Examination of Witnesses (Questions 640
- 659)
WEDNESDAY 19 JUNE 2002
JACQUI SMITH,
MP, MR RICHARD
HUMPHRIES, MS
MARGARET EDWARDS
AND MS
ANNE MCDONALD
Julia Drown
640. I have some issues about funding. Is not
one of the root causes of delayed discharges the disparity in
funding between health and social services—not to say that
health has had too much money, but that social services has not
kept up with that over the years?
(Jacqui Smith) I think there are a whole range of
reasons why we have delayed discharge. Some of it would certainly
be around the ability to develop, within the community—and
that could be either the health or social services spending—the
sort of alternatives to remaining in an acute hospital bed that
would be necessary. So yes, the investment is part of it—and
I shall come back to that in a moment, if that is all right—but
I think there is also an issue about the extent to which there
is good partnership working across the system. I think we are
also beginning to think as well of the extent to which that work
really focuses down not just on some general idea of partnership
at a sort of strategic level, but in relation to delayed discharge
how it really focuses down to a concern about managing an individual's
pathway through acute and back into community care again. My impression,
from having considered those areas where there is already successful
work around reducing levels of delayed discharges, is that they
do have that very close focus on that management. To come back
to your point about is money important, I think we have proved
to a certain extent, through the expenditure of the £300
million building care capacity grant focussed on reducing delayed
discharge, that investment is important in order to make a difference.
We quite clearly have evidence there, from our monitoring, that
that has enabled local authorities and their health partners to
develop some sort of provision that would be necessary to provide
community alternatives and to maintain capacity, for example,
in care homes through fee levels and through the way in which
they are funding placements. So investment is, if you like, a
prerequisite for solving the problem, but I am sure you will not
be surprised to hear me say that it also needs to be linked to
some sort of reform, and in particular, I think, in terms of the
way that in the future we are going to need to consider what incentives
we put into the system 1) to create that focus on managing individuals,
which I spoke about, and 2) to ensure that that interface between
health and social services really is managed in the most effective
way and that the investment goes into the areas where it is going
to be useful.
641. You mentioned there the short-term money,
the £300 million, and certainly it has been very effective
in reducing delayed discharges in Swindon. However, what I hear
is that having a short-term grant is not the most effective way
of developing services, particularly when there are national and
local shortages of people like occupational therapists and community
services people that you need to recruit. Should local authorities
be assuming that they are not recruiting short-term staff, but
that they are coming in for the longer term? How do you get over
that problem of wanting to develop services but you cannot, for
example, employ somebody or it is not so easy to attract somebody
if you are only attracting them for a year's contract or only
for an 18-month contract?
(Jacqui Smith) Firstly, your point about short-term
funding is, of course, an argument against earmarking and ring-fencing
of funds in quite the ways that we did with the £300 million.
One thing that was important about that was that we listened to
what the local authorities and care providers were saying about
the need for investment in the system in order to solve this problem.
We identified those resources and we focussed them very clearly
on where we identified the problems, focussing them so that actually
more resources went into hot-spot area; in a very centrally-managed
way, we identified what we expected that money to be spent on,
what we expected and the difference that we expected it to make.
By announcing it over two years, we have tried to give some certainty,
from the October announcement, that further money would follow
in 2003. That was important in order to ensure that people felt
able to enter into the sort of arrangements that you are identifying.
For the longer term, though, firstly, I do not think it is either
sustainable or desirable to continue funding the activity in that
particular way and in particular managing it in the way that we
did through that grant.
642. Do you think that authorities should be
taking the risk and assuming that the money will come through
in another way?
(Jacqui Smith) What I think authorities should be
doing is looking at the Chancellor's announcement about 6 per
cent real-terms increases in personal social services over the
next three years, and I think they should be looking at the announcements
that we have made as a Government about the significance of social
care, the important role that it has to play and our commitment
to funding it, as represented by that announcement, at twice as
big a real-terms increase as we have had over the last five years.
I think they should be seeing that as a sign that they ought to
be making long-term plans about how to tackle that problem.
643. That should be seen as the limit of it,
should it? You did say in your evidence that "The new social
services cash announced in the Budget includes resources to cover
the cost of beds needlessly blocked in hospitals through delayed
discharges". Does that mean all beds needlessly blocked in
hospital? Again, the feedback I am getting locally is that all
community care budgets are deemed to be very depressed because
the cost pressures are there in nearly every area of community
care.
