Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 720 - 739)




  720. This is the distinction, which is part of the problem.
  (Jacqui Smith) That is part of the distinction, but the other distinction is around whether or not you are using a net figure or a gross figure.

  Sandra Gidley: No.

  Chairman: We can kick this one around all afternoon. The conclusion from the advice we got was that 19,000 was a broadly independent figure if one took the net and gross issue that you have referred to.

Andy Burnham

  721. I am advised that the 50,000 figure was a convenient number to use as a bargaining figure to raise care home fees by various people. I think it is an irrelevance. The relevant figure clearly is how many care home places we are short of. Clearly, that is what matters. There may well be a lot of over-capacity in the market. Can I ask you whether the Department has done any analysis of as a country are we currently short of places, do we have too many? Clearly that might be 19,000, 50,000 or 100,000 or whatever, or it might be something far different.
  (Jacqui Smith) My understanding is that there is nationally some spare capacity in terms of residential care. However, I do not think that what I accept is an argument that says that what actually matters is what is available for people in any particular locality. But here as well it seems to me that what we need to take into consideration in a locality—and this is what I was talking about earlier in terms of how we commission services as a whole—is not in this locality how many residential care beds there are out there, important though that might be to meet a particular demand, but in this locality how do we commission to make sure that we have appropriate levels of residential care, home care packages, housing in care, so that we have the configuration necessary in order to enable older people to get help.

  722. Is there spare capacity? Some homes are refusing to take local authority residents—non-self-funders.
  (Jacqui Smith) I think there are some issues, as I understand it, in some parts of the country, about some providers' attitude to local authority placements. There I think that what it makes sense to do at a local level is to develop, along the lines of the agreement that I was talking about earlier, much better and more mature relationships in some cases between the independent sector and the commissioners, in order to make sure that the local authority has the provision necessary, is able to commission the provision necessary, and the independent sector has at the same time the certainty about what is being expected of them in the long term that will enable them to plan with some certainty.

  723. It has certainly been a problem—and I have seen this locally—that companies with not particularly a track record of care have moved into this sector, and some of them have moved out of it as well; there has been a lot of change of that kind. When we are talking of something where it is a question of people's life and death, it is vital that they have a stable environment in which they are living and that they are not subject to any fear of being moved or whatever. Picking up the Chairman's point earlier, have you thought about whether, when a company is providing care, you would seek a commitment from them that they are in it for the long term, because it is incredibly destabilising if there is this threat of homes closing and this is used as a bargaining tool to up the fees? Do you think that in such an important sector of society the companies that are involved need to be involved in the long-term?
  (Jacqui Smith) Firstly, I agree with you that clearly in any situation where a care home closes, the people that we need to be most concerned for are the older people, the residents in that home, which is why I think it is reasonable, as we say in the agreement, that local authorities in their commissioning recognise the cost pressures through the fee levels that they pay, but also that there is a responsibility on care home providers, which we have now, of course, formalised through the care standards, firstly to provide some evidence of their financial liability, but also to have in place appropriate procedures if they do get to the position where they have to take a business decision to close. So I do not think we can be in a position in relation to private businesses where, for example, we could ban them from closing—of course that would not be possible—but what we can do is get into a position where there is more long-term certainty through commissioning, fee levels that recognise what is necessary from care providers and recognise quality in their commissioning, and then also ensure that we have standards that do not allow, if anybody were minded to do it—and I am not suggesting that it does happen—a sort of fly-by-night approach to their residents. That combination of things I think is important to provide the certainty for residents in those homes.

  724. My final point is that you mentioned fee levels there. What assessment has the Department made of the current level of care home charges? Are they too low? Do they need to rise?
  (Jacqui Smith) What I think is interesting is that I think it was Laing & Buisson in fact who identified that what happened from some of the investment of the £300 million and this funding in the last year is that local authorities have recognised, by increases of fees in some areas as high as 10 per cent, the need to recognise fees as an important way in which you stabilise capacity. We have also recognised, through our analysis of the way in which that £300 million has been spent, that local authorities have invested in higher fee levels and in more places, so some of that money has gone directly into the independent care home sector to stabilise and to provide services. I do not personally believe that the most effective way forward is for the Department nationally to attempt to set fee levels, because to go back to what I was saying before, what we need to develop locally is a situation where we recognise the particular pressures that there might be locally and we recognise the need to develop diversity. In those areas where, as you yourself have suggested, there is a surplus of capacity, you may well have a different approach to developing other sorts of care than you do in those areas where there is a shortage of capacity of residential care. So I do not think we crack this problem through a national approach to fee setting. I think we crack it by making sure that there are sufficient resources in local authorities to develop the whole range of long-term provision, and by levering better practice, where it is necessary, in commissioning and partnership between independent and voluntary sector partners and the local authority commissioning.

