Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 660 - 679)



  660. Why?
  (Jacqui Smith) Because the reason why you have a partnership is not because you get on well and you just think it is quite a nice idea to work together. The reason why you have a partnership is in order to deliver certain objectives—for example, reducing the level of delayed discharges and ensuring that people are getting the care they need, when they need it. Any incentive put in place in order, if you like, to highlight that objective is going to help to promote partnership. What I was going to go on to say was that there are several people who have already expressed their view that this might be a useful way to go. Before I was interrupted, I was going to say that those include your hon. Friends, the Members for Westbury, Fareham, Bournemouth West, East Devon, Aldershot, Orpington, Galloway and Upper Nithsdale and Salisbury and the hon. Member for Wyre Forest, who of course all signed up to the 10 Minute Rule Bill in the introduction to which the Member for Westbury said that the Bill would facilitate a model based on the Swedish approach to delayed discharges, and went on to describe it as "that hugely successful innovation".

  Mr Burns: I think you are being a little tortuous in what you are saying, Minister, but I will not pursue that. I will not pursue it because none of the members of the Committee will have seen the introduction to the hon. Member for Westbury's 10 Minute Rule Bill.

  Chairman: Some of us do not even know who the hon. Member for Westbury is!

Mr Burns

  661. Dr Murrison. The Minister answered that she thought that this proposal of imposing, in effect, fines on social services departments that do not meet the thresholds of the policy is going to improve the situation and improve the work or further improve the partnerships and working relationships between health and social services departments. It is an interesting view. I was just wondering, why does the Minister think that, when numerous of her colleagues on the back benches have said in the Secretary of State's statement that they are most concerned, the Local Government Association have said they are concerned, including the Labour part of the Local Government Association, as have many directors of social services, the ADSS? Why are they wrong and you are right?
  (Jacqui Smith) Firstly, I take a bit of exception to your description of fines, I have to say. As I was explaining earlier, this is a policy which is predicated on considerable extra investment going into social services departments in order to enable them to provide the care for those people who are ready to be discharged from hospital. It therefore makes sense, having given them the resources in order to do that, we ensure the responsibility is clearly placed on them. What we are saying is, if you are successful, as in some areas they already are, in developing the alternatives to people remaining in hospital, all of those extra resources will remain with you as a local authority and you will be able to use them to further develop the sort of services we want to see for older people and vulnerable people. But if, having had the resources to support those people, for some reason it is not possible for those people to come out of hospital, the costs fall on the acute trusts and therefore it is right that those resources are transferred to the acute trusts for effectively caring for the older person after the time at which they should have been discharged from hospital. It would be wrong of me to sit here and say that the LGA have greeted this policy with open arms—

  662. Because they have not.
  (Jacqui Smith)—but there are considerable numbers of stakeholders, some of whom I have been involved in meetings with in the last few days, some of whom actually gave evidence to this Committee where they talked about the principles of incentives being a positive one, who are either very positive about the policy from the beginning or who, in the case of the LGA, certainly in the case of the Association of Directors of Social Services, are willing to work with us in order to ensure that the systems we develop achieves the objective we all have, which is to put in place that incentive to bring down delayed discharges and give better care for older people.

  663. Well, the President of the ADSS may want to work with you to ensure the policy you are going to introduce works, but he is root and branch against the principle of it, he thinks it is a nonsense.
  (Jacqui Smith) I have to say I have read the evidence and I did not read him suggesting he was root and branch against the principle actually. Certainly our work with the ADSS has been very positive in terms of taking this forward.

  664. Presumably to make sure a rotten policy actually works to cause the minimal amount of damage. Finally, logically on your argument, should you not then be introducing a financial penalty system for trusts which fail to meet their waiting list targets, on the same principle as delayed discharge targets are not being met?
  (Jacqui Smith) The whole principle of the financial flows work, which you went into in some detail with Alan when he was here, is that we precisely will be introducing into the system financial incentives and financial flows which benefit those trusts in the short term, which benefit those trusts which achieve—

  665. I am talking about penalties rather than financial flows.
  (Jacqui Smith) I am just coming to that.—which benefit those acute trusts which achieve above the amount contracted in order to meet their waiting list targets, and clearly disbenefit, cost, those trusts which achieve below the contract necessary in order to meet their waiting list targets. If what you are arguing to me is, what we need is financial incentives across the system of health and social care in order to ensure we meet our objectives, I think we are at one on this.

