Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 240 - 259)



  240. On the other hand, I certainly am talking to care staff working for my local authority, who are undertaking procedures which are variously being defined as nursing, such as catheterizing people or supporting primary care.
  (Mrs Robinson) Precisely. That is my point; that where individuals are undertaking what we would call nursing care—we call it that—and it is verging on what most of us would understand by basic care and has always been so, you are absolutely right, we are then having difficulties in discerning which is which, allocating responsibilities, and this is ripe for disputes between the two agencies. What seems to me to be important, rather than thinking about let us put them all in the same organisation and give them the same budget where they will squabble around this budget—at least I think so—is to think less about guidance and think more about the responsibilities and incentives that could be built into the system around individuals who are seen to have a mix of health and social care in the terms that I have defined it, which is to say that they have personal care and nursing care needs. We do say in our submission that we think it is worth a cautionary but nevertheless close look to see if we can build in some sort of incentives for the local authority to take on responsibility when they need to, and equally for the NHS to do so. Maybe there is some system of having kind of 50/50 agreements, almost laid down not so much in law but perhaps through instructions from the Department, around a whole gamut of cases where it is simply ridiculous to say, "This is social care" or "This is health care"—it is a mix. For a large number of people you can make that distinction, but there is a group of people—and I have given some examples of who they are—where we might need really to get down to the basics and agree that there is to be, say, 50/50 funding, no argument.

  241. You would reject the whole idea that it might be possible to come up with a solution where you completely abandon this whole issue of division anyway? Having worked in social care over many years, I just felt it was impossible to define, as you have admitted, the difference between the two. I cannot understand how you can sustain organisational structures that depend on a definition that no one can actually make. I do not know whether any of the other witnesses has any thoughts on this; whether you agree with Mrs Robinson's view that we retain the two separate departments?
  (Ms Harding) It seems to me that the two are moving closer together anyway, with care trusts and primary care trusts, and it will happen. There is already the potential for pooled budgets, so that is taking us well down that route. I think the problem which arises, certainly for the public, is knowing what is going to be charged for and what is not going to be charged for. That just creates an immense amount of confusion; people do not know which falls into which category, and they do not know, if they have a complaint, which complaints system they ought to use. From their point of view, it is a mystery and a nonsense really that we should have those two definitions. I think that also from the point of view of those people trying to determine at the sharp end, through the assessment process, what is nursing care and what is personal care, we now have an immensely complex administrative system of four levels of what constitutes nursing care and people having to make decisions which do not seem worth the effort to make, frankly.

Jim Dowd

  242. Is it not very important that you introduce the public subsidy into the argument? If it were not for the fact that nursing care was then covered, in part you would not need to define it, would you?
  (Ms Harding) Indeed, but a public subsidy in what sense?

  Jim Dowd: The nursing care element. There is an argument about the way some care home owners are actually responding to it, but there is now a payment for nursing care, and the need to differentiate between what is nursing care and what is not is now far more technical, far more refined, than it otherwise would have to be.

  Chairman: Which is important. You have always had that. You have that now in an institutional setting and you have always had that in the community.

  Jim Dowd: Yes. Technically it does not matter, because now part of the cost that they are meeting themselves has been met by the local authority previously. Now it applies to everything.

  Chairman: Whether it is a care bath or a nursing bath, if it is a nursing bath it is free, if it is a care bath it is means-tested.

Jim Dowd

  243. It now applies to every case, not just some.
  (Ms Harding) The problem is, we now have a system which is very difficult for older people and their families to understand, and we also have a system which is extremely complicated to administer. It seems to me that we ought to find ways of cutting through that. I think the distinction between personal care and nursing care has become a completely false one; it has been a sliding definition. The distinction sort of slid a long way in the last few years. We really ought to do away with it. That would involve making personal care free in the same way as nursing care is free.


  244. I notice that the two witnesses on each side of you were nodding. I do not know if there is anything they wanted to add?
  (Ms Whitworth) I was going to say that I think the case has now been well made for free personal care as well as for free nursing care, but that is not the point we are here to discuss. Can I just make a point about merging organisations. I think that from the carer and user perspective the issue really is outcome, and it is whether or not they are receiving a good service, a joined-up service. I do not think that the case has been made that demonstrates that putting everything into one would actually have that outcome. I suspect there are quite a lot of examples of good practice around the country where you would find that other types of models are delivering improvements. So I do think there are other things that could be put in place, and that would be better guidance around some of these issues, as well as perhaps incentives that Janice was talking about earlier.

