Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 460 - 479)



  460. So are you saying this did not happen?
  (Mr Hassell) What I am saying is that, at that stage, when this publicity was occurring, many of the home operators had, in fact, not received the cash from statutory authorities, from the health authority, generally speaking. At one stage, one of the groups, in fact, where they were acting as agent to receive what was approximately £3½ million, only half a million pounds had actually been received from the health authorities, yet there were suggestions in the media that they were withholding it; in fact, there was no mechanism in place, the cash had not been received, so they were certainly not withholding it.

Andy Burnham

  461. May I send you though a letter from a particular nursing home group that outlines the policy, which says that the policy will be to withhold funding until fees rise to an adequate level; that was clearly the stated policy of that group?
  (Mr Hassell) I am not aware of such a letter, but you have one.

  462. This was to a resident. So no home withheld the money, as part of a—
  (Mr Hassell) I am not aware of any home withholding money, the free nursing care money. I am aware of the fact that some homes have adjusted their fee levels, at the same time that free nursing care was introduced, but by relatively small amounts, compared with the free nursing care contribution.

John Austin

  463. If I can just pursue the beds that are being blocked as a result of exercise of right to choice. The exercise of right to choice, effectively, is about the long-term placement. There is nothing, therefore, to stop someone being discharged from a high-tech hospital bed to an alternative level of care, pending the solution of their right to choice over a long-term placement. Would you think there is any scope for reducing that number of blockages by the provision of alternative levels of care, in the intermediate period?
  (Mr Hassell) It may be that Mr Lewis wants to comment on it, but I am sure that there are opportunities to reduce the number of people who are blocking beds, it is an unfortunate term, but everybody seems to understand what it means, blocking beds. But I think we revert to what I was saying earlier, in response to Julia Drown's question, which is, of course, that you move into problems, I think, psychological and philosophical problems of moving people too frequently. I think there is also a risk, of course, that, if the person does not hold out for the home of their choice, they have little other leverage over the local authority; whereas I would imagine there is a distinct risk that if you compromise on your choice you may find yourself remaining in whatever placement takes place, but I have no evidence of that, that is just a personal comment and thought, but others may have different views.
  (Mr Lewis) I can certainly add to that, and I think that we can bring in, too, the whole question of intermediate care, because, for many of the people, a period of rehabilitation is appropriate, and is a move to a further placement, whether it be back home or, indeed, in a permanent alternative accommodation. We feel that the Government's strategy in introducing intermediate care, and indeed putting money into intermediate care, was something to be commended, and, therefore, we have experienced great regret that the potential of working in partnership with the independent sector has not been taken on board by the NHS and by local authorities, and indeed, had it, then I believe that we could have addressed many of the issues of blocked beds. We quote in our evidence to you our experiences in Birmingham, I could add other locations where we have developed relationships particularly with specific consultants and particularly with specific health managers, where we have been able to provide transitional care, if we do not call it intermediate care, provided a positive period of care, not just containment, because it is very different from long-term care, the sorts of skills that you require in that period following a phase of acute illness. And yet it has not been extended, has not been continued, and indeed, in some ways, is contributing to the problem of people being unable to be discharged from hospital. I do not think the choice is quite the issue, the choice often is authorities agreeing to fund the sorts of services that ought to be provided, that should be based on the individual's needs, and not merely warehousing people until they have got the place that they feel is most appropriate for them.

