Examination of Witnesses (Question Numbers
200-219)
MR RAPHAEL
WITTENBERG AND
PROFESSOR CAROL
JAGGER
5 NOVEMBER 2009
Q200 Stephen Hesford: If you look
at opinion polls, for example, and they have had problems over
the years—they got the 1992 election wrong—they have
a well-known and well-understood plus or minus margin of about
3% of their core projection. Do you have a plus or minus margin
or some margin for your projections?
Mr Wittenberg: No, because the
issue is really different. What is causing the opinion polls to
have this plus or minus 3% relates simply to the fact you have
taken a sample, typically 3,000 people instead of all 60 million
of us in the UK. Modelling is something different. It is partly
that we are using sample data, for example from the British Household
Panel study, but it is mainly these other factors and therefore
it is not at all comparable with opinion pollsters.
Q201 Stephen Hesford: Are you saying
your modelling is bigger and better and therefore is not subject
to this?
Mr Wittenberg: No; absolutely
not. It is subject to more uncertainties. May I just make one
or two other points as it may seem that I have been terribly pessimistic
about the modelling? That is not the message I intend to convey.
I intend to convey that there is a lot of uncertainty but surely
it is far better to make big decisions with such evidence as one
can get, recognising its uncertainty. I should like to make that
point. May I also say that it may well be that when one is looking
at different funding systems, things like the life expectancy,
if one got that wrong, that would affect all of them? So the gap
between the net extra cost will differ of course but it may not
be that dramatically out as the totality will be.
Q202 Chairman: We are in this sphere
of Rumsfeld's known unknowns here. I am tempted to ask you whether
you know how variable your unforeseeable variables are or is that
another Rumsfeld question? The implication of what Stephen has
been saying is: what have you learned by this type of modelling
over the years, if you have been using big cohorts and unforeseeable
variables? You have a measure of them over time presumably.
Mr Wittenberg: I can answer for
some bits but not for others. As far as the GAD, now ONS, population
projections are concerned, they did do their own analysis of the
extent to which they had been out in their previous projections.
My recollection of the paper I have seen, though it may not be
the most recent, is that they found that the biggest problems
related to the 85-plus group which is unfortunate because they
are so critical for this purpose. I think they were 10% out over
a decade but I may not have got the figures quite right. I would
have to check. They have looked at it and they have produced information
on their past errors that one can look at. At one point we did
our modelling saying "Supposing they were out by the same
amount in the future" but of course ONS would have learned
from their past error rate and taken that into account so I am
not sure it is right to do that; for that one there is information
on past error rates. I do not know whether one can do the same
on disabilities. For unit costs we can look at past information
and try to see how much those have risen and they have turned
into rises in real terms over certain periods of time and a bit
less at others. Expectations? I do not know how one would do that.
Q203 Mr Scott: Informal carers make
a key contribution to supporting people with long-term care needs.
Can you explain the interaction between informal and formal services,
who does what and for whom?
Mr Wittenberg: By "interaction"
do you mean if there is more formal care, what happens to informal
care and vice versa?
Q204 Mr Scott: Yes.
Mr Wittenberg: There is definite
evidence for England that with home care, people living alone
get more care than those who are married and living with a spouse.
So the system is not carer blind; it appears that councils do
take account of whether or not someone has a carer when they decide
on care packages. We did not find that in community nursing which
is different, so in that sense, from the point of view of the
council, they do appear to take account of the amount of informal
care. There is a whole body of literature about the relationship
between formal services, councils in our case, and informal carers—whether
they treat the carer as a co-worker or as an additional user and
so on. There is also literature the other way round, that is to
say: supposing formal care increases, do the informal family carers
drop out? The literature of which I am aware suggests no, they
do not drop out. They may reduce the hours a bit but not hugely
and they may change exactly what they do. For example, one piece
of evidence I am aware of relatively recently is the situation
in Scotland where Professor David Bell commented in his report
that the expansion of home care linked to the free personal care
in Scotland appears not to have caused family carers in Scotland
to drop out of providing care.
Q205 Mr Scott: Would it be fair to
say, with changing circumstances and the invaluable work that
informal carers do, sometimes unsung heroes to be honest, that
the pressures in a family of maybe both people having to have
jobs now is going to impact and informal carers will not necessarily
be able to put that time in any more which will obviously increase
the burden on informal care? Would you agree with that?
Mr Wittenberg: It is something
that is much discussed as to how much employment impacts on care.
I think the evidence I can recall—I cannot remember chapter
and verse—is that it depends hugely on the number of hours
of caring; a small number of hours of caring may not prevent people
remaining in employment. The biggest circumstance where there
appears to be a reduction, from what I can recall, is where the
people are older workers and who are providing very large amounts
of care. As far as I am aware, vast numbers of people are not
dropping out of caring because of employment, but some are. It
must be very difficult to know really what will happen in the
future.
Q206 Sandra Gidley: Alexandra Norrish
from the Department of Health told us last week that there are
good grounds for treating differently older and younger service
users, mainly because of the differences in their needs and differences
in financial means. Have you done any modelling on the difference
between the two? Are there any differences as far as you are concerned?
Mr Wittenberg: We have a model
for younger adults which leads into the work we have done for
the Green Paper as well as the modelling for older people. We
have considered issues about the resources and clearly they do
differ. For example, half the expenditure for young adults relates
to people with learning disabilities and the numbers are rising
very greatly. As I understand it, the evidence in work by Professor
Eric Emerson of Lancaster, for example, suggests, as you would
expect, that most people with learning disabilities have few savings
and few sources of income other than social security benefits.
