Examination of Witnesses (Questions 364
- 379)
TUESDAY 18 JANUARY 2005
MR PETER
HAY, MR
GRAHAM URWIN,
MS CHRIS
FEARNS AND
MS DOREEN
HARRISON
Q364 Chairman: We are delighted that
you could join us this afternoon. We had an informal discussion
this morning about some of the health issues around choice and
related mattes, and it would be nice to extend that into the social
care field. Can you briefly say what you think the increasing
emphasis on choice has come to mean in the social care field,
and flag up one or two of the areas where this kicks in?
Mr Hay: Thank you, Chairman. I
have tried to give you in the paper some very practical examples
of the range of choices that we are working with at any point.
I will leave the paper with you and will not talk you through
it. At the end I outline the outcomes that face people who use
social care services. It is different from education and the NHS;
it is not a universal service and is one designed to provide specific
support for people on the edge of communities, to keep them in
our communities. Choice, in terms of people with mental illness—we
know that only a quarter of them get employment. We know that
there are poor outcomes for children that are looked after in
educational attainment, and we know of the difficulties about
child poverty facing families with disability. Those are the outcome
bits where we have to bring choice to bear on some of those outcomes
that we are delivering for some of those people. At the opposite
end of the spectrum is the importance of choice in people's daily
lives and how fundamental that can be. One of the biggest rows
as Director of Social Care that I have ever walked into was the
one that became known as the "dippy egg" row, with older
people in residential care making a very serious stance about
the council's stance in catering terms of "dippy egg"
and beef. As a Council catering service, we had applied rules
which applied to schools, ie, children, who did not have choice
in that sense, to old people's establishments. People in their
late eighties in frail condition were not being allowed soft eggs
and they were not being allowed to eat beef. That raises the big
question that sometimes it is the choice in daily routine that
is really important, and particularly in the case of residential
care, when food is really, really important. One of the big issues
we are facing now is the right of older people to run a hot bath
at any time of day or night when they are in care, and what that
means in terms of regulation. At night it is an issue of staffing
levels, which is where the regulator comes in; but there is also
people's right to be independent. The whole issue particularly
around adults is, "whose risk is it anyway, and who is taking
the choice about risk?" We have a community with growing
numbers of older people, and clearly growing areas of challenge
around that such as dementia, so the issue of risk and how much
risk is tolerable to take in making decisions about one's life
are critical. That is one that we struggle with on a day-to-day
basis, and clearly there are bigger implications around that whole
issue, as I have outlined. Choice is linked to the whole concept
of trying to empower people to be part of our society and to be
part of social inclusion. There is the work we have done with
carers, aligning all our expenditure around their wishes and needs
and choices about how that money is used, as well as the work
we have done with young people in care, where they have designed
and run a service about bullying, because they have identified
that as a big issue. People's choices in running and designing
services are quite critical. I have talked a little bit about
choice in the shape and provision of services, with direct payments
being obviously a major issue. We have moved significant numbers
of people into direct payments this year, which we are very proud
of, and we are also very proud of the way in which we have tried
to ensure equality of access to that from all communities. It
is not just one way of working. Finally, the take on choice for
us is how we fit it around new ways of thinking about choice.
I know that the adult green paper is still eagerly awaited, and
I have put a reference in to a scheme that we are working on at
the moment which sees the value of a care package in cost terms
being shared with carers, and giving some choice about the services
that are deployed. Those are very extensive issues. All of that
fits with the tensions between individual choice, and—a
bit like schools but slightly different—where individual
choice begins and ends, and what that means. If direct payments
mean that ten people withdraw from a service aimed for 40, what
does that mean for the remaining 30? Does it affect economic viability
of running a particular service? Those are the kinds of things
we wrestle with in how we plan and shape services. That said,
our experience is that people know also the limits of choice.
We have been doing some work today with parents of children with
disability, and one of the things they are immensely responsive
to is if we say, "the limit of the resources we have is X;
we can do what we like within X". That works quite well.
Sometimes we are frightened to put parameters on the table, but
when we do we find how amazingly keen people are to work within
those parameters and to help make the choices. That is a different
way of working than perhaps traditional approaches in local government
and planning.
