Examination of Witnesses (Questions 265-279)
17 MARCH 2005
DR STEPHEN
LADYMAN MP, MRS
ANNE MCDONALD
AND MR
CRAIG MUIR
Q265 Chairman: Would you like to introduce
yourselves?
Dr Ladyman: I am Dr Stephen Ladyman,
Parliamentary Under-Secretary of State for Community Care and
my colleagues are Mrs Anne McDonald and Mr Craig Muir who work
most closely with me on this issue.
Q266 Chairman: Thank you for your co-operation
with this inquiry and the evidence you have given to us. We are
most grateful. Perhaps I can begin by talking about what I feel
to be the core issue at the centre of some of the problems we
have picked up in evidence. I am sure you have noted some of the
evidence we have had, and we have just heard from the Ombudsman
about the information that they have picked up as a result of
complaints. If I were to refer to a key feature of numerous inquiries
that this Committee has conducted during my nearly eight years
as chair, the whole debate around the margins of health and social
care perhaps will come out as the most important issue that has
never been resolved. You, as a minister, are landed with a problem
that has not been addressed by successive governments in my personal
view—and colleagues round the table might differ on this.
Do you feel that we are at a stage where over and above the continuing
care issue we need to be looking much more radically at how we
address the problems around that divide. I am not sure how much
money has been spent on this Committee in looking at the issues
of health and social care and the problems arising around the
margins, but I meet numerous officials all over the country whose
entire work relates to arguing with somebody the other side of
the fence—health or social care—about who is responsible
for a particular individual's care. It struck me on many occasions
that we must spend millions and millions of pounds employing suits
on each side of the fence to argue with each other, when that
money could go on funding care. We may even save money by moving
in that direction. Do you have any thoughts on that?
Dr Ladyman: Let me deal with the
principle and then the practicality. What you are saying in principle
is absolutely right. There are many disputes that arise because
of it. If we just go back, for example, which is most often quoted
in relation to NHS continuing care, the Coughlan judgment,
that is quite often misinterpreted. The Coughlan judgment
said that there is a maximum level at which a council which has
a responsibility to provide funding for social care can be expected
to provide that funding, and beyond that it is ultra vires.
The Coughlan judgment did not make comments about NHS continuing
care; it simply said: "Here is the most that a council's
remit allows it to pay." In making that judgment, they acknowledged
what you are saying; that this grey area between the two is a
real problem. The question we then have to grapple with is the
best way of resolving that. I know that you personally have always
advocated health and social care coming back together again, which
is more or less the situation in Northern Ireland. I have to say
that from my discussions with people in Northern Ireland, even
there, where the two things are put together, the situation is
often just as difficult to deal with. Some people will tell me,
"oh, yes, it works wonderfully", and some people will
tell me, "no, it is chaotic". In the end it comes down
to how closely social care and health professionals are working
together; how well they understand each other's needs and are
discussing these issues and are making sure they understand where
funding of particular types of care should come, and the structure
does not much matters. If professionals have that sort of relationship
and understanding, then it works well; if they do not, then irrespective
of the structure, it works badly. When you see the Green Paper
Adult Social Care, we will be addressing some of the ways
we see we should be moving to try and address that divide and
get people working more closely together.
Q267 Chairman: Yesterday I tabled a question
for next week's health questions, which you will be relieved did
not come out in the raffle, but it was this: what would your estimate
be of the costs of administering the demarcation between health
and social care? One of the problems the Treasury has with the
statutory background to social care being national systems which
require means-tested provision, the NHS side of it is free, and
any Treasury minister would be very concerned if we were to suggest
combining the two areas, and make the social care entirely free.
That would have significant financial implications. However, what
struck me is that we have never come up with an estimate of what
it costs to police that demarcation line. Do you have any thoughts
on that? I know that the amount of time we spend as a committee
and the amount of time the Ombudsman spends investigating these
cases, and the amount of people we have got—an absolute
industry involved in arguing it from a health care or social care
agency aspect as to who is responsible. We have cost shifting
and cost shunting; we have the Delayed Discharges Bill, and it
still continues. There is a huge amount of money that could be
saved that would offset the implication, surely, of moving in
the direction where we have entirely free care, and we end the
division that no-one can define between health and social care.
