Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 420 - 439)



  420. But the key figure clearly is how many places we are short of, that currently are not provided for, that we need, and do you have that figure?
  (Mr Hassell) The figures we are currently short of, I do not, no. I think what is important, of course, is, and there is always a danger in just looking at today's situation, the (LSE) has certainly calculated that, by 2010, I think the figure is, 8 to 10 per cent, I need to check that figure, but I think it was 8 to 10 per cent more beds would be required. So that is worrying, at a time when we are actually losing beds from the market.

  421. But, do you accept, 50,000 is not a helpful figure; is it not overstating the problem deliberately to—
  (Mr Hassell) No, I do not think it is, because, as I said, you have 200 different markets, or 150, whatever the local numbers are, and that is the relevant situation.

  422. So, therefore, the 50,000 figure is not relevant, because that is trying to say, nationally, we are short of 50,000; if you are saying to me, and to the Committee, that it varies across the country, the national figure, by your own argument, is irrelevant?
  (Mr Hassell) If you are one of the people awaiting discharge from an NHS hospital, or you are at home waiting for a placement into a nursing home, and there are none in your area, that figure of 50,000 is highly relevant.

  423. If misleading?
  (Mr Hassell) I do not think it is misleading at all.


  424. We can come on to that, because I think this is a specific area that, as a Committee, we have got to be absolutely certain, we have got to know what we are talking about here, because I think we may still be talking about two different figures and we need to be sure we are talking about the same area. Can I pursue, perhaps with Mr Lewis, the point that indirectly Mr McClimont referred to, that we are bogged down with this debate about 50,000, 19,000, or whatever; there is a school of thought that says, well, really what we ought to be saying is, moving away from this whole idea of people entering homes, and that this is a recognition that we have failed to offer people alternatives. I recall talking to you, not that many years ago, about a particular country not far from here that does not have any care homes, Mr Lewis, that has managed to develop a system, a very effective system, that we looked at, without care in nursing homes. How do we get to that stage from where we are now, arguing about how many we have lost and how many firms have gone bankrupt, and things like this, people being made homeless?
  (Mr Lewis) I think that there is a danger of us purely counting what we think we can count, and after that discussion I am not sure we know what we are counting, but that we concentrate on counting beds, counting places, rather than looking at services. And I think that, if we go back to square one and say, first of all, that it is welcome that the emphasis on assessment, even if it is assessment for free nursing care, but, to an extent, and in fairness, the emphasis in the original community care legislation and guidance mentioned the concept of multi-professional assessment before services are being provided. I think that if we are looking very carefully at how we best meet the needs of dependent people, of elderly people, then we begin to put into some sort of rightful context the services that Bill and his membership are able to provide; and, of course, local authorities are providing the technology, that people like Tunstall are able to provide, to keep people independent. We then have to look at the other side of the spectrum, which is those that are most acutely dependent, and Westminster's submission is that there is a role for a limited number of very specialised nursing homes that are complementary to the provision that is within hospitals. We would not necessarily be arguing that there should be an expansion of the old continuing care facilities within hospitals, and, I sadly have to say, there is some evidence that that is happening, rather than focusing how best we meet the needs of people; and, for the most dependent people who do not require independent interventions, the nursing homes, or the care sector is able to provide a service. But we are not comparing like with like, which is why if our sole argument is that we have not got enough beds of the type that we used to have, is the case, then I think we are on very dodgy ground. The issue has got to be much more that there are specific roles, in order that we have this spectrum of care. In terms of countries like Denmark, I think it is a question of what you define is a nursing home, or what you define is hospital provision, and, of course, they have a much more integrated service.