Q365 Chairman: In our discussions
we have been tossing around an idea as to whether choice is a
means or an end; that is to say, is it a value in itself because
people should have choice over their lives, or is it just a useful
tool to produce improvements in services? Do you see choice as
something that is so important to people that they ought to exercise
it? We asked this of the PCT this morning, and they said people
are that not much fussed about choice; all they want is to know
that the services or any other public body provides are good services
whether or not choice is an ingredient. Is it a bit of your toolkit
that enables you to lever up quality, or do you think it is important
in itself so that you have to deliver it, irrespective of the
consequences it might have?
Mr Hay: Experience would suggest
that choice is meaningful when it is about levering up quality.
A choice between two things of poor quality is not really a choice.
It is about how it fits with driving quality. Our general experience
is that people are not that fussed on who the provider is. The
choice of provider is not as important as the choice of fit to
that person.
Q366 Chairman: We have heard a quite
different story, talking about council housing.
Mr Hay: Absolutely.
Q367 Chairman: They told us that
the reason the council tenants voted to stay with the Council,
irrespective of the fact that it was not in their housing interests
to do so was because it did matter to them who the provider was,
so I am not sure that we are entirely persuaded of that.
Mr Hay: No, and perhaps it ranges
from different sectors, but it is the quality of the service being
offered, and particularly in social care where it is not that
universal fit. It is something you come into contact with at a
particular stage in your life. It is what we provide and what
you think about that service as you get it. Clearly for us a big
issue is anticipating what choice might be. A big issue in this
city is the future of our residential care for older people, where
the clear message to us is that that is not a choice people will
want to be taking in the kind of numbers that they are now and
would want to exercise the choice to live at home for longer.
Part of our work is to have a range of services that will enable
people to make, or be in line with choices people will make, at
the point they get there, because to some extent we are anticipating
that now. We will move the shape of services to be in line with
a generation of older people that are going to be more consumer
orientated than people who are in our care at present.
Q368 Mr Prentice: I just wonder how
many elderly people want to run a bath in the middle of the night.
Mr Hay: Believe it or not it has
come up as an issue with the regulator. It was about somebody
who was feeling discomfort and ran a bath for comfort, and it
was about their ability to do that and whether they should be
allowed to do it.
Q369 Mr Prentice: I ask the question
because in your paper you say "social care is a rationed
service" and choice requires spare capacity and additional
resources. The fascinating thing you said is that people are prepared
to work within parameters. If you tell them the choice will be
constrained, amazingly they accept that.
Mr Hay: I put that in there because
essentially we are set up by legislation to accept the criteria
for assessment linked to resources. Clearly, we are resource constrained.
Ultimately, the Council puts a sum of money aside and that is
what we have to work to. There is a level of need in the community,
which at some levels you could almost say is infinite, and where
you draw the line is a choice element made in local government
but increasingly in consultation with local people in a whole
range of ways, as well as about the electoral mechanisms. Then,
working within those choices where we recognise the resource constraints,
we decide how to use it best. For example, in relation to parents
with children with disabilities, we have at the moment six units
that provide residential care. Perhaps that is the wrong balance
of resources; perhaps we could use slightly less and use more
in communities. Would that provide a stronger range of support
or a weaker range of support?
Q370 Mr Prentice: To what extent
do people engage positively in those kinds of debates? When you
tell us people are prepared to work within the parameters, and
there are resource constraints, are the parents of a severely
disabled young person prepared to go along with what you consider
to be the appropriate level of resources?
Mr Hay: Not always, and clearly
they can take that into a political dimension as well. Clarity
in discussions about what we have and what we can work within
and—
Q371 Mr Prentice: It is just that
there are cynics out there who say choice is only meaningful if
it can be exercised, and just to have a discussion about possibilities
without anything happening on the ground could leave people feeling
cynical.
Mr Hay: That is absolutely right.
In setting up those arrangements, as an authority you have to
be clear that you are going to follow that through. That is why
I mentioned service design with people because you have to follow
through, otherwise it is a talking shop, and that in itself creates
frustration and anger.
Q372 Mr Prentice: What about people
who are confused about the choices? You mention in your paper
the mentally ill and we heard this morning about that. To what
extent is choice meaningful or does it confuse mentally ill people?