Julia Drown

  464. Just to pick up a point that Mr Lewis actually made in his evidence, on the need for longer-term planning to get over the problem of delayed discharges; you said there needs to be a minimum of three-year plans and contracts with earmarked funding. Can you say a bit more about how that would work, and particularly picking up the point I was raising with Mr Hassell, about what happens if you have made a contract for the use of a certain number of beds and then the care home does not want to take that particular person, because they are only a temporary resident?
  (Mr Lewis) The Government have encouraged trusts and health authorities and local authorities to consult the independent sector; sadly, that consultation, all too often, and again there are very good examples where that is not the case, but they are the minority rather than the majority, sadly, too many authorities have consulted the local independent sector when the decisions have been made, when the policy has been established. Now, if we are to create partnerships, they have got to be partnerships, and partnerships mean pooling of ideas, pooling of skills and sharing in the decision-making processes; that, sadly, does not exist. I believe that if it did exist and if the timescales were longer, clearly, you cannot expect, indeed a local authority would not be allowed, to enter into commitments for ever, there have to be review points, there has to be a period when you can go back and say, "Are we doing the right thing, and, if not, can we get out of what we have committed ourselves to do?" otherwise it becomes institutionalised. But the short-term nature of agreements, the fact that the majority of placements are spot placements, makes it very difficult for us to have this joint approach, and yet I can recognise that there are the focused skills that are around within the independent sector, combined with the commissioning responsibilities within the public sector, that make sense in being brought together. And what I was trying to illustrate was the fact that, despite, I believe, the right sounds coming from central government, it has not yet got to practical implementation at a local level.


  465. You have been around local authorities a long time, and I knew the area where you spent a fair bit of time. Would you accept that there are some fairly obvious reasons why a lot of local authorities are uneasy about involvement with the private sector, and that relates to a genuine sort of concern as to the consequences of having a profit sector and the impact upon the care involved? We have heard from Mr Hassell's evidence about thousands of residents losing their homes; a lot of people would say, "Well, should we allow a market to prevail, in terms of care for vulnerable, elderly people?", that is an issue. Do you think we can ever overcome that problem, because I suspect that the kind of people that I know and you know will continue to be very uneasy about profit being made out of vulnerable, elderly people?
  (Mr Lewis) I welcome the introduction of best value tests. I accept that maybe the mechanisms need to be refined, but the concept of applying best value is something that I was quite at ease with. However, what I have been saying, with my colleagues in the independent sector, is that best value applies to them as much as it does to the public sector. I noted with interest your question about profits. We have shared with Laing and Buisson, with the King's Fund, indeed with local authorities' own auditors, our expenditure, the return that we would expect on the investment, because I think it was fair to try to arrive at what is a reasonable price for the service that is being provided; and the measurement about the reasonableness of the service is an important aspect. What I think that the independent sector can bring to the debate, particularly around discharge of people from hospital, is a focus, a specialism, that perhaps is difficult to achieve now in local government, and indeed within the NHS, because they are not direct providers of services themselves. You have only got to look at the statistics on the amount of residential care that is being provided by local authorities, the amount of home care that is being provided by local authorities. Partnerships have got to be made to work, because, in fact, without partnerships with the private sector then the whole structure of our public services for elderly people will collapse. So let us be real, but let us also recognise that we have to be transparent and honest and apply the same tests across the whole sector; because in some ways we are as much the public sector, in providing, shall we say, in some areas, almost 100 per cent accommodation funded via the public sector. We must be part of both the planning processes, to come back to the original question, and also the audit processes, in ensuring that we deliver best value.

Julia Drown

  466. To Mr McClimont. Earlier, you said, in response to a question from Dr Taylor, about your conversations with Government on the reduced fee, your estimated cost of the impact of regulation from £150 million to £25 million, so I am pleased to hear the Government listened on that. Could you tell us a bit about what is remaining in that £25 million, and particular recommendations you might want the Committee to look at, with respect to that? You also said, and I do not know whether this would still apply now the number is much smaller, but, without funding to meet these standards, there would be severe disruptions in the home care sector and a loss of capacity. Do you have an estimate of what that sort of loss might be, and perhaps you could say a bit more about how that remaining £25 million has been costed?
  (Mr McClimont) I have to say that the 150 was the wastage element, the element that we considered to be limited impact on quality with cost, and I would have to, here, be totally fair, to say that the remaining £25 million is the subject of some dispute about one's approach to human resources management, and say that we think that there is an excessive concentration on things like group staff meetings, which have been long the tradition in public sector but which, as yet, the independent sector remain to be convinced of the value. So I would say that that is an area where we would probably rest and not die in a ditch over that £25 million. The impact, if the remaining funding gap is not covered, is a very, very difficult one for us to pick up, and, as I said earlier, it does separate into the pay and standards issues. Real life, I think, probably says that, because of the change in the balance of supply and demand now, effectively, prices are going to go up, so it is not possible to have this theoretical position where the price does not go up; and the result will be that the funding issue is not one directly for the provider, but becomes one for local authorities, as the intermediary between Government, who give most of the money, and providers, who need to fund what they deliver. But my best guess, from talking around the market, is that there is likely to be a short-term drop in capacity over this coming year, before the new monies start to come in and before purchasers universally react to this change in market provision, of something of 3 to 4 per cent overall of the home care market, and that is probably going to exist mostly in the smaller providers, rather than the larger ones who have got cushioning against the effects. That implies, probably by the end of winter 2003, that we could see a reduction in capacity across Britain of around 20,000 places in home care. I would have to say though that I do not think that is going to be the way it looks, because we were talking earlier about local markets, there are some where local authorities are already paying quite close to viable numbers, so there will not be much effect there; there are others where things have been screwed down to an unsatisfactory level at the moment, particularly in metropolitan areas, where a home care service can simply go and provide to the next-door authority, you may see virtually all publicly-funded and independently-provided care evaporating, which would amount to something like 35 to 40 per cent of the total capacity in that area.

