Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 560 - 579)



  560. Are you clear what the definition should be and which way it should be collated? Could you help us with that?
  (Dr James) I am not clear how it should be collated. I am sorry to disappoint you. We should be very clear how we can count these figures so that we can readily benchmark across our organisations. I should like to mention in terms of definition the concerns about the scope of the definition. A lot of the discussion so far has been around the patient, which is fantastic. For me the tragedy of delayed discharges is that for that patient in that bed care has ceased. Rather than their delayed discharge, which is an organisational term which means they are felt to be a waste of space unfortunately, in reality their care has stopped. Maybe one of the ways we can define a delayed discharge is not necessarily in how long they have been staying but whether they are there appropriately or not, whether their care has stopped, whether they should be elsewhere. If, however, the assumption is that that delayed discharge solution will create capacity in our health services, that is entirely wrong. I am very happy to give some examples of why I believe that.

  561. It is not that their care has stopped: many of those people are still getting nursing care. It is just not the most appropriate care. Anybody else want to help on this definition issue? If not, we shall just have to take it forward ourselves.
  (Dr Morgan) We can give you written evidence on it. I shall come back quickly on that for you.

Andy Burnham

  562. May I turn to capacity problems? In your evidence you identify the major losses in capacity which have occurred in independent sector care homes and also pressures on the home care side. As a Committee we have had a blizzard of statistics about the loss of places in the independent sector. A new figure was quoted in your evidence of 35,000 places having disappeared in the last three years. The Independent Health Care Association use another figure of 50,000 places lost and the Department would point to a net figure of 19,000 lost. Could you shed a bit more light on exactly how you arrived at that figure of 35,000? Could you comment on the 50,000 figure and the 19,000 figure, as to which is the most accurate?
  (Mr Ransford) I do not know which is the most accurate. We would all agree that a significant amount of capacity has been lost and there is no doubt of that. It is a tremendous number.

  563. Was there over capacity?
  (Mr Ransford) There was over capacity; historically there was over capacity. Mr Leadbetter mentioned in evidence earlier the system in the 1980s which was driven by cash through the social security system. There is no doubt that there was a perverse incentive in the system then for residential care as an outcome. As commissioning came in, with the passage of the community care responsibility to local authorities in the early to mid-1990s, the market stabilised somewhat and I know personally that some capacity disappeared because it was no longer of the type that was acceptable in terms of quality or space or whatever for individuals. So some capacity needed to go. The point was whether the providers were part of an overall planning system to ensure that capacity developed to meet the needs or whether we got perversities coming into the system, as I am sure we did, capacity going for the wrong reasons, that providers could no longer afford to provide it or they could use their facility for different purposes. The equity in residential accommodation changed as a result of general market conditions, a whole series of factors changed things. What we saw was a significant loss of space, a lot of it targeted in particular areas. It happened all over the country but in the South East, as a result of high property prices, high wage costs, changing regulations, a whole series of things gradually disappeared.

  564. It would seem that 50,000 is over-stating it. You suggest 35,000 and it is fair to say that it seems that 50,000 is a conveniently large figure.
  (Mr Ransford) We stick by our figure, but the situation has moved on.

  565. Your figure is different from that of the Independent Health Care Association, is it not?
  (Mr Ransford) Yes, it is. There is no denying that it is a significant figure and has severely affected capacity in terms of having the right choices available to people, the right choices made professionally to meet their needs.

  566. Do you recognise the Department's net figure of 19,000? Obviously some places have opened while others have closed. While some have clearly closed, do you recognise that net figure? That is obviously the important one, is it not?
  (Mr Ransford) Yes. I would need to go and research before I gave you a definitive answer on that. I would need to go and research that. Certainly we need to look at the net figure, we need to look at the figure for places in the context of what other resources are available. We talked about intermediate care. If intensive home schemes have opened which are alternative to residential care and meet people's need better in their local community, then that is a genuine alternative and must be looked at in terms of the whole system.

  567. Is not the real thing, the one which is of use to this Committee, how many places we are short of?
  (Mr Ransford) Yes.