(Jacqui Smith) Certainly in terms of that 6 per cent,
the way in which we have modelled the need to reduce delayed discharge
is in order to meet our target to get down to a frictional level
of delayed discharges, and it is on that basis that, if you like,
we were successful in getting what is a pretty significant increase
in personal social services funding. So yes, with regard to that
6 per cent, that social services settlement, clearly there are
discussions that we are still having and there are discussions
that we are having with the Treasury about how that money is allocated,
how it is used and, for example, what sort of PSA targets we might
be setting around it, but our modelling is that that provides
us with the funding or provides the local authorities with the
funding in order to be able to tackle this problem. For example,
this settlement would buy from 2002-2003 to 2005-2006 some 8,000
extra intermediate care places supporting another 70,000 people
a year, public support for 7,000 people in residential care, 30,000
more packages of home care.
644. That is if all the 6 per cent went on this
particular aspect?
(Jacqui Smith) No, that would not imply all the 6
per cent going on this, because clearly there are other cost pressures
that local authorities face as well. I think it is 40 per cent
of a social services' expenditure which goes on older people,
and of course we recognise that if you take children's budgets,
part of what brings pressure onto older people's budgets is pressure
that feeds through children's budgets, which is why we are also
undertaking action to try to ensure firstly that the investment
necessary there goes in, and secondly through, for example, our
Choice Protects Review that the sort of functions that local authorities
are doing helps to ensure that that money is being spent.
Chairman
645. Do you think, going back to the question
I asked on the cost, that there is sufficient awareness elsewhere
in the Government of the knock-on effects of investment in one
Department's operations on that of another? I am thinking in particular
that yesterday some of us went to an extra care housing scheme,
which I believe you have been to, in Stoke-on-Trent, and we were
very impressed by the impact of work they were doing—at
least I was impressed, I cannot speak for others—in the
housing environment on health care costs. What is frustrating
me on the issue Julia has raised is the way in which there has
been insufficient awareness, fairly obvious to most of us and
probably to you, of the impact of social services budgets on health.
What about the wider aspect of the housing budget and health?
Are you happy with the extent of commitment from elsewhere in
the Government on areas of policy? You have to be careful how
you answer that, I appreciate that. Have we got sufficient cross-departmental
working which enables you to stress to those departments that
some work on housing can directly impact upon your ability to
admit people into acute beds in the NHS?
(Jacqui Smith) Housing is a very good example—and
I think Richard would agree—because it is an area where
some of the evidence of where there is successful delayed discharge
work often relates to where there is imaginative use of housing
resources, for example, to develop extra care housing, or being
imaginative about the way in which adaptations are made, for example.
So there is certainly evidence that is if you like another link
that is very important. Just tomorrow, Chairman, for example,
the Department of Health is organising, and I am speaking at,
a housing seminar bringing together representatives of health
and social services and housing providers precisely to look at
how we can develop more of that type of housing provision. One
of the examples of where the £300 million has been spent
is on some step-down provision where they used some of their existing
housing stock and then provided the sort of packages of care necessary
to make that appropriate for people coming out of hospital. I
am very keen that we pursue this area of work in relation to housing
and there is already work across the Government where that is
happening. For example, I am sure everybody is aware that in January
2001 with the then DTLR we published a strategic framework for
older people's housing called Quality and Choice for Older People's
Housing. I say I am sure everybody is aware, and I will not test
people, but I suspect there are some people who are not aware
actually, so part of what we have to do is get up the profile
of that framework and to provide some more guidance and some more
push to what I think people are very keen to do at a local level.
We are now working with the office of the Deputy Prime Minister
on guidance to help local authorities to plan for those housing
needs of older people and to meet those needs. We are working
on a set of performance measures so we are going to be able to
track the progress nationally on extending the choice and quality
in housing and care services. We are looking at practical ways
of getting good advice to older people about what those housing
options might be, and also, because I think this is an important
area of our provision generally, practical ways to improve access
and provision for older people from black and ethnic minority
groups as well. That was all part of work going on across government
which was previously work which I was doing with Sally Keeble
and will obviously take up with her successor. There is one other
issue on this. When the officials came before you, and certainly
in the past and in the Next Steps document, we also talked about
how we promote new sorts of joint ventures, new sorts of approaches
to providing housing, and I think here there is a very good and
important role for the co-operative sector for different forms
of ownership to help us promote housing solutions. I think it
was last week or the week before Hazel Blears had a very good
seminar in the Department looking precisely at that type of social
enterprise, how to promote that type of work, including organisations
who were currently working on housing solutions for older people
which linked into health and social care needs as well. So this
is an area where we need to and we could make a lot of progress.