  425. But you are aware that Denmark passed legislation in respect of, I do not use the term `institutional care' in a derogative sense, Mr Hassell, I mean in terms of where people would go and live collectively under one roof; they passed legislation. I was interested in Mr McClimont's comments about positive justification for admission. Should we not be doing far more of that? We have had a traditional arrangement for children in care, that we review those children, we require justification. And yet we have here, and I visit quite frequently care and nursing homes, and, as somebody who has been professionally involved, I certainly think there are many people who end up in permanent care settings who could very easily be assisted by the kind of provisions that Tunstall have got, by home care, by Care & Repair. How do we get to that stage of challenging this assumption that we have to have this huge residential and nursing home care industry, where other countries manage without it?
  (Mr Lewis) I think, first of all, we have to look at the routes to funding of those aspects of care, which I know is a very big, separate subject, but while we have disparate routes of funding then it is very difficult to bring them together. I think perhaps the most important issue, and we mention it in our evidence to you, is the need for there to be comprehensive assessments. We are disappointed that the Government did not take on board our suggestion that they should look further at the available comprehensive assessment strategy systems that exist. As a company, Westminster has invested in developing a system called MDS, regrettably it comes from America, but it is a very comprehensive way of measuring the needs, the total needs, of dependent people. The current assessment strategy, in terms of free nursing care, is extremely limited. If we have the right gatekeeping, if we have the right ability to bring together the resources, whether it be from housing, whether it be from work and pensions, whether it be from the individual, whether it be from the local authority or the health trust, if we have the ability to bring them together then I think that we begin to see the opportunities of providing this spectrum of care and recognising and reshaping the markets; because at the moment that is what is happening, the market is being reshaped, but in a very crude sort of way.

Mr Amess

  426. To get back to this whole issue of closures. I have got a huge number of residential and nursing homes, although, of course, they are one and the same thing, in the area that I represent, so I have had to immerse myself in this, and I was also on the Committee Stage of the Bill; now whether Mr Hassell can steer me in the right direction, or anyone can contribute. I recall discussing this with the Minister, John Hutton, we had a very good presentation at the Department, where we literally walked the square feet of the rooms, we did the whole thing, to understand what the argument was about. And then I observed both sides, and I got the impression from him that the homeowners had all got together, and they said, "This will never do," it was all very dull and there were going to be massive closures. Now are we aware if, following those discussions, and there was going to be some laxity in the rules and regulations, I am thinking for the medium-size, the small homes, has that made any difference? Because I have told the Minister that in my area, unfortunately, that guidance came too late, and these homes, and I am not just talking about adaptations for lifts, and things like that, that they have told me the guidance came too late, and they had to make a commercial decision, and they have now developed their homes into different things. But I wondered if any of you could tell me whether that move by the Government, to try to meet the homeowners' concerns, has made any impact in stopping so many of these homes closing?
  (Mr Hassell) I think that is very difficult to comment on, because nobody actually collects that sort of information at that sort of level. Certainly, as you know, there were concessions over the implementation date of some of the standards, and I am sure that has helped people. I think, if I may, actually, the PSSRU published a report in February, which was funded by the Department of Health, which looked at the reasons for closures; and they cited, in fact, that local authority pricing policies was the first reason, care standards certainly was one of the reasons, and the cost of converting homes to bring them up to the required standards. Changes in the type and level of demand, which is along the lines Mr Lewis was just saying, how the nature of services is changing; staffing issues, that is a major issue for everyone; the property market certainly has come up for some of them. And, of course, the overall commissioning and regulatory environment. So there is a whole series of factors. But one has to remember that some of these problems have been accumulating for years, and what we are actually seeing now is a result of underfunding over quite a few years.

  427. I will not labour it any more. I just wondered if this bigger figure, the very big figure of 50,000, was what was expected, or these were actual closures that had taken place?
  (Mr Hassell) Those closures, remember, that is a cumulative number over five years, or so.


  428. Mr Hassell, before I bring in some of my other colleagues, you have talked about the problem of independent sector home closures being a direct result of this issue of fees. What is your view on the size of the shortfall, or average shortfall?
  (Mr Hassell) There is a range of studies, but those studies vary in suggesting that the shortfall per home, per person, per week, is between £64 and £89 a week, and that if you take the shortfall, and I believe Mr McClimont may have some view on it, I think there are shortfalls in the funding of home care as well, but the annual shortfall is in the region of £1½ billion, and that clearly is a huge figure, but that is exactly why homes are moving out of the market, because they are no longer viable. Whether you are operating a charity, or whether you are operating a `for profit' organisation, you cannot sustain homes, either professionally or financially, at those sorts of shortfalls.