  245. Would you accept the organisational distinction, the distinction between health and social care, the division, is extremely difficult to determine?
  (Ms Whitworth) It is unhelpful from the point of view of a user or carer, but I would observe, as I think I have said before, that in terms of traditions and practice, the distinction is there, and that it is important to take it into account if you are thinking about merging. One of the concerns is that social care is so small alongside the NHS that many of the advantages and the things that have been learnt by people working in social care could easily be lost in a merger.

  246. Ms Herklots?
  (Ms Herklots) I hear what has just been said. I think it is important having social services working together, and I think we need to see how the new flexibilities in the Health Act really play out and what sort of benefits that has. There are a couple of points I would like to make. One is that whatever the structure, I think there are going to be lots of cultural issues that need to be tackled and overcome. You need to go back a step and look at things like training and joint training between health and social care staff or whoever they are, whatever jobs they are doing. The other point I wanted to make is that there is a danger, in focussing on health and social care working together, that we exclude two other essential elements of, if you like, the care package for older people, which are housing and access to benefits and monetary help. So I think we need to be careful not to put too much focus on health and social care working together and forget about the importance of housing and access to income.

Jim Dowd

  247. Mrs Robinson seemed to be saying that if we were just to merge health and social care with unitary budgets, all we would wind up with is a different set of anomalies to what we now have and simply displace one with another. I understood you to be saying as well that precisely because of the concentration primarily on the acute sector, perhaps one could say that primary care was therefore competing for the same budgets. Did I understand that correctly?
  (Ms Herklots) Yes.

  Jim Dowd: Thanks, fine.

Julia Drown

  248. While we are on the personal care issue, given that those with low incomes do get personal care free at the moment, would that be your top priority for the next bit of government money, to make personal care free, or would it be to look at services, or would you do a bit of both?
  (Ms Harding) There are real problems with setting those two in opposition with each other. There are real problems with paying for personal care, one of which is that people turn down services or refuse services even when they meet those very high eligibility criteria because of the cost. We know that happens. A fifth of people limit or turn down services because of the cost of those services. I do not think you can say, "Do you want better services or do you want free personal care?" That is like saying to a bare-foot man, "Do you want the left shoe or the right shoe?" I think we need both and I do not think that is divisible.

Jim Dowd

  249. A couple of points to Ms Herklots. You mentioned the low level of local authority fees generally which covered some of the questions I wanted to ask about the consequences that has for people and their families. You call in your evidence for a comprehensive review of the way residential home carers are funded, which I presume is an allied field. What would you want that review to cover and is Age Concern open-minded completely about it or does it have some views of its own about what this ought to achieve?
  (Ms Herklots) This has been a problem for some time and it is becoming acute. What there is not clarity about is what good residential and nursing home care costs. What we do know, for example, is that the levels that are paid for older people in those settings are considerably less than for other groups of people who might need residential or nursing home care. You could well argue that is age discrimination because it is allowing lower costs for residential care than other age groups. One area we would like to look at is what is the cost to provide quality care and, importantly within that, to look at the issue of staffing and training, because one of the problems is that residential care could be seen as a place that no-one wants to go to in terms of to live or no-one wants to work in. Neither of those things are totally true but it does have a bit of an image problem. For some people residential care is a choice they want to make. For too many people it is the only option that they have. It is part of the system, as others were saying earlier, perhaps for people who have severe dementia who need that sort of environment. We do not have enough information about how the funding is going in terms of free nursing care, for example, and what sorts of fee levels you need to run good quality residential and nursing care, and that is what we would like the review to look at.

  250. When you say the way they are funded, do you mean who funds them rather than the way they are funded? The way they are funded at the moment is that most of them are private undertakings that have to cover their overheads one way or another. Not the way they are funded but who funds them rather than any structural issue?
  (Ms Herklots) There are some complex issues here around how homes set their fees. For example, the fact that if you are a self-payer you are likely to be paying a higher fee than if you are funded by the local authority and therefore in a sense you are cross-subsidising that place because they are charging two different levels of fees. We also know that homes run by voluntary and charitable organisations are having to put their own charitable funding into them. It is those sorts of issues we want the review to look at.

  251. In my own constituency, Abbeyfield, which I am sure you have come across, said exactly that; they were funding each local authority place to the tune of £100 plus a week. Okay. Mrs Harding, you have referred in your evidence repeatedly to the under-funding of social care and the problems that creates and we have been through those earlier this afternoon and the fact that social care is severely rationed. What is your estimate of how much that under-funding amounts to?
  (Ms Harding) I think it is quite hard to arrive at a figure.

