Examination ofWitnesses (Question Numbers
120-139)
MR DAVID
BEHAN, MR
JOHN BOLTON,
MS ALEXANDRA
NORRISH AND
MR JEFF
JEROME
29 OCTOBER 2009
Q120 Dr Stoate: No, of course they
do not.
Mr Jerome: And I am getting my
ear bent quite frequently about it. We have a lot to work through
on this contracting basis. I have come across quite a few situations
recently where through the contracting approach local authorities
on the grounds of efficiency are requiring individuals to transfer
care from one provider to another and I think there is a problem
there in terms of the philosophy of choice. We have to do some
thinking around that. Where does efficiency hit choice when we
are putting forward a policy objective? I have had a few conversations
recently with local authorities around that. We have to try and
work out the best way of approaching that. It seems as if the
concept of framework agreements, which is where you might accredit
or list providers in a particular area and the requirements of
quality et cetera, will be the way forward rather than concepts
that are linked to cost and volume, but there are issues there
around efficiency.
Q121 Dr Stoate: It certainly has
not worked in terms of residential care because self-funders pay
significantly over the odds compared to local authority purchasers.
Mr Jerome: That would depend on
the arrangement with the individual providers. As you know, there
is evidence of that in places. Again, it depends how a local authority
as a purchaser works with the provider and how the provider then
chooses to sell through the private market and all those arrangements
are different.
Q122 Dr Stoate: My point remains
though that in the real world self-funders end up paying a lot
more than local authority funders for what looks like pretty similar
care.
Mr Jerome: Generally.
Mr Bolton: Can I help here because
this is something we have looked at. Interestingly, despite the
evidence—you are right—about the disparity in potential
costs in residential care, the evidence in domiciliary care is
not the same. The evidence is that it is probably marginally pretty
well the same. It varies according to the deal the local authorities
got. If you talk to providers about that, they will suggest that
they need to put a considerable hike on the cost of a contract
with a local authority because of the bureaucratic requirements
that the local authority place on them. At present we are looking
at a scheme that might help them through using an electronic monitoring
scheme and some software which software providers have developed
to help do that which might reduce that, but actually at this
point in time there is no significant evidence in the domiciliary
market of a significant hike up of price, just so you are aware
of that.
Q123 Dr Stoate: That is useful. Just
a final point again to Mr Jerome and that is: is there much scope
for personal funders to get together in consortia and purchase
effectively in bulk themselves?
Mr Bolton: There are examples.
Mr Jerome: There is quite a lot
going on on the Internet and other places. The whole purpose of
this programme anyway is to try and get self-funders and public
funders alongside each other in a market situation rather than
what has been the case up to now which is really that self-funders
are out there on their own. Through some of the universal support
and advice that we have talked about earlier and through increasing
use of Internet and other approaches and local community organisations,
to assist people to do that, we are moving in that direction.
Dr Stoate: My main point is to ensure
that individuals are not disadvantaged compared to other users.
I have some reassurance now that at least that is being addressed.
Thank you for that.
Q124 Charlotte Atkins: Mr Jerome,
can you explain the principle of preventative social care and
early intervention because this does not seem to have always been
part of the social care package?
Mr Jerome: I will bring John in
on this again in a minute because he is very expert in this area,
but in thinking about universal services the thinking is that
in all communities there will be a preventative and health improvement
type of approach of inclusivity. As an ideal, local authorities
with their partners will be trying to create that. There are a
number of aspects to that around employment, education, transport,
suitable housing, and information and advice as well as good health
improvement programmes, so that is a general starting point. That
goes back to the earlier discussion about how you keep people
as healthy as possible. Added to that there are issues about what
sort of targeted intervention programmes you need around rehabilitation,
recovery, et cetera. That is seen as a main part of the operating
model we are now trying to push forward which is a more individualised
approach than that collective stuff I was just talking about,
so it would be part of an expected operating model for us to look
at individual need. This will be both people who are likely to
fund themselves in the current model as well as those people who
get a council personal budget. We would look at individual need
and assist people to identify whether there was any potential
for them to improve well-being and independence and there would
be targeted programmes. I would like to come back to the fact
that we still need to bear in mind that high numbers of people
in this care and support service are towards the end of life so
there are two aspects to this and it is not always going to be
suitable.
Mr Bolton: Obviously as a department
we are looking a lot at this area and I accept it has been a grey
area in social care as to what the evidence really is about what
prevention is. We tend to use the word to cover a whole range
of things, some of which probably do not prevent anything. We
start at the end of well-being, as I call it. Are people happy?