  568. You could have closed 300,000 if 300,000 needed to close. How many would you say were needed?
  (Mr Ransford) How many spaces we are short of and how many other resources have been made available through innovation and new practices which meet people's needs must be considered together.

John Austin

  569. May I ask whether you would agree that the availability of the cash in the 1980s to purchase care in homes actually acted to prevent the development of the home care and domiciliary services needed?
  (Mr Ransford) Yes; certainly. There is no doubt that was the case.


  570. One of the mysteries to me is why we are so hung up on this debate about the need for care home places when other countries seem to manage completely without care homes? We went to Denmark a few years ago and saw a system there which has developed alternatives to institutional care which was in my view quite refreshing. Do you not feel we ought to be moving in that direction? If we are not moving in that direction, why not? We seem to be bogged down with the whole debate around the interests of the market as opposed to the interests of the people who were placed in care; the interests of the patient and the user.
  (Mr Ransford) My answer to that is that there is a case for care homes, there is a place for nursing homes, depending on the needs and wishes of individuals. Just as we must look at the acute sector as providing its service to people at that time, we have to look at it in the context of a system which should be primarily community based. What has happened in recent years is that there has been insufficient investment in community alternatives and considerable investment for different reasons in residential care and acute care, which has made the problem worse. We are stuck with a double whammy of having a crisis in terms of demand and a crisis in terms of historic investment being in the wrong places and it takes time to change that round.

  571. I may differ with you on the issue of needing care. In all my time in social work I must have dealt with hundreds of people going into homes. I have yet to meet one for whom it was a positive choice. That is an interesting factor from my point of view.
  (Dr Morgan) What I have here that may help—and it is only one data source—is the Laing and Buisson report which comes out every year looking at the beds lost and the new beds. The figures go back to 1996-97, so I am happy to leave that with people because it has both the ins and outs in probably the most authoritative data source that we have.

Andy Burnham

  572. Is it fair for me to conclude therefore that the 50,000 figure has been raised by care home owners and the care home industry and perhaps picked up by some of their friends in Parliament and blown up when in fact it slightly misleads on the changes that are going on in the home, community and residential care sector. Would that be a fair conclusion?
  (Mr Ransford) It may be your conclusion. I am not going to speculate. I am not going to speculate on why figures have been put forward and why people have drawn conclusions from it. All I say is that we have to keep all statistics in perspective in terms of the requirements we need to provide the right service for people in need.

Mr Burns

  573. I just wanted to clarify a point. Is the 50,000 figure not the one that Laing and Buisson has produced? Is that not the source of it? It is not care home owners or some of their so-called friends in this place.
  (Dr Morgan) Yes, their figure going back to 1996-97 is a total bed loss since 1996-97 of 51,1147 and a total new bed figure of 18,924. That is the best source we can find which looks at it comprehensively.

Dr Taylor

  574. In the evidence from ADSS, it says, "The local Health Services are paying more and aggressively recruiting from the nursing home market, with dramatic consequences on the sustainability of that market". Can you give us any sort of figure or any feel for the severity of that as a problem?
  (Mr Leadbetter) I can give you a feel. After the Coughlan judgment certain authorities changed their purchasing practices in line with the judgment and health trusts started purchasing care. Our view was that because they were not as experienced at commissioning some of the nursing providers used the opportunity to increase prices. We found locally significant increased pressure on prices in the nursing care sector. We had been purchasing in larger numbers and it was not necessarily being picked up that the nursing homes were using that new business opportunity to increase rates. Combine that in Essex with the very significant problems we had, particularly around the London and Hertfordshire fringe, actually recruiting staff to work anywhere.