Mr Hay: A clear part of the remit
on social care is dealing with people who have no choice, whether
that is mental illness or people who have complete mental incapacity
and guardianship. The issues in those areas are how you demonstrate
what you have done to best effect, and where you have taken choice
away and how you have done that. It is also back to being clear
on an individual basis what elements of choice you are removing
and what elements you are giving back, because we also want people
to re-integrate into the community at some point in the future.
Clearly, that is an individual tool, but there are significant
challenges for us within that and that will pose a whole range
of other risks and dimensions alongside that, which are increasingly
difficult for us to manage.
Q373 Mrs Campbell: Can I come back
to our friends from the PCT. You call yourselves the "listening
PCT", and this Committee is inquiring into choice and voice
in public services. Can you tell us the ways in which the health
voice networks operate have made a difference to the care you
provide?
Ms Harrison: Do you mean the way
we consult with users?
Q374 Mrs Campbell: No, I mean what
practical difference has consultation made to what you provide.
Ms Harrison: It has made a significant
difference, I would say. We consult regularly with service users
and the wider public, and that then influences the way we develop
our strategic thinking and commissioning of services. In terms
of service provision, we do very regular satisfaction surveys,
focus groups and patient forums with our service users, and we
have made quite a lot of significant improvements in the services
as a direct result of people saying "we would like things
to be done this way, rather than this way". I feel we could
demonstrate quite clearly in many areas where we have had significant
change.
Q375 Mrs Campbell: Do you want to
give us one or two practical examples?
Ms Harrison: In terms of satisfaction
surveys, if you think about people, and older people's services,
they make choices about times of meals and the kind of meals they
want to eat, the times they want to go to bed and get up. As a
result of that, we have introduced a protective mealtimes policy
so that doctors and other people cannot go in and say "we
want to examine you now" in the middle of their dinner. That
may seem quite trivial, but that is about exercising choice in
your daily life. On things like, "are your spiritual and
psychological needs being met?"—"no, we spend
long, boring days waiting for the physiotherapist to come".
We have set up activity programmes that are meaningful and age-appropriate
for those people so that the time passes more quickly. That is
a small way we have changed things. Graham has just whispered
to me about a programme we are doing. We are looking at different
ways in which different groups can be empowered, and one of the
areas we are looking at is people with particular conditions being
given some—using the expertise they have developed over
the years, because if you have a long-term condition you develop
expertise on how you handle that. It is about sharing that with
other sufferers with the same illness in order that they may be
able to manage their disease process better and have a better
quality of life. A good example of that which I can give you is
the Breathe Easy Group, for people with chronic chest conditions.
It is a self-help group. They go through an exercise programme
because people with chronic breathing difficulties tend to sit
around because they are frightened because they get short of breath
on the slightest exertion. If we can gradually increase their
level of exercise, that gives a significant improvement to the
quality of life. That means that somebody who sat at home and
could not do anything can start to go out for a period and do
things to improve the quality of life.
Mr Urwin: I think that reflects
on some of our more focused initiatives. We described a process
to you this morning where we engage in a whole range of activities,
where we invite people to meet with us, which gives us an opportunity
to do a number of things. We can ask them their views on very
specific subjects but we can also engage with them more generally.
At all of those sessions where we have invited people to come
and talk to us, we have had a range of other activities going
on as well. We have a range of services that puts health back
into individuals' hands and gives them choice. The first choice
people should have is choice about their lifestyle. All the choices
we offer about the way our services are run and delivered become
secondary to empowering people in the first instance to make a
choice about their lifestyle.
Q376 Mrs Campbell: Can I ask you
about two groups that are often quite difficult to consult, elderly
people who are at home who find it difficult to come to consultation
meetings, and ethnic minority groups where there might be a language
barrier. Do you make any special efforts to reach out to those
people?
Mr Urwin: Every document that
we produce inside its cover has a very short statement in all
the major languages that we know to be used within Birmingham.
We do not produce all of our documents in a number of languages,
but effectively we have a message there which invites people to
contact us, and we will arrange a document to be produced in an
appropriate language or for a specific interpretation service.
It is also important to say that four PCTs in Birmingham jointly
fund a project called the Birmingham Integrated Language Translation
Service, which means that if anybody presents for interaction
with the Health Service—and this is at a point when somebody
is diagnosed, or they suspect something is wrong—we will
arrange for an interpreter to be available within that service
so that we can make sure the message is appropriately communicated.