  666. I was not arguing anything with you, I was just asking you questions. A simple seeker after truthful information.
  (Jacqui Smith) I have provided you with both truth and information.


  667. I certainly must have been asleep when we had the witnesses who were supportive of this in the Committee, but it is a possibility. One of the things that certainly has been interesting is that I have seen some fairly well-sourced stories which indicate that some ministers of the Department are rather uneasy about this policy. Are these articles inaccurate?
  (Jacqui Smith) Yes.

Andy Burnham

  668. Can I take you back briefly to the conversation with Dr Naysmith about the hot spots and targeting resources at the hot spots. Is it a fair conclusion to say that the use of health resources targeted to those social services authorities was plugging gaps and problems created by shortcomings in the local government funding formula?
  (Jacqui Smith) No, I do not think it was. If you are saying to me, do we need to review the local government funding formula, the answer is we are for 2003-04, but actually if you look at the 55 local authorities which were hot spot authorities, there was a variety of reasons why they were hot spots. In some of them it was frankly, I would argue, because there was not a good developed working relationship between health and social care, and in many others it was because there were capacity issues that needed the extra investment to help them to respond. I think that is more of an explanation as to how we identified those hot spots.

  669. Do you have a concern that the current outturn unfairness of the formula, coupled with how health resources are distributed as well, may be limiting the ability of the NHS to clear the system and get on and do its job, ie social services departments which are under-funded? Have you fed any views into the Department, formerly the DTLR, about the local government funding review and, if so, could you share some of your thinking on that?
  (Jacqui Smith) As a department which is responsible for the determination of the social services SSA we are a part of cross-government work in relation to the local government finance review. Our priorities there have been to recognise that the system as it stands at the moment lacks transparency, is very complicated and because it has not been reviewed for some time may have some distributional aspects which need to be looked at.

  670. Would you agree with the crude assessment it gives least to some of the areas which need it most.
  (Jacqui Smith) Not necessarily, no.

Siobhain McDonagh

  671. Look at London.
  (Jacqui Smith) I think there might be arguments. You probably represent a metropolitan district, Siobhain represents a London borough and I represent a shire constituency in a shire county, and I think we could all make a strong case about what we would want to see come out of the distribution. My concern is that as a minister contributing to that overall review is that based on proper evidence we have formulae which deliver what we want to see. The review of local government funding distribution is important, but the problem for social services, I would contest, was not how the money was distributed but how much of it there was in the first place. That is why increasing investment into social services over the last five years and the doubling of that real terms increase over the next three years is going to be more significant than any distributional effects which might happen through the review.

Dr Taylor

  672. This is really just a brief comment. My problem with penalties as they are proposed in this country is that they imply blame of just the local authorities, and that the blame is entirely theirs. We certainly know examples locally to us where health authorities have made changes without thinking of all the consequences, and it is totally unfair that social services therefore get blamed for all the problems. I have no objection to penalties if they are shared, although I would much rather have them called incentives and encourage good practice, rather than the opposite. That is just a comment. There is no particular question there.
  (Jacqui Smith) I agree with you that what is not helpful in the system is to develop a blame culture. We have come some way in terms of better working and a common understanding between health and social services, I think, about recognising that this is a problem that everybody shares. I agree with you that what we need to do is to develop a system of incentives. Part of the focus on the new incentive system that we want to develop around delayed discharge is that I suppose it fails to recognise the incentives that PCT development and the commissioning role that increasingly the PCTs are taking on, the sort of incentives that will exist more there, because the situation in Wyre Forest, in Redditch and Bromsgrove will be that the PCT, with responsibility for commissioning, will have a much stronger emphasis and a much clearer incentive on ensuring that the patient pathway (to use that jargon) is appropriate, that there are not delays at various different stages, that there is the proper sort of rehabilitative intermediate care necessary, that there are services like those which are being developed in both of our constituencies around preventing people from having to go into hospital in the first place. Those incentives increasingly, as we devolve responsibility and funding for commissioning to PCTs and as we develop further the work on financial flows, will be in the system anyway. What we need also to do is to ensure that those incentives are in place between social services and the health service. That is the reason for going forward, as we are, on developing the incentives that we are proposing.