Do they have the opportunities? Do they live in communities where
activity goes on and they can have fulfilled lives, whether they
have disability or old age? There are those kinds of services.
The POPPs pilots, in particular the older people's pilots, of
which we are about to see the final results, has been a major
study into the impact on people of those kinds of schemes. I think
the evidence is going to show us they have a particularly positive
impact in reducing people's need for healthcare.
Q125 Charlotte Atkins: What sort
of schemes are we talking about here?
Mr Bolton: They tend to be older
people undertaking collective activities together. That would
be a characteristic of that.
Q126 Charlotte Atkins: In a range
of settings?
Mr Bolton: In a range of settings,
yes.
Q127 Charlotte Atkins: You were talking
about evidence earlier. What evidence is there of both the cost-effective
of this and the effectiveness in terms of health?
Mr Bolton: That is what these
pilots, which have been running now for two years and have just
concluded, and the research is just putting that together, and
that is going to be available to us in the coming months. I think
it is due to be published in December.
Q128 Charlotte Atkins: Is it particularly
elderly people doing things together?
Mr Bolton: That has been particularly
focused on elderly people.
Q129 Charlotte Atkins: What sort
of things have been piloted? Doing things together, what, going
on holiday?
Mr Bolton: Social activities,
engagement in community activities, engagement in activities,
getting information and advice, running things themselves, being
active citizens. There is a range of schemes that have been developed
by older people for older people.
Q130 Charlotte Atkins: How does this
work in with the personalisation and preventative approach? How
do the two work together?
Mr Bolton: That is the beginning
of the spectrum on prevention. The second area of prevention is
the understanding that there are things you can do that can either
stop people needing a service or defer the need for a service.
We talked about the importance of when people come out of hospital,
for example, that they get the right recovery programme to help
them get back on their feet and not end up staying in a state
of ill-health. There is evidence of what we call in our jargon
reablement, which is a promotion of independence model, which
actually helps people get back on their feet. There is very strong
evidence that people will recover if given the right kind of treatment
and help, particularly from occupational therapists and physiotherapists
but also through staff who may not have those professional skills
but who are supported by those professions and they can actually
support people to regain their confidence and regain their independence.
That can be a big thrust for older people in making sure they
do not enter the care system when they do not need to because
we can get people back on their feet.
Q131 Charlotte Atkins: An obvious
scenario would be where someone has had a stroke and they need
to reintegrate into the community. If we are going down the avenue
of personal budgets and personalisation and so on, how would people
choose perhaps to go to a good day centre or involve themselves
in some sort of community initiative, but particularly how will
they buy into that because we have focused in this evidence session
very much on people employing or having other people employ personal
assistants and so on. How does that relate to buying services
which are provided either by the local authority or by a voluntary
organisation?
Mr Bolton: I think it starts by
actually seeing that there are services you can provide for people
well before they get to the stage of considering a personal budget.
For the kind of prevention and early intervention we are talking
about, which is an aspect of personalisation, where most people
would if they possibly can like to retain the independence of
their lives as the way they express their choice, it is actually
ensuring people have the right services and the right environment.
We recognise the housing in which people live and having the right
aids and adaptations (and in this day and age the new technologies,
the telecare products, that are available for people) all of which
can keep people outside of the care and support system where you
might get a personal budget. Our prevention and early intervention
strategies are focusing on how do you help those people who do
not need to be in the care system remain outside it and to retain
independence and have fulfilled lives in a suitable way.
Q132 Charlotte Atkins: We are really
talking about quite a long time-span. We are talking about pre-personal
budget needs and then we are talking about people who perhaps
because they are vulnerable do not find it so easy to go along
to the local pub or whatever and enjoy a social life and therefore
they need a more sheltered environment where they can enjoy social
interaction. What worries me about the personalisation agenda
is that personal services are delivered to the person concerned
or the person concerned is taken out to do things, but it is very
much a one-to-one delivered to the home so they spend 24/7 at
home not really interacting with a whole range of people. How
can you reassure me that the personalisation agenda is not about
that?
Mr Bolton: I think the context
of Putting People First starts with the kind of society in which
people live. It starts with a message about what it is that is
available in the community and it only ends in a sense with social
care. Part of what we are trying to achieve is that the towns,
the cities, the villages in which people live actually are taking
them into consideration and these people are contributing to the
kind of offer, as it were. Some of the best examples we see are
in places like Herefordshire Council where they are investing
in their village halls. That has enabled older people who might
otherwise have gone to the day centres in the past to re-engage
with their own communities using the activities in the village
hall as a mechanism. That is how they have spent their personal
budget to get to the village hall rather than to sit and wait
for the council's transport to take them to the nearest town to
go to a day centre which may or may not have the activities going
on that they wanted. That to me is a really good example of personalisation.