  725. I have one very final point. We went so see some schemes this week which are neither residential care nor sheltered housing, but almost in the middle. Would you favour a move towards those? Do you think we are over-reliant on residential care in this country?
  (Jacqui Smith) I think I have already said earlier that where I think we want to see growth is in housing in care options, in home care options and in developing new forms of residential care, but we need to maintain capacity as we go through that changing configuration, and there will always be a need, I believe, for some forms of residential care.

John Austin

  726. The Chairman referred to the growth in the 1980s when there was this shift and the massive expansion into residential care, whether we say people were "banged up" or use the expression "moved towards geriatric". Is it not a possibility that we should be celebrating this less reliance on residential and institutional care? Was it not that growth in the 1980s of some fairly unscrupulous people running old people's homes and so forth which actually provided the disincentive for the provision of those supporting schemes for long-term services?
  (Jacqui Smith) Where I agree with you is that what should not drive the development of long-term care provision is funding streams, and that, it seems to me, was the problem with the development throughout the 1980s. What should drive the development of long-term care is a careful analysis of what older people actually want, what we need to provide in order to promote their independence, and that should be the basis on which we commission.

Sandra Gidley

  727. Very briefly, you were talking about fees. What is happening in a number of councils now is that there is a differential rate, with new residents on one rate and existing residents on another. Do you think that is equitable? Is it not an admission that actually social services have been underfunding nursing homes for too long? There is about a £50 difference in my part of the world.
  (Jacqui Smith) I think that is a judgement that needs to be made locally on the basis of decisions—funding decisions, where people want to see developments, what sort of quality they want to pay for, what sort of provision they want to pay for.

  728. Do you believe it is inevitable?
  (Jacqui Smith) I do not know the circumstances, so I am not going to make a judgement.

  729. Fair enough. To come back to capacity, although there may be over-capacity in the system as a whole, then certainly locally in the south of the country I believe there is a real problem, but presumably the Department has some forward planning. Therefore, do you actually expect the care home market by, say, 2007—which is not in the too-distant future—to expand or contract? What does the Department think is going to happen?
  (Jacqui Smith) Once again, we are getting into a position where we are highlighting one particular part of the capacity for providing long-term care. We have been quite explicit that what we think needs to happen is that we need to maintain capacity in care homes in order to ensure that that option is there, but we also need to develop alternative forms of care. So the answer, I think, would depend on what you already had in your locality. Where you had an over-provision of care home capacity and an under-provision of intensive home care packages or other forms of care, I would expect to see a shift out of care homes and into those other forms of provision, but where you have a situation where clearly there is a demand for care homes and there is a tightness on that capacity, it makes sense to reflect, in your fee levels and the way in which you commission, the need to maintain or perhaps in some areas even expand that residential care provision.

  730. So are you saying that you do not know basically?
  (Jacqui Smith) I am saying that it depends on local circumstances.

  Sandra Gidley: I would like to pursue this, but I am aware that there are a lot of other questions, so I think I had better leave it there.

Julia Drown

  731. When you said, in answer to a previous question, that the number of extra beds and places were 6 per cent of the yearly divide, did you take account of the fact that some places were having to increase care home charges by 10 per cent? Obviously that wipes out more than half of the three years' funding.
  (Jacqui Smith) We recognise, both in the £300 million and in our analysis of what was necessary to maintain and develop capacity, that there were issues about fee levels, so we recognise in that 6 per cent, as we did in the £300 million, that in some cases the correct response is to increase fee levels.

  732. So it was taken into account in those figures?
  (Jacqui Smith) Yes, it was.

  733. What about the choice? We have had the British Geriatric Society raising their concerns that there is not any legal mechanism to insist on interim placements. Are you considering having to deal with that concern?
  (Jacqui Smith) What is very interesting is that there is a big discrepancy across the country in the extent to which older people do stay in acute hospital beds effectively to choose, and those were their terms. What seems to me to exist is that where there is good practice in terms of alternative provision, and where there is good practice in terms of explaining early to older people what the options are, the fact that actually it is not good for people to stay in acute hospital beds whilst they either have further assessments made or make a choice, what we tend to see is that actually there is a very small amount of people who are staying in acute beds because they are wanting to exercise some sort of choice.