Dr Ladyman: I agree with you that
there must be a cost to it. We have not got an estimate for how
much it is. I am not convinced it is as substantial as you think
it is, and as we move forward and talk about how we should be
doing this over the next hour, if we move forward to providing
an easier framework for making these judgments, then I hope we
can gradually eradicate those disputes. I think personally, although
I entirely accept the public do not understand it, that it is
possible to distinguish between the two, and we do need to do
that because, as you said, we cannot provide all social care free
at the point of need. The Treasury would just never accept it
under any government of any colour, red yellow or blue. We already
spend £12.5 billion on adult social care, under the current
system where people contribute to the cost of it. We know roughly
speaking that there will be four times as many people needing
care by 2050; and their needs will be far more intensive. The
fastest growing cohort of the population at the moment is people
over the age of 100. To suggest that we could quadruple the cost,
and then go further and not charge people and make it all free
at the point of need is just utterly, utterly impossible to comprehend.
We do have to keep a distinction between the two, because I am
afraid it is inevitable under any flavour of government that people
will have to contribute towards the cost of their social care.
Chairman: I do not think it is fair to
throw in fiscal measures that might be taken to recoup the money
from people who do not need that support, but that is a factor
that we should throw in. I was struck yesterday—you said
you think it is possible to define the distinction between health
and social care, and I wish you well on that one because I have
met thousands of people who cannot. Yesterday, we had a lobby
of people from the Alzheimer's Society—and you probably
met some of them yourself. It struck me, talking to a number of
people who were caring for parents with Alzheimer's or dementia,
that it really seems totally wrong to suggest that somehow in
a complaint of that nature, at some point you are moved from one
section to another and nobody really knows when that happens.
We will probably come back to that.
Q268 John Austin: Can I come back to
the confusion about the eligibility criteria and particularly
the Ombudsman's report. You have partly accepted the recommendation
of the Ombudsman's report in carrying out the review and asking
SHAs to carry out reviews across their areas.
Dr Ladyman: Why did you say "partly"?
Q269 John Austin: You did not fundamentally
adopt the national criteria and review—
Dr Ladyman: We are going to move
to a national framework and we have those discussions to have
as to exactly what that national framework will include.
Q270 John Austin: Initially, you got
the SHAs to review the criteria.
Dr Ladyman: That was the initial
stage, yes.
Q271 John Austin: Some of our witnesses
have suggested that that has reduced the postcode lottery from
95 to 28, but there is still a difference of interpretation between
SHAs on those criteria.
Dr Ladyman: That is undoubtedly
true, but there was another stage in the process as well, do not
forget. As well as asking the 96 health authority criteria to
be replaced by criteria adopted by the strategic health authorities,
as a department we also published criteria that they should base
their criteria on, so there was a central national criteria, and
then the SHAs, where each expected to adopt their local processes
and criteria to the national system, and then were expected to
go and make sure that they had advice that the system they were
proposing to use locally was compliant with our national guidelines
and legally compliant. The framework was sound on a legal basis.
You are right that on the face of it we only reduced it from 96
to 28, and therefore there were 28 different postcode lotteries;
but actually those 28 were based on the national guidelines, so
there should have been far more consistency between those 28 than
ever there was between the 96 they replaced. We did that because,
frankly, going from 96 to one, at a time when we had this huge
review to carry out, our judgment was that it would just have
been an impossible task to do that. We are taking what we see
as being a progressive approach to meeting the Ombudsman's recommendations,
and having got the 28, having gone through the review, we will
move from here to a national framework, and we will have that
discussion over the next 12 months.
Q272 John Austin: You are giving an indication
that the new national framework will effectively have a single
set of eligibility criteria.
Dr Ladyman: Certainly. There may
be differences. We will have to talk to the SHAs, because we have
to accept that there are two parts to the equation. First, there
is the eligibility criteria, and secondly the process you have
to go through in any particular local area in order to have that
assessment made. Some areas have different problems than others.