There has been a good start. Given your question, Chairman, I
would not like there to be a suggestion this is not an area where
there is no cross-working across government, it is, but it is
probably an area where we need to boost the profile and make sure
that people are making the most of the opportunities which exist.
Chairman: I am reassured by your answer. It
is now ten years since I was on the front bench developing this
area of policy with my housing colleague, Mr Raynsford, and it
seems to be very slow coming forward. I welcome the fact that
you have clearly personally recognised the importance of this
area of policy. My concern is that we have so much emphasis on
the private sector, but the private sector does not recognise
the importance of this area and certainly the local authorities
I speak to also seem to be very slow in coming forward—and
it is probably wrong to generalise because we came across a local
authority yesterday which really was in the front line on this—but
I can see no reason why we could not do much more in that direction,
and I welcome the point you have made.
Dr Naysmith
646. Before we move off this area of additional
finance for social services, there have been a couple of reports
from your Department, the Emergency Care Report 2001-02
and Delivering the National Health Service Plan. In the
first of them it was indicated by the end of March 2002 the target
reduction of a thousand delayed transfers of care since September
2001 had been achieved, and that is a 20 per cent reduction and
that is very commendable. Then the report concluded that winter
pressures had been dealt with by improved planning, expanded capacity
and by major new investment including the specific funding to
tackle delayed discharges. So that was the reason that the Department
achieved its reduction. If that is the case, that recent progress
has been achieved in reducing delayed discharges, and it has been
due to targeting the resources, central intervention and close
monitoring of progress. Why is it that in the document, Delivering
the NHS Plan, which was similarly not long ago published,
it states in paragraph 8.7 that this approach would not be seen
as sustainable in the longer term. Why is it that what you think
is a good solution is being rejected in a very similar document?
The reason I am raising it now is because you have touched on
it in what you said.
(Jacqui Smith) Yes, I did. We had seen some success
in reducing the delayed discharges but, for all the arguments
which we talked about earlier around the whole system, it was
important we made further progress in reducing delayed discharges
and we really got a grip of the problem and tackled it. That was
the reason why we identified the £300 million extra investment
and that was a very important part of helping to tackle delayed
discharges. I have said, Alan has said, this is a good example
of where investment makes a difference in the Health Service and
delivers. My argument was not that we did not need that investment,
we do, and that is part of the reason for continued investment
in social services, my argument is, is it sustainable in the long-term
to tackle it in the way in which we did.
647. What is the answer to that?
(Jacqui Smith) I do not believe it is because, for
example, quite a lot of hon. Members, my hon. Friends, came to
me and said, "Look., we've got an extremely successful local
health and social care system, very good partnership working,
real focus down on delayed discharge, we've been really successful
in tackling the problem, and therefore we're not getting as much
money as we would do if we were a hot-spot area." I do not
make any apologies for focussing that money as we did. Every authority
got some, but we did focus it on 55 hot-spot areas, and for those
hot-spot areas we had an extremely top-down approach to monitoring
and to ensuring that that target was met. We expected a specific
target. We expected specific outcomes in terms of the way in which
that money was spent. We had, I think it was, weekly meetings—it
seemed like that often—between Social Services Inspectorate
and officials in the Department and representatives from those
local health and social care communities. That focus and that
money made a difference.
648. But has that partly made a difference because
that is where the problems were, because if you are suggesting
that other areas did not have the problems, that they were not
the hot spots, why should they get the money?
(Jacqui Smith) There were problems across the country,
and every local authority, of course, got part of that £300
million. Even in those areas we were less strict about the way
in which we monitored it and inspected it. In the long-term, though,
what we have said in Delivering the NHS Plan—the next
steps on investment and reform is that we now need—and
this is really the whole approach that we are taking to health
and social care—to put into the system the sort of incentives
that deliver what we need to see in the system, and we need to
devolve responsibility down to a local level, alongside the extra
investment that is going into health and social services. I do
not think in the long term, therefore, that that type of very
close, top-down management monitoring is a way in which we are
going to achieve success, which is why, of course, we are now
thinking about what we need to do both to devolve that responsibility
and to put in place incentives through the system that will enable
us to tackle delayed discharges. If what you are saying to me
is, is investment important, yes, it is. The question is, how
do you direct it and how do you set up the system to deliver what
you want to come up the other end.