  429. What kind of assumptions are made, if it is a `for profit' establishment, on the profit that would be made; if you were evaluating the weekly cost to the residents, what assumption would your members make, in relation to what was a reasonable profit per resident, per week?
  (Mr Hassell) I do not think I can actually answer that, because, of course, at the moment, many of the establishments are operating at a loss. There is an interesting piece of research, I believe, coming out in a couple of months' time, which is actually looking at the sort of rate of return that is appropriate for this sort of business, but I am afraid I do not have a figure. I think the issue of a profit, or, of course, surpluses, which is the term used by the `not for profit' organisations, what is important, of course, is that the surpluses generated by any organisation are the funding source for future innovation, for new developments, in services, so it is an important element in any business, whether it is a `not for profit' or a `for profit' organisation.

Mr Burns

  430. On this point, would it be fair to say that the experience amongst care homeowners is that, because of the overspending by most local authorities over SSA on social services, because of the pressures and the statutory requirements that social service departments have to provide, particularly in things like children's care, `care for the elderly' budgets are squeezed at a social service local, a local government level, and they then are either forced or use their power in the market-place to force down the weekly levels that they are prepared to pay, on a `take it or leave it' basis for care homeowners, which is putting a severe financial strain on them? You then have another situation, which is that, of course, many of these homes will have self-funders in them, and the care homeowners themselves, if they have had someone whose home it has been for some considerable time, they do not want to remove them because the local authority will not pay a realistic rate from their point of view. And so the care homeowners will take a decision that they will allow the person to stay in the home, so, in effect, you are getting a kind of cross-subsidisation, or it becomes so difficult that they turn round and say, "Is it really worth it financially?" because of the demands and pressures upon them. And, particularly if they are in certain parts of the country, they will see that they own a very valuable and appreciating capital asset and think it is just not worth their while, so they will sell up and get out of the market. Is that a fair assumption?
  (Mr Hassell) If I can comment on the latter point you made. Firstly, I think, some people, of course, have decided, for whatever reason, their age, or other factors, that they want to move out of the care home market, they are unable to sell their businesses, for the reasons we have already touched on, they are losing money, so it is not a very attractive investment opportunity; in some areas, of course, property prices, for the first time in a long time, have changed, and it gives some operators a reason to close their business. For many others though they have decided that because of the low level of fees they are not prepared to compromise on their standards, with a business which is not viable, and they have simply closed down, rather than lowering standards. I think, as regards local authorities, again, it is very difficult, because of the number of local authorities in the country, to comment on particular spending patterns over SSAs, but it is certainly the view of many members, I am not so sure it is empirically proven, but it is certainly the view, their feeling, that money is moved around into other services rather than into care for the elderly. There is no doubt about it that local authorities do use their monopoly position to hold down care fees; we have certainly had situations where increases of less than inflation, I think, the year 2000-01,—

  431. And there, presumably, you are talking about price inflation, rather than wage inflation?
  (Mr Hassell) Yes, I am, yes; and I think increases were held down to below 2 per cent, in most cases, at a time when SSAs were being increased by over 6 per cent, if I remember. So, yes, the authorities certainly use their market power to hold down prices, and I think there has been some pride within local government in doing that, but I am afraid the price for that is being paid now.

Dr Taylor

  432. The first bit is actually a question; if I may just say something personal, then a question. Because I was so interested in this gap of £60 to £80, at a meeting I had a week or two ago with Independent Healthcare Association, I did ask for some detailed figures of costs, and I do have an extremely useful letter, that was not actually in their evidence, with costs for residential care in the independent sector, local authority residential care, independent sector nursing home care and NHS hospital costs. And I think these would inform the Committee, if I can circulate this letter, because those were very helpful to me. The question really is to Mr McClimont. We have heard about the shortfall, £60 to £80 in the residential care sector; what is your shortfall? It is totally impossible, I would imagine, for you to give us an average cost, because home circumstances alter so much, but can you give us any sort of guidance on average costs and average shortfalls?
  (Mr McClimont) Not in the same terms, but it is easier, actually, to aggregate, because we tend to measure, at the moment, in hours of care delivered. Across that, we have two parts of the difficulty. Firstly, we have a difficulty with the pay levels of the workers concerned, and because we are constrained about the price we can charge, we have been forced into pay and conditions that very few of us like, I will not say none, because I am sure there are some out there that do, but very few of us do; and I believe there is a shortfall there of at least £1 an hour, that we should be paying more, currently. In relation to the upcoming standards, which are due to take effect in July, that is going to be an incremental process, and I am happy to say also that my evidence is now rather out of date; ongoing discussions with the Department suggest that the regulatory waste, that I pointed out at above about £150 million, is probably down now, in my estimation, to about £25 million, so that is a very positive move. And so the end result, taking into account the increase in National Insurance, announced last week, will mean that by about this time next year we will have a shortfall of around £395 million annually across the whole of the sector; that covers statutory as well as the independent sector. And that, broadly speaking, is something of the order of £2.70 per hour, on an estimate that I would say, an average, of about £10 an hour cost, in the independent sector.