In a city strategic health authority it is easy to get people
together to carry out multi-assessment cases. In a rural environment
it might be different, and there might be differences in the way
people want to carry out the reviews that are necessary in order
to meet their own local pressures and local issues. Broadly speaking,
we want to end up with a system where absolutely everybody in
England will be able to say, "the assessment I have had would
have come to exactly the same conclusion, whether it was held
in London or Carlisle or wherever it was.
Q273 John Austin: The new national framework
will have a single set of national eligibility criteria.
Dr Ladyman: We have those discussions,
but my belief is that that is where we will end up. This is a
consultation; we are bringing the 28 strategic health authorities
together to identify best practice. They are giving us a very
clear message. They want to have one single set of national eligibility
criteria, so my belief is that is what we are very likely to agree
with. If, in the course of these discussions, we find that is
not practical, we will have to have something different. At the
end of the day the key has to be that a constituent of ours in
one part of the country must know that they would have had exactly
the same decision wherever they had that decision made anywhere
in the country.
Q274 John Austin: In the report of the
independent review it refers to SHAs saying there had been a staggering
lack of guidance from the Department. Would you ensure that that
it is not the case in the future?
Dr Ladyman: I would not accept
that at all. We worked incredibly closely with the strategic health
authorities and with the Ombudsman. I have not heard what the
Ombudsman has just had to say to you, but I would be surprised
if she has not pointed out that we work very closely with her,
and when they bring issues to our attention we do try and follow
them up. Equally, when strategic health authorities have identified
that they have had problems, whether it is a problem with a lack
of understanding or practical problems, we work very closely with
them to try and resolve the issues. I would dispute that, but
people's perceptions are their perceptions.
Q275 John Austin: My understanding was
that one of the recommendations of the Ombudsman's report was
that the Department should review their guidance to strategic
health authorities on eligibility for continuing care, and that
was not done, was it?
Dr Ladyman: What the Ombudsman
would have liked in the first place was for us to move to a single
set of national criteria, and we took the view that that just
was not a practical option when we had a huge retrospective review
to carry out, when each of those cases which were previously considered—the
errors had been made because of the attempt to try and carry them
out under 96 sets of criteria. It was just too much of a task
to go to a single set of national criteria and a national system
in the time that the Ombudsman wanted us to carry out the review.
That is why we took a pragmatic view that we would go to 28, and
now having done that and made what we believe is substantial progress,
we have taken the further step of saying we will now go to the
national framework. We are agreeing with the Ombudsman. We have
got to where the Ombudsman wanted us to be, but we got there perhaps
over a greater length of time than she would have really wanted.
At least we got there, and I do not think we would have got there
if we had tried to do it in one step.
Q276 John Austin: I am not suggesting
one step, but I was a member of this Committee 10 years ago when
we said there was basically inequity in local eligibility criteria.
Would you agree it has taken rather a long time to accept the
recommendation that we made 10 years ago?
Dr Ladyman: I am certainly very
happy to suggest that the Government of 10 years ago made mistakes!
Q277 John Austin: You mentioned the way
in which you were seeking to co-operate with the Ombudsman, and
we are aware of the letter that the Ombudsman sent to the Department
regarding the confusion in SHAs on the whole procedure of assessments
under continuing care funding and RNCC, and there was a suggestion
that in some areas the assessments were being done in reverse
order.
Dr Ladyman: Which of their letters
was that?
Q278 John Austin: The letter to Ms McDonald
on 1 February 2005. The Ombudsman told us earlier that there had
been a response, but I wondered if that response could be put
in the domain of the Committee.
Dr Ladyman: I am happy to let
you have that. I suspect you are probably entitled to ask for
it under the Freedom of Information Act, even if I did not want
to give it to you. I am happy to give it to you.
Q279 Mr Burns: As we have been talking
about the Ombudsman, last September you very helpfully made a
ministerial statement about the current situation with regard
to the reviews, and with that statement you had a very comprehensive
chart by strategic health authority on the number of complaints
that had been received on different timescales, the number of
cases that had been completed in their review and the percentages
of those that had been reviewed, and those that were successful
to the individual, i.e., the complaint was upheld and money was
paid to them as a result. Of course, life has moved on since then,
and Parliament likes to know about these things. Why did you block
my question in December when I asked you to update those figures?
Dr Ladyman: Block?
| 