  252. That is why I asked you!
  (Ms Harding) The local authorities themselves say they are over-spending to the tune of £1 billion on older people's services. The total gross cost of local authority expenditure on older people's services is £5.6 billion and the net cost something like £4.1 billion. If we made up that £1 billion pounds extra that local authorities say they are paying for now, we would still be falling short. We would still have the same level of rationing. We would still have the same lack of access to care and not enough care for people and not the kind of quality that we are looking for. I do not know how much more it would take to bring it up to the kind of quality that we would want to see. I think we need to do that exercise.[18]

  253. So it is at least £1 billion to not solve the problem, so it is beyond that to start dealing with it?
  (Ms Harding) Exactly.

  254. What kind of cost factor would making personal care free add to that?
  (Ms Harding) The best estimates we have got on that are the Royal Commission on Long-Term Care's estimates and they also came up with a figure of around £1 billion. I think we have got to take into account the potential savings. We are here talking about hospital discharge after all and emergency admissions and the cost of that to the NHS. We have got to look at that whole cost-benefit analysis in order to decide what we ought as a nation to spend on supporting older people and meeting their social care needs.

  255. You bring me to the final point I wanted to make on delayed discharges. In your evidence you say two-thirds of all acute patients are older people. Therefore, those affected by delayed discharges (these are the ones that cannot get into the acute beds for treatment) are disproportionately older people in the same ratio, I imagine?
  (Ms Harding) Yes, who will be waiting for their hip replacement or their knee replacement or their eye operation which will enable them to keep their independence. It is a very complicated calculation and I would not pretend to second guess it.[19]

Dr Taylor

  256. Going on to premature discharges and readmissions, first to Age Concern: how much of a problem is this?
  (Ms Herklots) It is a problem. Certainly one of the issues is around people's home situation not really being sorted out for them to go home. So they might be medically fit but if they are discharged back and the care support is not there, then there is a likelihood of readmission. There has been some work done in Leicestershire looking at reasons for readmissions and one of the findings from that work showed that people discharged on a Friday were more likely to be readmitted, not surprising perhaps. We know that if you are discharged on a Friday there could be problems in getting the right sort of care available at the weekend. But this is not rocket science to solve, it seems to me, and we ought to be able to sort out a system so people are not being discharged when people are less likely to be there. It is an area that we ought to monitor quite carefully particularly around the cut-off point on intermediate care and to look at the reasons for readmission.

  257. Have you any idea why the figures throughout the country vary? In the league tables it was Preston and Chorley who are best at 3.9 per cent and St Bart's worst at 8.7 per cent.
  (Ms Herklots) We have not done a study of that. It seems to me that one of the factors of readmission is what sort of community support is available. If you are in an area where a lot of funding is channelled to acute care or institutional care and there is proportionally less community support available, that might be a factor, but we have not done any thorough study of it.

  258. Could I bring in Diana here and the Carers UK experience of readmissions?
  (Ms Whitworth) Yes. There are two issues here. One is that early discharge can actually have quite a bad effect on the carer's health, if, say, somebody goes home too soon, without proper support at home, without proper help in lifting or the right adaptations to get a wheelchair into their house. That is not an unusual situation, for somebody to be discharged having had their leg amputated on the Sunday over a bank holiday weekend, with no arrangements to get them into their house, to a home where the carer was also elderly and had had a stroke recently. So that is fairly typical of the experiences that are reported to us. In fact that happened to my friend's mother, and I imagine that there are many of us who could cite similar stories. Of course, it is also an issue for readmissions. When we were looking at the experience of carers at hospital discharge last year we had the benefit of being able to compare it with a similar survey that we carried out in 1998, and it was done in a survey by Melanie Henwood in 1998. We found that the proportion of people who had had to be readmitted within two months of being discharged doubled from 19 per cent in 1999 to 43 per cent in 2001. Obviously as to the cause and effect of that, I cannot guarantee the cause of the readmission was early discharge, but in addition to that the proportion of carers who felt that the person they were caring for had been discharged too soon rose from 23 per cent to 45 per cent. So there is an issue, and the link between early discharge and readmission I think looks fairly evident.

  Dr Taylor: Thank you.

Julia Drown

  259. The Committee wants to look a bit more at the issue of support at home. I know Age Concern has expertise particularly with its "handyperson schemes". I wondered if you could tell us a bit more about that, why they have come about in some areas and what the potential is for wider use of those?
  (Ms Herklots) Yes. Age Concern does run some handyperson schemes. A lot are also run by Care and Repair and Staying-Put organisations across the country. One of the issues there is that not every area has that sort of service available, and we would certainly like to see care and repair schemes in every local authority area.

18   Note by witness: The £1 billion overspend is for the whole of social services, not just older people. I think older people account for around 21% of that, according to the latest GLA/ADSS figures. Back

19   Local Authorities themselves say they are overspending to the tune of £1 billion on Social Services as a whole-of which about 20% is on older people's services. Back

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