  Dr Taylor: Thank you; that is very helpful.


  433. Before I bring Julia in, I am conscious we have not involved Mr Rice and Ms Adams so far. One of the issues that has come out of the evidence that Mr McClimont has put forward is the way in which his organisation feels this debate, this whole area, has been kind of hijacked by the interests of care home providers. Would you subscribe to that view, in view of the fact that you come at this from a very different sort of perspective? Mr Rice, are you frustrated about the kind of nature of the debate?
  (Mr Rice) I think the debate needs to broaden. Our view would be that there are certain aspects of the debate that are not out in the public arena and not appreciated. In our case, it would be the deployment of technology to reduce the load on the acute and nursing home areas, which is something that most reports, whether they be Government, local authority, consultants, or whatever, pay lip-service to, but do not typically explore and develop, because we think there is a lot of scope to relieve the pressure by using technology. So, yes, we would say, there is always one thing that seizes the headlines, which is the issue of intermediate care, at the expense of other parts of what is a very complicated problem, needing an holistic and very complicated solution, which requires a number of other areas to be debated.

  434. We have had the opportunity to look at your company twice, visiting twice; would you say that perhaps there is insufficient awareness of the potential of the kinds of products that you and your competitors are able to offer, in this debate?
  (Mr Rice) As I said in my introductory remarks, 95 per cent of local authorities and housing associations use our kit, so they are aware of it. Do they use it to full potential? We think, probably about one in ten of the people, in age terms, who could benefit from the deployment of technology actually get it, so it is not as fully deployed as it could be. Would you like me just to expand a bit on the benefits of technology, or would you like to defer that for later?

  435. We might come specifically to you later on, with some more specific questions. What I was conscious of, and it is broad, general debate at the start, I wanted to know what your views were on the sort of overall direction that parliamentary discussions, for example, take on this general area?
  (Ms Adams) I would like to see a broader debate as well, really. I probably would not use the term `hijacking', because I suppose, as Care & Repair has always focused on older people in their own homes, we have always had to be headline-grabbing. But I do think we need to take short, medium and long-term views of the whole issue. And the other thing that people are always surprised about is that the sheer numbers we are talking about are actually terribly small, in terms of the number of older people in special needs housing; and that tends just to get lost. And you were talking about 5 per cent of older people who are living outside the general housing stock, and we are not taking on board the whole trends around owner-occupation. And just as a very sort of small thing I was dying to jump in on, you said, why is there a tendency for people to go into residential care. I think, one of the things we have to remember is there is a financial incentive there, because owner-occupiers, if they are on their own, you sell their house, and the proceeds from the house pay for the care; whereas if you are an owner-occupier and you stay in your own home, social services pay for that. So that is not everybody, but we have got growing numbers of older people, with growing levels of equity, in some parts of the country, and it is a factor that drives that direction at a local level. Yes, there is a short-term crisis, I think, and I think there will always be a role for some people who are highly dependent, particularly around trends in dementia and growing life expectancy, for having people clustered together in some sort of accommodation, because community care is very expensive, if you deliver intensive support, one to one, scattered in the community; but, again, it is a tiny slice of the population. And what is much less headline-grabbing is the idea of preventative work, small-scale intervention, small-scale level of support; it is just not headline-grabbing to say we should actually have a mass programme around small-scale adaptations, to have lifetime homes, to get rid of thresholds; but from a distant social policy perspective, financially, for the state, it makes much more sense, because falls are the major reason people end up in hospital, and they do go back to their own homes, and they often go back to their homes and they fall again. And, in terms of our expenditure on those sorts of things, it absolutely pales into insignificance compared with what we spend on residential care; the total state expenditure on all adaptations across tenures is only £220 million, and you could say that is a lot, but it is a very small amount compared with residential care. So I do think it is looking at a short-term crisis, longer-term planning, a bigger vision for the future, recognising where people live, and recognising the financial conditions that drive social policy.
  (Mr Rice) Could I add a supplement to what Sue said, on the key statistics. Falls are the leading cause of mortality in the over-75s; 400,000 people attend A&E each year as a result of a fall, 14,000 people die as a result of hip fracture, and 1,000 to 2,000 beds are occupied by hip fracture; although that is not within the bed-blocking stats. From these numbers you can see the scale of the issue.
  (Ms Adams) A million people in casualty, as a result of domestic falls.