It is the community and the individual coming together in the
same way.
Mr Jerome: I would take you back
to stroke for a second because the crucial area is what is collectively
there for people in terms of the universal offer. I think part
of that is health. I say this because the whole first year of
my working life was in a stroke unit and there was a time when
people stayed in hospital in rehab/recovery for three months or
longer after a stroke. That is not the current approach, so the
thinking has to be—and this is where it goes back to that
joined-up stuff between health social care earlier—there
have to be community-based programmes between health and social
care with health funding around trying to maximise independence
for people. If you took stroke, it would be clear programmes that
worked with people in their own homes to maximise their independence
which is part of that collective investment, part of the universal
offer, part of which is the Health Service, before you come to
a view about what their individual pot of money through a personal
budget for long-term care and support needs would be. With strokes
some people can recover quite extensively if they have the right
sort of rehab which will mean that their care and support needs
are much fewer. That has got to be joined between the NHS and
social care and particularly the NHS has to look much more strongly
at its role in that area.
Q133 Charlotte Atkins: You mentioned
universal services. Can you explain how that works and how that
relates to creating social capital and how that all fits into
personalisation and the Social Care Transformation programme?
Mr Jerome: The thinking has to
be if we are going to keep people at home and in their communities
with their families, supported by these sorts of things, particularly
those ones that are collectively invested in for groups of people,
that you can build around individual family and community input.
There are examples of that in different ways through the different
sorts of social enterprises being created and through different
arrangements for family support, and particularly where you give
people a personal budget or individualised care and support programmes,
you can then build family and community environment around that.
That is completely different from where you say to people you
have to take something from a contract; it is only delivered in
this way. It starts to build around individual need and aspiration.
There are at the moment things more on the fringes around that,
things like time banking and credit unions that can still input
into that.
Q134 Charlotte Atkins: What is time
banking?
Mr Jerome: That is a bit on the
fringe but with people with learning disabilities or older people
who have something to offer people, there are some good examples
of where they are able to perhaps support an older person but
gain a credit through a time bank concept in a community so they
get something back from somebody else who can offer them a skill.
There is some quite interesting American stuff on that.
Q135 Charlotte Atkins: Can you give
us a concrete example of where this is working? There are all
sorts of theories and what I would like to know is where it is
working, where has there been a positive difference by creating
universal services which people could really buy into? I have
to say from my experience you have personal assistants very often
who are taking out young people with learning disabilities every
day of their lives, which might be great for some young people
but not great for other people, and they find themselves going
out in the community but not really integrated in any way and
being quite isolated because all they have is a relationship with
their personal assistant and they are not having a relationship
with the community or indeed with youngsters of the same age.
Mr Jerome: There are many examples
around learning disability. There are people working with personal
assistants but a common way will be to try and group people in
terms of community activity and environment. There are many examples
particularly around learning disability in fact where people are
working around various community activities, sometimes in employment
scenarios, sometimes just in social enterprise model-type arrangements—bakeries,
sandwich arrangements, catering—but also in and out of everyday
community activities. I only gave you one time bank example and
there are 16 time banks for example in Essex where somebody with
a learning disability could go and work and do some gardening
or some cleaning or some work with an older person and gain a
credit so it gives them some sort of employment concept as well.
There are examples out there.
Mr Behan: If it helps, I have
two specific examples. You were asking John earlier about prevention.
One of the pilot schemes that I have visited over the past 18
months is the Dorset Partnership for Older People Pilot for older
people in that rural county of Dorset who are housebound—so
the point you are making about isolation is a powerful issue for
many of them—and the way that the Dorset POPP works is that
it brokers a relationship between other older people who want
to be volunteers who visit the isolated older people in their
own homes. In the visit that I made I met both the people who
were being visited and those people that were doing the visiting
and that was an example of how the community, largely based on
the villages in Dorset, was operating to support people, and it
builds on the example that John gave.
Q136 Charlotte Atkins: Let me make
it clear, I was not talking about people being house-bound; I
was talking about the fact that with the personalisation agenda
services are delivered very much to the home and rather than people
going out, they are actually having the services delivered to
their home and therefore are not involved in the community, whether
it be a day centre or their local community because the services
get delivered to them. That is what I was talking about.