  673. But if we are looking for true partnerships, then penalties should be shared, just as incentives should be shared, rather than pick out one bit.
  (Jacqui Smith) I think what I was suggesting in what I said was that the way in which we are setting up the incentive system does effectively—If your financial flows are such that you benefit from ensuring that older people get through the system, whether or not that is health or social services, as effectively as possible both for them and for the service, then effectively it is a penalty if you do not, because you lose out on your incentive. Your penalty is how you lose out your incentive.

John Austin

  674. Rather than developing incentives and penalties and cross-charging, would not a simpler thing be to have a single budget?
  (Jacqui Smith) That is certainly an approach that we have promoted. Developing and supporting care trusts is one of the responsibilities that we have given to Richard's Change Agents Team. In terms of the use of Health Act flexibility, we have now £1 billion which has been delivered through arrangements that come under Health Act flexibility. We have four care trusts up and running, more in the pipeline. So I certainly think that developing that type of pooled budget arrangement often is, and has been, a good way to develop the partnership that is necessary. The two things are not contradictory, however.

  Chairman: I think we might come back to that issue, because one of our colleagues—Sandra Gidley—who wanted to be here, wants to raise one or to points around that area, so it may be that we shall come back to that.

Jim Dowd

  675. Before I come on to the main point of my question, I want to follow that a bit further. I share Richard's concern that clearly it has to be people being penalised for things that are within their control, and it is grossly unfair to penalise them for things which are beyond their control. However, what would happen to an authority that consistently found itself being penalised or disincentivised, or whatever word you care to use? What would you do with them then?
  (Jacqui Smith) The point of an incentive is that it creates a dynamic. The idea of setting up this system is that you shift behaviour. As I understand it, the experience in Sweden and in Scandinavian countries is that actually there was much less transfer of funds from, in those cases I think it was, the municipalities to the county councils who had responsibility for the acute provision, than was perhaps expected, than was expected, for example, by those providing the acute services. The reason why it was so was because the incentive worked. The reason why you set up an incentive is because you want to change behaviour. In this case we want to ensure that everywhere we promote the development of alternatives to older people remaining in acute hospital beds and, by driving the system, to ensure that you do not have people who have authorities which are continuously in that situation. So it is a dynamic system, and it is because we are confident that it will have that effect that I do not think we will end up with the position that you are talking about.

  676. Can I return to another of the variables that affects the calculation of the cost and the number of delayed discharges, and that is the use of the definition of a delayed discharge. The Department in April last year introduced what it hoped would be a uniform definition of "a delayed transfer of care", as it is called. We have received evidence and have actually seen evidence on one of our visits that commissioners and providers are actually using different definitions, and even hospitals in adjacent areas are using different definitions. From the fact that that is going on, would you accept that this confusion does exist in practice, and that it does call into question the accuracy of the figures we are talking about?
  (Jacqui Smith) People should not be using definitions that are not the definition that has been laid down. I would be very interested to see the evidence that the Committee has found where that has happened, because we have been very clear about what the definition is. I think there has been a focus onto the sort of information-sharing and agreement between health and social care particularly, about responsibilities, that there is probably a need for more development of that, but I think we are pretty clear about the definition and I am pretty confident that it is on the basis of that definition that we have achieved the success that we have in reducing levels of delayed discharge by over 1200 since September 2001 and March 2002. So if there are problems about the way in which people are interpreting the definition, I will certainly look at the Committee's evidence with interest. It may well have implications for the future in terms of the way in which, as we introduce the new system, we define very carefully the point at which somebody is ready to be discharged from hospital. If, however, your suggestion is that somehow or other the concern around the definition means that our progress is not real—I am sure that is not your point, but if that were—I would disagree with you, because I am certain that we have made very real progress in reducing the number of delayed discharges.