  734. It is 8 per cent of the delayed discharges overall. Is there not a relationship between where the problems are and property prices?
  (Jacqui Smith) No, I do not think there is any evidence that there is that. What there is is a relationship between good practice and bad practice. For example, in, I think it is, Darlington they have used some of their £300 million .

  735. So you do not think any legal change is needed?
  (Jacqui Smith) No.

Jim Dowd

  736. Briefly, on NHS funded nursing care, was not that really just a subsidy towards a sector which absorbed it and just costed things out at a different level? I remember writing to Alan a letter about a constituent who had a component of £72, but by the time they had got to a review of prices and all the rest of it, they only actually saw a saving of £17, and this was going on throughout the country, so all it was was a huge subsidy to the nursing home sector, was it not?
  (Jacqui Smith) It was because there were some places where there were concerns about the extent to which in that last financial year £100 million was actually getting to the people for whom it was intended, which were those people who funded their own care in nursing homes, that we actually took the action that we did around strengthening the sort of information that individuals can have about what sources of funding are for nursing homes and what the costing is of the constituent parts. So both through our scheme and the Care Standards Commission to focus on standard 2 of the care standards and through changes that we will be consulting on or making to regulations and to the contract that we issue to local NHS bodies to use in their payment of the nursing care contribution to nursing homes, we have taken action to make sure that that money gets through, benefits those people for whom it was intended, and there is much more transparency in the system than there was previously, because this is a significant investment into nursing care in those homes. There are actually quite a lot of good examples of where that is already benefiting not just financially, but where there are benefits through the NHS becoming more closely involved in people's care; better advice about continence, for example, better communication about the sort of nursing care needs that people might have. Those have been quite important benefits over and above financial benefits that have come from them.

  737. Are you convinced that the systems are robust enough now to ensure that that money is directly benefiting residents in terms of nursing care, rather than being used as a subsidy by the nursing homes?
  (Jacqui Smith) I believe that the approach that we have taken, which is to cast light on that money going into the system, is the appropriate way to ensure that people who, after all, have individual contracts with nursing homes, have both the information and the clout in order to make sure that it is benefiting them.

Julia Drown

  738. Our visits around the country and local knowledge point to staff shortages being a particular problem, particularly in the area of occupational therapists. There are two issues on that. One is, what is the Department doing to try to make sure that where there are restrictions on what people do—for example, occupational therapists defend their territory in terms of saying who should be able to advise on home adaptations, and that does happen to be reasonable—that does not cause inflexibility in the workforce? Are you doing anything on that in terms of creating a new rather more flexible, more multi-tasked, more multi-skilled person to deal with unnecessary admissions and facilitate discharge? Also, what are you doing on those workforce numbers, particularly around therapists?
  (Jacqui Smith) As I suggested earlier on, we are taking action, and it has been successful in terms of increasing the number of therapists. I agree with what you said that what we also need to do quite often is to find at a social level a way of developing teams where there is more of a trust in multi-skilling, where there is a more co-ordinated approach to the care that is being provided. Off the top of my head, I could not think of something specific that we were doing to address the particular issue that you were talking about, but if we come up with something perhaps I can let you know.

  739. I think we are interested in things like district nurses and do they also have those skills to advise on home adaptations and so on. The other thing was that again, we would like to know what technology can offer in terms of supporting people in their own homes, allowing early discharge. What are you doing to encourage the roll-out of successful schemes throughout the country, which have demonstrated their potential?
  (Jacqui Smith) Clearly, as Richard's team goes around the country more, one of the important roles is to share the things that are working. I agree with you that there are areas where technology is actually quite important in terms of developing alternative support for people living in their own homes. Some of the best practice advice and the way in which we are disseminating that, I think, is probably at the moment the best way in which we are ensuring that that happens. Of course, there is an incentive on authorities and health care providers to develop. Once people know what works, and once they know the challenge to reduce delayed discharge and make sure people are getting the right care, that gives people the correct incentive to investigate the alternatives and to invest in the more successful ones.

  Chairman: If there are no more questions, Minister, can I thank you and your colleagues for the very helpful way in which you have given your evidence. Thank you very much indeed.

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