  436. We are interested. I think it was either Canada or Boston, where we found out that they have people going out and nailing down the carpet to prevent people falling, which seems a sensible thing to do, but I am not sure we do it here.

Dr Naysmith

  437. I can start off by saying I am a very enthusiastic supporter of Care & Repair, because in the Bristol area it is very active, and it is one of the best areas for—
  (Ms Adams) It is, yes; you have got the best.

  438. And I first came across them really two or three years back, with a scheme they had whereby GPs were allowed to prescribe little improvements and repairs which made a huge difference, and they are still operating very successfully. So, a couple of months ago, they contacted me and said they were going to launch this document, On The Mend, which is directly related to what we are talking about now, about delayed discharges; so I went and saw the people there and went out with them, in their little van, and they were doing little repairs and things. And what I was amazed about is something that you have just said, the relatively small amount of money that they can use and they can spend on small-scale repairs, and it can make all the difference between getting in and out. So what I want you to tell me is, why do you think it is that these delays occur in the system that your organisation can help with?
  (Ms Adams) The repairs and adaptations?

  439. The need for them, and why cannot it just be done quickly by, say, social services; and I am not blaming anybody, I am just asking for why you think it does not happen?
  (Ms Adams) There are two things. If we just perhaps pick out adaptations. We have evolved a ludicrous and complicated system for addressing adaptations in people's homes, because it is different depending on what sort of property you live in, where you happen to be when you get assessed. And so, just to expand on that, you have got one stream of money if you are a council tenant, another stream of money, potentially, if you are a Registered Social Landlord tenant, another stream if you an owner-occupier, you have got little pots of money in social services, you might be assessed by a social services OT, if you are in hospital it will be a hospital OT, and then they have to cross-refer. And you do need a root and branch reform of that whole adaptation system; and perhaps the whole introduction of Primary Care Trusts and future Care Trusts might give the opportunity for that to change. And there is a review going on between DTLR and DoH, but my understanding is it is not quite as root and branch as I would like to see. And so there is the whole issue around changing perhaps, without upsetting OTs, but you also do have to look at changing professional approaches to things as well, to make that very concrete. In two of the seven small hospital discharge schemes that I looked at, in Leeds and Bury, in Lancashire, as a result of this fast-track system, the occupational therapists were going out to fewer people's homes, they were cutting down their visits by half. And they have done two surveys in those areas where they looked at what people asked for, some of it is about trusting what people ask for as well, and 14 per cent in Leeds got what they asked for in the first place but they waited eight months for an occupational therapist to go and tell them that they needed what they wanted in the first place. So it is multi-faceted, it is how it is driven by money, where the money comes from, that holds things up. It is who makes assessments, and so I think we worked out that seven different professionals could be involved in a Disabled Facilities Grant, because you have got social services, health and housing, and the Audit Commission have done a succession of reports on how things fall down at the interface of those three places. And so, longer term, assuming Care Trusts come on stream, it would seem entirely logical that that is where you put adaptation money. The sensitivity around that, of course, is, it is a mandatory system, with an identified pot, that currently goes to housing authorities, and there are a lot of concerns about that money just disappearing into a global health pot. But I think we have to look at the two things, it is assessment practicalities and streams of money, and simplify the whole thing.

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