  677. I would not imply anything of the kind. Can we look at the definition itself. How satisfied are you that it is a reasonable one in practice? I will read to you, if I may, from the evidence we received from the Deputy Chief Inspector, Social Services Inspectorate, where he told us that the definition, ". . . allows no time whatsoever to conduct a full assessment of what a patient's care needs are when they leave hospital. It must be one of the very, very few performance targets which gives no time whatsoever to due process once the hospital based team has decided the patient is fit for discharge." If that is true, does that not mean it is not measuring the right thing, and putting undue pressure on?
  (Jacqui Smith) What it seems to me you are highlighting there is not a problem with the definition but a problem with the practice, if there is not the sort of joint working that enables discharge planning to take place at the time that it should happen. One of the things we would want to do as we develop the new scheme is to put a much closer focus on what is expected of all partners in planning for discharge, which I think actually is slightly different from the broader assessment that would clearly be necessary, in fact expected, as we move forward to the single assessment process laid down in the National Service Framework for Older People. But there is a distinction between what you need to do to plan somebody's discharge and the definition of the point at which that person is therefore both planned for and ready to be discharged and the wider issues around assessment, and the problem is that a problem exists I think if people believe that an appropriate place to assess all the needs of an older person is whilst they are in an acute bed in a hospital, because I do not think anybody would believe that was good practice.

Siobhain McDonagh

  678. The definition relates to general and acute beds in hospitals but delayed discharges may be even more difficult to cope with in the psychiatric system. Certainly people who have come to see me recently have had great difficulty getting, normally, their adult children out of psychiatric hospital even though they are ready to go because they have not got anywhere to go. Has the Department done any work on the whole question of mental health care?
  (Jacqui Smith) You are right, we do not calculate delayed discharges on the basis of this monitoring information for mental health, but in the longer term I tend to agree with you that what we need to develop in terms of the system is a system which can longer-term look at where there are other problems around delayed discharges which could potentially exist in mental health as well. It is a bit more complicated there because what you tend to find there is that often people are delayed, or not able to get the sort of community provision they need in mental health services, sometimes because of problems with housing for example, so there is an even broader range of agencies involved in supporting somebody coming out of acute mental health provision than there is even for older people. But actually, of course, the work we are doing around the Mental Health National Service Framework, the work we are doing to develop new teams to support people in the community with the impact that should have on the number of people who then will not need to go into inpatient acute provision at all, the work in developing the new Mental Health Bill where for the first time it will be possible to have compulsion under mental health legislation in relation to treatment received in the community, in other words not having to necessarily have it, if it is not appropriate, in acute provision; all of those things I think will help to ensure in the mental health area as well people are getting the right care where they need it. I agree with you that whilst it is right at the moment that we focus on acute beds particularly in relation to older people, what we need to do is develop a system that overcomes delays and difficulties in the system wherever they occur and for whatever reasons and in whatever service.

Dr Taylor

  679. Changing tack slightly, what part do you think the electronic patient record will play when we get it in lessening delayed discharges?
  (Jacqui Smith) One of the issues certainly around ensuring health and social care work better together is how we assess and how we share information, so in fact improvements we are making in terms of social services records and information sharing will also be very important. All of those things contribute to there being better shared information and a better approach to that way in which people move through the system.
  (Ms Edwards) Particularly in the early days of electronic records, which will be about bringing within the hospitals improved information so the pharmacy and the wards are linked together and share computerised information, I think what we will see is improvements before the delayed discharge stage, so in terms of providing the care for the patients.

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