  467. Those smaller ones though, which you were saying might not be able to withstand the change, is that because structurally they are not big enough to function, given the new regulations, or is it the case that if local authorities properly planned for this those could survive as well?
  (Mr McClimont) I think there are a few, particularly the very smallest, who will find the structure of a very defined and clear quality mechanism, find it difficult to marry with that. I have one member, for example, who provides eight care hours a week, and it is simply not going to be viable for them to pay a registration fee, and so on. So that kind of size will disappear because of the nature of what we are doing on quality. But there are other elements that are much more to do with pricing and with recruitment; and recruitment I cannot overemphasise. We are already in a position where local providers are turning away work from local authorities trying to buy from us, simply because we have not got the workers to deliver the job, but the local authority will not permit the kind of increase in fees that would enable us to pay more to recruit in competition with Tescos and Safeways. We have got people in the north east of England being paid £7 an hour to stack shelves, in a nice warm environment, where they get 10 per cent off their shopping as well, and we are being forced effectively into minimum wage levels.

  468. So just a quick follow-up on that. Where the small provider, you gave us a good example there of somebody providing just a few hours' care, is going to find it difficult to continue, does your organisation have a role in trying to make sure the care that is provided there, if it is quality care, is subsumed under something larger that can cope with the regulation and make sure it is of a sufficient standard?
  (Mr McClimont) No; our organisation is very much professional standards enhancing, or that is our aim, enhancing professional standards, we do not have any involvement in the commercial operations of our members, so that is not a role that we could take. Although we have looked at trying to broker buyers with sellers, but there are many services that do that, so that is available.

  Chairman: I know that Mr Amess had a question to you and to others, I think, on the issue of recruitment and retention; you may have partly answered it. David, have you anything to add?

Mr Amess

  469. Without wanting to do it to death, but there is a considerable part of your submission, and I have got a sister who, for many years, has done this sort of work in Derby; now she has just thrown the job in, not because she has had a row with anyone, or because of the pay, but basically it is her back, keeping lifting these people who are so frail. Now, other than money, have you got any other issues that you would want to bring to the Committee's attention, how we can resolve this? Because it seems to me, going through the homes, it is not that we have not got marvellous people working in them, but, for many of them, unfortunately, the relatives do not even visit, so the person looking after them forms a very close relationship, and it is hardly a trivial matter. Do you have any bright ideas what we can do about it, and will this £6 billion help?
  (Mr McClimont) That will depend entirely on which direction it heads in. I think there are many ideas and many things going on that should help. The care standards implementation, for example, will, we believe, have a very significant effect in job satisfaction levels, on two fronts. One is that we are going to raise the status and the perception of the work and the levels of training and involvement, which is reportedly having a very promising effect on recruitment and retention in some areas. The second is that I think there will have to be changes in the way that local authorities commission services, as a result of the care standards work, which will give a greater level of autonomy and working with the user, so that individual workers and managers will have more of a responsibility to negotiate with the user exactly how the care is delivered, and to get in that relationship that you were describing a higher level of job satisfaction. So I think that there are good measures there. I have to say though that there is this hygiene factor, if you like, of money, below which many people cannot work, or where it is just not worth their while, and that has to be one of the major issues there.

