures rather than government ones—they are usually more accurate, we find.
  (Jacqui Smith) So do I. So if you use the Laing & Buisson figures, which are the basis for that 50,000 figure, of course, what Laing & Buisson say in that market survey 2001 is that between 1996-1997 and 2000—and these are figures, incidentally, which relate to the whole of the United Kingdom and only to the independent sector—as I understand it, there has been a 51,147 places reduction because of deregistration, a 1,280 reduction because of other net changes (that could be things like changing into different forms of care, for example. So you like to use that figure. Where I would dispute with you is that what Laing & Buisson also show in their analysis is that there have been new registration places of 33,522, so the net figure therefore is 18,905, which is where we get the 19,000 figure from.


  716. So it is gross versus net?
  (Jacqui Smith) Yes.

  717. Basically, that is the difficulty?
  (Jacqui Smith) Yes.

  718. Which is what I think we calculated at the start of our inquiry.
  (Jacqui Smith) It is gross versus net, and occasionally it is political mischief versus the truth as well.

Sandra Gidley

  719. On that point, can I question this, because we been given breakdowns by various people, but my understanding was that the 50,000 figure did take into account the pluses and minuses, but also included the long-stay NHS beds. Would you care to comment on that?
  (Jacqui Smith) That is not my understanding of the care figure. There is another figure around.

  Sandra Gidley: The figures I have are: number of residential home places in 1996 307,500, estimated in 2001 297,600; number of nursing home places in 1996 220,200, estimated in 2001 196,800; number of long-stay beds in 1996 47,900, estimated in 2001 31,500. I have done a bit of maths, and if you just take the residential and the nursing home beds—that is, 33,300—and add in the NHS beds, then you come to a figure of over 50,000.

  Chairman: Are we talking there about England?

  Sandra Gidley: I think this is UK.

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