  575. Any comment on that?
  (Dr Morgan) It is a massive issue. The biggest issue facing health and social services is supply of staff. There is a shortage of nurses. Anywhere you have a market or a competition to deliver, nurses will move round the system and organisations will try to get nurses from wherever they can. What is happening in a number of places is that people are trying to get out of that and stop regarding nurses sitting in one other part of their system—because this is a whole system problem—as belonging to somebody else. Some imaginative schemes are starting in PCTs, where they are beginning to look at how they run a pool of nurses who could both support what goes on in the NHS, look after what goes on in the community and find ways of providing some of the input into nursing homes. It is quite fraught because there are some technical problems about that in terms of legality. It is also quite difficult, because what we should not forget is that we require nursing levels and nursing standards in nursing homes which are significantly higher than we require within the average NHS ward. We have put in a lot of extra burdens in terms of the numbers of nurses in nursing homes, because we do not want single-handed practitioners, whereas in many hospitals we run wards at night with single-handed trained practitioners. There are some very complicated things here which are not going to be resolved by thinking about the nurse sitting in any one block, but thinking about it comprehensively. There is a second issue which is actually much more concerning about nursing homes and care homes which is the availability of care staff in areas which have high employment. Nursing homes and care homes have driven down wages and in many places like the place where I was Chief Executive, you could work for twice as much in Tesco's overnight as you could providing care to some very disabled and disadvantaged people. There is a whole set of other market forces which are making it very difficult for nursing homes as well as nurses. You have to take it in the round. There are some hopeful things in the NHS. The workforce development confederations which now have the money to train and develop staff do have a remit to look at the training and development of staff in the independent sector. Out of that are coming some of these innovative schemes to think about how we both maintain high skills but also begin to use the pool of nurses in the community more wisely than we perhaps have done in the past. It is not easy.

  576. Yes, we have heard about Tesco's before. This is a prime example of the whole system approach, how it really could work if there were one pool of nurses which could be shared.
  (Dr Morgan) It is. There are some legal difficulties with that because of independent organisations but people are exploring how to work creatively through the legal framework.

Sandra Gidley

  577. Acknowledging the fact that more money is being paid to care home providers in many places, the local situation—I do not know how widespread it is—is that Hampshire County Council and Southampton City Council have decided to up the amount quite considerably, by about £50 a week, as a recognition that that is a fair rate. The sting in the tail however is that existing patients are still paid at the old rate. I have certainly had a case in my constituency where a nursing home was threatening to throw out all the people on a lower rate. I do not think it will actually. Do you think this is the right thing to do? Do you think it is morally defensible or is it a step in the right direction?
  (Dr Morgan) Whenever the system draws rules, we do not spend enough time thinking about the potential perverse incentives which go with the rules. We think about what might happen on the positive, but we do not think about the tiger traps. If you believe, as I do, that people actually behave rationally, whatever rules you give them, they will behave rationally for where they sit in those rules, so it is not surprising we see things which perhaps do not fit our own perspective of how to manage the system. The issue is how to get out of that and that is about defining rules, remembering that people are going to behave rationally and try to play them for all they are worth, because that is what people do.

  578. I do not think it is just a case of playing the system. Some of these nursing home owners have been struggling for some time, particularly faced with the problems of the Care Standards Act and now feel that it is just one more attack.
  (Dr Morgan) Indeed; That is why I think that back in the communities who are thinking about this there needs to be more effective engagement at the planning stage of how you are actually going to put these incentives in, proper thinking about what the incentives will be and how people will respond to them and doing that in a joint way. Sometimes it happens with bits of the system sitting in one room and other bits of the system sitting somewhere out there feeling badly done to. There are really good examples of where that is no longer the norm, yet all around the country there are effective engagements with the independent sector between health and social care working jointly. They are avoiding some of these tiger traps, because they are designing the system to achieve the ends they want rather than putting something in which achieves the wrong ends.

  579. Are these differential rates a good idea? I did not quite get an answer to that question.
  (Dr Morgan) Certainly in the patch I worked in, we did not go down the route of differential rates because we felt that would put in a whole set of perverse incentives. You cannot comment from one place to another because the issues are different. Where we were, we wanted to protect the marketplace in one of our four PCTs, not in every PCT. We had spare capacity in some places and under capacity in others. We had a particular issue around specialist care homes which provided particular support for people with complex mental health problems. We were using our resources to encourage people to come into the marketplace in an area where we wanted it. It is how you design the system to meet the ends which are appropriate in a local place. It is back to encouraging that proper joint analysis of what your local problems are, what your local opportunities are and then a set of solutions which will address your local solutions. It is putting that in place which is more important. You cannot comment from one place about another place because you do not understand those circumstances.

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