  Mr Amess: It is a bit ironic your giving evidence today, because only yesterday all MPs got letters from the Local Government Association, who were somewhat perplexed at the new arrangements being made, and they are arguing the case that they do not think, now the problem is apparently going to be passed on to them, they are very concerned about the funding. But I just wonder if that is going to have any impact on . . .

  Chairman: We touched on this while you were out.

  Mr Amess: Did you? I am sorry, I apologise.


  470. Mr Rice, do you want to come in on this?
  (Mr Rice) Just an observation. I would not discount the profound impact that domiciliary care could have, on relieving the pressure, not just on the acute sector but on the care home sector as well, and that is again part of the broader solution. There are people who are in care homes and people who are in acute beds who could actually be in their own homes being monitored and attended to, and clearly that relieves the pressure in both those parts of the system.

Mr Amess

  471. You are talking about the link-up things?
  (Mr Rice) It is deploying home care, whether it is nurse care, it is Care & Repair type support, it is the technology being deployed in order to relieve the need to put people into care homes and into hospitals. One of the things we have not touched on—

  472. The technology is marvellous, but, at the end of the day, for goodness sake, we do want the human contact, do we not, really?
  (Mr Rice) But the psychology, which Mr Burnham mentioned, is quite important, because we have not touched on carers here, and I noticed, when reading previous minutes, that you had touched on carers. One of the things that drives admissions is carers really believing that perhaps the best place for people is in a care home or in a hospital, because it gives them a break, and the ability to have systems that can relieve the pressure on family and friends of caring for people, which is absolutely profound, as everyone, I suspect, in this room, has found out personally, through their own personal tragedies. As I have said a couple of times before, the problem is a complex one, and you do have, for example, clinicians believing that monitoring is best done in the hospital, and we have not done a very good job, I think, of convincing clinicians that the technology is robust enough and capable enough to make their life easier, with monitoring being done in the home. And you have carers often promoting the admission of people because they are concerned about their loved ones and they believe that the best place for them is in an intensive care or intermediate care location, and it also gives them a break as well. So deploying the right measures to address the problem is quite important. When we talk about penalties, I am more interested in incentives to get people to behave in the right way. You cannot separate this from the issue of ring-fencing various pockets of funding in order to encourage, addressing all of the issues in what is a very complex and holistic problem. Certainly, the funding in the technology area of healthcare tends to be vulnerable to the immediate demands of the acute and intermediate sectors.

John Austin

  473. I am hoping that, if we ever get there, we come on to the `high touch' versus high tech sort of argument later; but can we stick with the intermediate or alternative levels of care, for a moment. In response to Mr Hassell, I share your view that, for some patients, more than one move, or a frequent move, may not be desirable, for many. (I think we have changed our cultural acceptance.) In the past, people did not necessarily feel, whatever they were in hospital for, they were going to be discharged to be in a home, they may not have been fit to go back to work or to go back to home and they may have convalesced somewhere. We seem to have lost that culture of convalescence, which do you think we are trying to reinvent in some ways with the intermediate or step-down or alternative levels of care?
  (Mr Hassell) I think, generally, in this country, rehabilitation, including convalescence, seems to have gone through phases, and I think there is still a need in this country for longer-term, real rehabilitation programmes. In my mind, I think intermediate care is, in fact, short-term, intensive rehabilitation and convalescence, as you put it. There certainly are, amongst our membership, some good examples, not so much of people who are awaiting placements in homes, as we were talking about earlier, but there have been some good examples amongst our members where they have actually developed good, partnership, intermediate care schemes, which have enabled people to move from the acute setting back into their own homes, in the community. There are schemes in Leeds, Mr Lewis has mentioned schemes in Birmingham, there are schemes in Camberwell, Halifax and, in fact, in Powys; so there are some good examples, but, unfortunately, there are also problems in other areas, and I think we have all qualified many things we have said this evening, that the experiences vary. We have some good partnership arrangements with statutory authorities, but I am afraid the independent sector has been frequently ignored, again, not involved in the planning, not involved in the development of the services.