Mr Behan: I think it is a completely
legitimate challenge. I would want to argue that that is not about
personalisation. Our argument would be that personalisation is
just as much about what happens in a group living setting, in
sheltered accommodation and for people who live in residential
accommodation. Personalising care around individuals, whether
they are living in their own homes, attending a day centre or
in a residential setting, is key to the policies that we have
been pursuing. A personal budget where somebody chooses to use
it, as John has said, is actually used by a number of people but
our policy of personalisation applies to all people. On the issue
around isolation we have been attempting to address the notion
of social capital and I thought you were challenging us to give
some practical examples of how people are coming together to use
the capital in communities to support people so they do not become
isolated. My offer of the Dorset POPP was not disputing the fact
that isolation is a key issue. Arguably, isolation and anxiety
is one of the great challenges of the next few years that we need
to address. I do think it is a particular issue that we need to
address but the concept of social capital making a contribution
to the way the communities can provide care and support to individuals
and to groups of people is one that we want to encourage. There
is a variety of different ways that can be developed through 1970s
community development ideas, working with John's example from
Herefordshire about using village halls, and they are all examples
of how people are beginning to think creatively and laterally
about the contributions people want to make. On the issue of social
contribution, I think many people who have got to retirement age
who are in their late 50s or early 60s will still want to make
a social contribution. They may make that through volunteering
or through engagement in the governance of voluntary organisations
at a local authority. There are a thousand different ways that
people will make that.
Q137 Charlotte Atkins: If you have
a personal budget, you can spend that budget on anything you want,
including services provided by a council or a local volunteer
organisation? I know with direct payments there have been issues
about you cannot use them to access a local authority facility.
Mr Jerome: It is a managed service
on the council side. You will be told what your budget was and
you would be told the cost components that were making up that
budget, so if you are using council services what you really need
to do is to see an account that tells you what the cost components
of what you are getting from the council are. The council is still
holding the money rather than giving it to you because there still
is a provision to buy a service from the council but it is the
same concept. The big issue, frankly, is that councils are going
to need to understand their cost components and in doing so individuals
will see whether that looks to be good value for money or not—those
individuals who are able to do that—and that is quite a
big change for the public sector.
Mr Bolton: I could give you quite
a lot of examples if you wanted me to. I wanted to get the principle
across. What I have seen is that this one-third I described who
want to take some of the councils' managed service and use some
of the money themselves, quite commonly it is not new commissioning
they are looking for, it is access to the existing services in
the community. I can remember being in Doncaster recently and
they said quite a lot of the older people were wanting to access
things that were available in that community with their personal
budgets alongside keeping the domiciliary care support that they
also were getting. Staffordshire has very similar models. If you
want a community activity go to the brand new sports centre in
Sunderland where they have a programme to support people recovering
from mental ill-health or who have learning disabilities to join
in sporting activities with other people. While I was there there
were some mental health service users engaged in some swimming
activity which was going to support their engagement with that
pool. We might be on the edge of it but we are beginning to see
some really creative, much more imaginative use of the money in
ways that both links to the community, builds on the social capital
but also contributes to the massive raising of opportunities for
people within social care.
Q138 Charlotte Atkins: How are you
suggesting that Staffordshire is doing it differently?
Mr Bolton: I was particularly
struck by Staffordshire in talking with their social workers because
they felt freed up to work with people on creative solutions to
the problems they faced in which they were massively encouraged
by their council to look at the community offer as part of that
solution.
Q139 Charlotte Atkins: I cannot say
I have noticed. But anyway, can I just ask you about people who
do not qualify for local authority support who have to fund themselves.
What can they expect from personalisation and from the National
Care Service?
Mr Bolton: I think we have covered
those issues. The universal offer that we talk about ought to
be available to self-funders. I suppose the big issue is getting
the right information and advice so they make informed choices
about how they want to spend their money, they know what is available
to support their care needs, and they have access to programmes
like the intermediate care reablement programme, so when they
have been ill they also get the whole range of those preventative
options open to them. That is the kind of direction, to make sure,
as Jeff said, that they are a part of the system because in a
sense in the new system at one level everybody becomes a self-funder
and how you get them to work together using that is part of the
challenge.
Mr Jerome: A simple one liner
which colleagues said recently is they would expect to get support
to make what would appear to be the right decision around care
and support services, irrespective of whether they are going to
be paying for them or are getting some sort of contribution from
the public purse.
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