In some regards we know that it is not appropriate to have a family
member interpret, especially where we have communities of Bangladeshi
Muslim women where the translation is done by a child or a male
family member, so it is very important that we offer those services
in a range of ways. I would be the first to say, though, that
when we described to you this morning the public consultation
events, these are events where the invitations went out with local
free newspapers through the front door of every home within our
patch, but we are the first to acknowledge that the people who
become engaged with us are those who at that point in time want
to become engaged with us. We have to do an awful lot more to
engage prospectively with people who we do not engage with at
present. Once people start to access the services, we are very,
very good at breaking down the barriers for them, to make sure
that there are interpreting services and culturally appropriate
services. What we sometimes do not do is reach out to those communities
in a prospective way, and that is something that will be a big
challenge to us over the coming years. When you talked about those
hard-to-reach groups and choice, I thought you were going to ask
me something different, so I would quite like to answer the question
I thought you might have been going to ask! I told you this morning
that we provide learning disability services across the city,
and we have 1,000 staff working in those areas. We are continually
working on the Valuing People Programme that effectively allows
them to make more choices about the circumstances they are in.
Maybe they do not have a choice about where they live for example,
but increasingly we are involving users and carers in the interviews
of the staff we employ. Indeed, we do not employ staff now to
work in residential care homes, for people with learning disability
or nursing homes for learning disability, unless we have engaged
the patients or the service users in that process. That enables
them to have choices over their lives which may be constrained
choices but nevertheless they are being valued as individuals
and giving them more say in how their lives are managed and run.
Q377 Mr Hopkins: Can I return to
long-term care and choices in care because I am very dubious about
the genuineness of this apparent choice. In my own local authority
some seven years ago, the local authority chose to close a care
home. I took up this issue with the local councils—against
the then Labour council. Some of the local councillors were passionate
about keeping this care home open and wanted it to stay as a local
authority home and not become a private care home. The arguments
the local authority came back with were that people wanted to
stay in their own homes. Fine, care in the community and all that—and
secondly they wanted if possible to move into sheltered housing.
That again is fine, but we are talking about people for whom sheltered
housing was not really possible and families who might be uncomfortable
about the possibility of looking after an elderly and frail relative.
I had a long discussion with the assistant director of social
services in private and we went through all the arguments. In
the end he said to me, "it is about money". I said:
"Ah, so you are restricting choice because of money"
and he said: "It is obvious, isn't it? Private care homes
are non trade union; they work longer hours, they have shorter
holidays and all this saves us money, whereas if we employ properly
trained staff in our care homes with proper holidays and pay,
with trade union membership, it costs more." I said: "Ah,
that is what it is all about!" The officer was moving jobs
and left about two weeks later, so you could say that he did not
care any more and he was burning his boats locally. What he was
doing was restricting choice in care. That process has continued.
Another restriction on care is that the Government refuses to
provide free personal care for people in long-term care unless
they are extreme cases, and they are provided then with medical
care not personal care. Families are having to sell granny's home,
lose what little equity there is in the family, to pay for long-term
personal care. That means perhaps that these families try their
best to keep granny at home as long as possible to avoid having
to put them into a home, as they would see it, and losing the
equity in the house. It is never said—it is unspoken—but
these factors restrict choice. Do you not think that the Government,
if it were really serious about choice, should provide local authority
homes, if that is what people choose, or free personal care, so
that there is no constraint on them living in the residence of
their choice, and particularly involving the families? That is
a long question, but that is the reality, certainly where I live.
Mr Hay: I will take that in two
halves, the first point being around closure of residential homes.
That is an issue that has quite a history here in this city, as
we have 29 of our own homes still, and we have spent 13 years
in various guises dealing with what we are going to do about them.
There is quite a salutary issue in relation to choice about that.
It is a matter of public record that some of our 29 are in extremely
bad condition and are very close to not meeting regulatory standards.
I have taken it upon myself, as part of my duties, to see what
it is like at the front end, and we went into one that is particularly
poor. The quality of care was fine. The building reflects years
of under-investment. What was quite interesting was that the overwhelming
voice of the people in the service was, "if you had lived
in what I lived in in the 1930s this does not really shake on
it." The physical condition of the building was not an issue
for them. In 20 years' time, physical conditions for the next
generation will be a very different issue, and some of our choice
is to keep up the standards and expectations. I thought it was
an interesting question back because often we hear that one of
the reasons for closures is the quality of the building, and one
of the big voices back was that that was not an issue for them.