  474. Let us look at one of your successes; particularly you referred in your evidence to Birmingham, where Westminster Health Care enabled 273 bed nights at the Orthopaedic Hospital to be freed up, and that seems to me to be an enormous achievement. If somebody is waiting for a hip replacement but they do not get it, the chances are they are going to fall over at some stage and break their hip and spend even longer in hospital, at the end of the day, so if you can free those up; what is it that has led to success in Birmingham that has not been successful elsewhere?
  (Mr Hassell) It might be more appropriate for Mr Lewis to comment, because it is actually one of Westminster's schemes, in Birmingham. I am not sure. I will pause.
  (Mr Lewis) The sad thing is that it was not funded with money that was earmarked for intermediate care, it was funded through one of the trusts, through the orthopaedic surgeons recognising the benefits of patients being able to be discharged from hospital more quickly and receiving the rehabilitation that then enabled them to go back home appropriately and safely. It comes back to the funding issue. Everybody was happy with the service, it speeded up the discharge of patients, it enabled the consultants to admit more quickly other patients, but it was coming out of mainstream health funding, and has stopped, I sadly have to say, because the Trust is no longer able to fund it; so those facilities now are not being used for the purpose which Westminster had invested considerable amounts of money in, believing we had a partnership. So it is a success story, on the one hand, but it is a total failure, on the other, because I do not think, generally, there was the recognition of what intermediate care potentially can do.

  475. Recognition by whom?
  (Mr Lewis) Largely by our colleagues who manage the intermediate care money that the Government has made available. Now, I think, in fairness, they may well be able to turn round and say, "Well, we invested in something else, this has got a better return." But certainly that was not the view that was shared by those consultants, in particular those orthopaedic surgeons, who, in fact, were very enthused by what was happening. And, importantly, it was a partnership, because the physiotherapy and the OT were being provided by the hospital-based Trust personnel, we were providing the care and the environment.

  476. At least we are going to ask the question here, the biggest delays in admissions are often in the area of orthopaedics, one of the biggest areas of delayed discharges is orthopaedics; why is it that the commissioners cannot see that this is an area precisely where the intermediate or step-down levels of care are required?
  (Mr Lewis) And here I stay silent, almost.

  Chairman: Dr Taylor is going to ask them the question.

Dr Taylor

  477. No, he is not, he is just going to ask, with the changes that took place on April 1, and PCTs getting the commissioning power, is this going to improve intermediate care, or are you worried that funding will be even worse to find?
  (Mr Lewis) I am very hopeful that, as money flows with the individual, it is going to improve the situation, because no-one in their right mind is going to pay for an orthopaedic bed in hospital at over £1,000 a week if, in fact, for half that amount of money their needs can be met more appropriately elsewhere; and that just does not mean in a nursing home, it could well mean by putting a package of services together in people's own homes, including things like the Tunstall technology, and, indeed, there are examples of that happening.

  478. Do you think plans are in place for the interregnum between the health authorities and the Primary Care Trusts; do you think there is going to be a huge gap, or do you think it is going to be seamless?
  (Mr Lewis) I am not sure that there is going to be a huge gap, I think that would be unfair and I do not have the knowledge to say that. I am pretty sure it will not be seamless. What I do fear is that there will be almost a moratorium on development, because everybody will be so busy establishing themselves; and, obviously, too, that they will be concentrating on other areas, perhaps areas where they are being measured, in order to meet the expectations of those that are measuring them.

  479. Is there anything we can do to try to stress the importance of this?
  (Mr Lewis) I think the importance is, first of all, in ensuring that funding is earmarked and directed in the direction it is intended to go, and rather than being diverted to alternative services. The second is that I think that there needs to be evidence that there really is joint working, with measurable outcomes, and it is the outcomes we should be measuring, and I am not sure we are actually there yet. Many of the performance indicators do not measure outcomes, they actually measure outputs.

previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2002
Prepared 29 July 2002