649. The next question is what further targets
for reducing delayed discharges are to be introduced following
the success in meeting the target since September? What sort of
targets are you going to have?
(Jacqui Smith) We clearly have a national target to
reduce delayed discharges by March 2004, so we have national targets
and we will maintain a focus on delayed discharge, but we will
ensure that it is delivered in a different way to the way in which
we incentivise that activity at a local level.
650. So do you think you will be able to get
delayed discharge down completely, or is it at a level at which
it is acceptable? What is it?
(Jacqui Smith) There is what I think we describe as
a frictional level of delayed discharge.
Chairman
651. Did you say "frictional" or "fictional"?
I heard you use the term before and I was not quite sure I heard
it correctly.
(Jacqui Smith) "Frictional". Nothing about
this Government is fictional!
Mr Burns
652. Pull the other one!
(Jacqui Smith) It is a frictional level of delayed
discharge—that is, the argument is that there will always
be a certain level, but tackling delayed discharge is—
Dr Naysmith
653. What is that level?
(Ms Edwards) It is just about the natural process,
in the sense that there will always be people going through the
system, people who have been admitted to hospital inappropriately,
and even in an ideal world, given appropriate admission, appropriate
care, an approach that recognises that they are going to need
a nursing home or some other sort of care, there will always be
patients waiting one or two days for that sort of care. So even
in the ideal world, with the numbers of patients we treat—6
million patients going through the acute sector every year—there
will always be one or two of them, a tiny proportion of them,
waiting for the next process, and one of the aims is really to
try to get an appropriate approach.
654. There must be some places where that level
has been reached already. Have you any idea what that might be?
(Ms Edwards) We are nationally saying somewhere around
2500, which is about 2 per cent.
Mr Burns
655. I briefly wanted to ask the Minister a
question, because I was fascinated by her saying that a lot of
her hon. Friends were coming to her to say that they had excellent
schemes in their localities where health and social services were
working extremely closely together in this important field, which
is a) a very positive step, and b) one to be encouraged for the
future. What I was wondering was, did she think, or did any of
her hon. Friends who came to her to discuss this mention, that
possibly these very good relationships and working together might
be strained or damage might be caused to them as a result of the
proposal, in effect, to penalise social services departments for
delayed discharges?
(Jacqui Smith) Actually, they—
656.—welcomed the proposal, did they?
(Jacqui Smith) Actually, they did not.
657. I thought not.
(Jacqui Smith) They certainly, as do we, believe that
tackling delayed discharge is more effectively done where you
have good partnership, but I am sure that, like any of us who
have constituency surgeries, at the centre of their concern is
what we need to do in order to ensure that older people are getting
the right care at the right time and in the right place. None
of my hon. Friends, as far as I am aware, came forward with this
suggestion, but I am aware that the hon. Member for Westbury—
658. Hang on a minute, before you get on to
Westbury, just for one second, I did not quite understand what
you were saying. Could you repeat the first half of that sentence,
before you get to Westbury?
(Jacqui Smith) The first part of what I was saying
was that my hon. Friends share my view and this Government's view
that we need to take the necessary action, through both investment
and reforming the system, in order to make sure that older people
are getting care where they need it, when they need it.
659. With respect, that was not what I was asking
you. What I was asking you was, do you think that the proposal
to place financial limits on social service departments who are
involved in delayed discharges is going to enhance or impair the
good working relationships that some of your hon. Friends have
raised with you of health and social services working closely
together in partnership to deal with the problem of delayed discharge?
On the second part, before we get on to Westbury, you may not
have heard it, because presumably you were not in the House of
Commons when the Secretary of State the day after the Budget made
his statement on carrying the NHS Plan forward, but if you were
to read Hansard—as presumably you were not there—you
will see that a number of your hon. Friends expressed grave misgivings
about this one aspect of the Secretary of State's proposals in
that document. Perhaps I could have an answer to the specific
question about will those penalties or proposed penalties improve
and enhance or damage the relationships that have been forged
in such a positive way between health and social services?
(Jacqui Smith) Improve.
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