There is of course—and it is an important issue particularly
for current generations—a kind of psychological contract
about local authorities and standards. There is an issue about
trust in private sector care, and we have to be honest and identify
that. There is something about the welfare contract, if you like,
that is there particularly for older people and for a whole range
of vulnerable people. It is an issue as much for the older parents
of a young adult with learning disabilities who know they are
facing death at some point and want to know who will pick up the
care of this young adult as it is for older people. It is an important
issue. In the closure debate, not only are there issues about
the cost of running homes but there is also obviously the difference
in benefit, which means that even without the cost differential
it is £100 per week more being a local authority home than
a private home, and if you factor in the costs of labour and all
the rest of it you can see the difference. So if we are talking
about running a rationed service, there are clearly issues of
efficiency that affect that, and it has not always been transparent
in relation to those issues. The position that we have reached
is that we have to honour where we are with current people and
build an alternative alongside that. We have moved from the debate
that closure is the only option, which has not been deliverable
because of that level of protest and concern, to building something
up and then moving in to that arrangement. That is how we have
handled the care home issue because it is still a live issue for
us. It is a complex position to be in, but it is slightly different
to the "all or nothing" bust closure.
Mr Urwin: There seemed to be a
presumption in the question that the alternative to local authority
provision was for-profit provision, when actually we have a very
viable mixed economy here where a number of housing associations,
which have roots in their local communities and are in some instances
faith-specific, expand their remit; and they offer a range of
services where they also offer care homes and staff recruitment.
I would not want us to feel that the only alternative to local
authority provision is provision by the for-profit sector. There
are a number of other statutory not-for-profit providers in this
market and we have a very diverse mixed economy in operation.
Q378 Mr Hopkins: People are fearful
of losing that little bit of equity. For working-class families,
granny and granddad bought their little terraced house after years
of struggle. It is the only bit of equity in the family, and now
that is threatened by looking after granny because the government
will not provide free long-term care. It is free in Scotland but
not in England.
Mr Hay: Again, that is a policy
choice, and we work within policy choices. Those with equity of
course increasingly now are extremely well advised and we also
find that those for whom that policy has been devised, ie, those
with great resources, tend to have taken tax advantages some years
ago and that money is untouchable, so it is building in an equity,
and it is the whole issue of choice and equity that comes back
consistently around that. Equally, it has created a degree of
reticence on the part of older people, particularly where money
is such an issue as you have referred to, about coming forward
at an early stage for preventative type services. There is a fear
element that is not always helpful, and it is how you can get
over some of those issues and create more care at home. That is
partly what is driving the issue about people wanting to stay
at home for longer. It also comes down to the choice society makes
about where to put the resources. At the moment the cost of care
in the community, particularly for older people, is borne by the
individuals and the families.
Q379 Mr Prentice: Chris, you told
us earlier today that fortunately there are open lists in South
Birmingham, or open practice lists. On the key question of patient
choice in relation to the GP, what does that mean in practice?
How much choice does the patient have?
Ms Fearns: Until the new GP contract
came in last April, people could go to the door of a GP practice
and for no very good reason be turned away on the grounds that
that practice could not take anybody else on its list that day,
but the next day it might decide differently on the basis of a
number of issues. I would like to think that that was not happening
wholesale, but there were elements of that. The new contract states
that you cannot do that any more. The rules have changed and you
have to categorically declare publicly that you are either open
or closed, and if you are closed the PCT has to approve that closure,
and it has to have approved it for very good reasons, which are
detailed in the contract guidance. At the moment we have a small
number of practices that are without doubt under pressure for
a variety of reasons and will no doubt be coming forward at some
point to discuss closure with us, possibly on a temporary basis.
We will look at those cases individually. It the main, all are
open at the moment, so if a patient applies to a practice and
that practice turns them down, they are within their right to
come to us and complain, and we will have to follow that up, and
we will follow that up immediately on the grounds that that is
not legitimate, without good reason. The doctor has to give good
reason, and that guidance is detailed in the contract.
|