That puts them in a different position from an older person who
may well own their home, because home ownership among older people
has been rising and the value of the homes—not recently
but until recently—have been rising as well. The economic
circumstances are very different and that has led us to look at
the modelling differently. For older people there is an overwhelming
case for wanting to do some micro-simulation so that you can take
account of this diversity in incomes and savings. For people with
learning disabilities we have not done that, partly for data reasons
and partly because it would not have the same value if they collectively
have few incomes other than benefits and few savings and the issues
really are different there. That is something we have implicitly
taken into account in the modelling.
Q207 Sandra Gidley: A slightly different
question. Is there any evidence of age discrimination in social
care services?
Mr Wittenberg: My colleague at
the University of Kent, Professor Jules Forder, did a report for
the Department of Health which was published in the summer of
last year which looked at that question using data sets. It looked
also at the British Household Panel Study and the evaluation of
the individual budgets which I mentioned earlier. He found that
there were differences in receipt of care, looking effectively
at amounts in money terms per week between older and younger groups
after standardising as best as possible for need. Whether that
is discrimination is of course a second question. That depends
on what one counts as discriminatory. I had better leave that.
Q208 Sandra Gidley: There is no overt
and covert discrimination.
Mr Wittenberg: I agree that legislation
has direct and indirect but what I am saying is that the modelling
that Professor Jules Forder did looked at the differences; whether
discriminatory or not is in a sense a second set of considerations.
Q209 Sandra Gidley: Were there any
cost implications of addressing those differences that he highlighted?
How significant was it?
Mr Wittenberg: The conclusion
of the research that Jules Forder did was that, subject to a long
list of caveats, the cost to public funds of eliminating age discrimination
in adult social care by increasing the services for older people
would be in the range of £2 to £3 billion per year but
that was on the basis that all differences had to be eliminated.
Whether that is the case or not is quite another matter. He commented,
for example, and others have commented, that there may be differences
in the unit costs and you could have an identical care package
for a younger and older person but the cost is different because
of market factors. There are also issues as to whether it is necessary
to provide the same care package in order to achieve the same
outcomes for older and younger people. There is a lot of scope
for discussion around this.
Q210 Sandra Gidley: I am a little
confused. How can the same care package cost less to deliver to
somebody who is older?
Mr Wittenberg: I was thinking
in particular of care homes; it could do if the competition is
far greater among the providers. That may be true for some very
specialist groups of younger users. If there are not many providers
there is scope for a bigger mark-up and there is a suggestion
that may be happening. That is just an example of why one needs
to take the £2 to £3 billion with caution.
Q211 Sandra Gidley: When you say
"a bigger mark-up" it could be him saying that we are
being ripped off for younger adult services.
Mr Wittenberg: I am not aware
of particular evidence.
Q212 Sandra Gidley: There is no evidence
either way.
Mr Wittenberg: I am not aware
of evidence one way or the other but it has been suggested that
the mark-ups could differ and that it could be part of the explanation
of the expenditure differences.
Q213 Dr Naysmith: One idea which
is incorporated in the Green Paper is building the budget for
Attendance Allowance into social care funding and that is proving
quite controversial. I know it is controversial because a lot
of people in my constituency have written to me about it and yesterday
there was a lobby here of people with disabilities and this was
one of the points they were raising. Could you tell us about the
main characteristics of this benefit and how it relates to the
social care system?
Mr Wittenberg: The main characteristic
is that it is a benefit payable at two rates: a lower rate and
a higher rate. Unlike social care, it is not means-tested and
I think I am right in saying that it is also not taxable. The
numbers of people receiving Attendance Allowance is around 1.3
million in England recently. It is therefore rather larger than
the numbers we were talking about earlier; the numbers of people
receiving home-based community service. A wider group of people
apparently seeking Attendance Allowance and also some receiving
Disability Living Allowance need to be thought about as well.
I have a note about the overlap between the two which might be
useful. An analysis that colleagues did of the data set known
as ELSA for the Wanless Review, for example, found that only 26%
of the Attendance Allowance group received social care, either
publicly or privately funded, and that 29% of the Attendance Allowance
people received neither formal nor informal care. So the overlap
is not overwhelming between the Attendance Allowance and social
care. It is to a considerable extent a bigger, wider group of
people and to some extent a different group of people in the community
receiving Attendance Allowance. As far as care homes are concerned,
as you know, the publicly funded group in care homes are ineligible
to receive Attendance Allowance after the first four weeks.
Q214 Dr Naysmith: Do you think it
is reasonable to include in the Green Paper as something to be
considered in this way?
Mr Wittenberg: I feel that is
a policy matter.
Dr Naysmith: Last week one of our witnesses
painted a picture of rich pensioners using Attendance Allowance
to pay for the odd luxury item like SAGA cruises. Do you think
there is any validity in this criticism?
Q215 Chairman: Is there any evidence?
Mr Wittenberg: As I understand
it, colleagues tell me this was a comment made at one of the consultation
events; someone said they had heard this. My understanding is
that some of the stakeholder groups are quite interested to find
out how people actually spend their attendance allowance and have
told colleagues at the Department that they hope to include that
in their responses to the consultation. I have to say that I think
it is methodologically quite difficult. If you ask people what
they spend their Attendance Allowance on as opposed to their pension,
I am not sure how easy people would find it to answer that.
Q216 Dr Naysmith: You are not going
to find out really.
Mr Wittenberg: It would be difficult
to get a categorical answer to this question.
Q217 Dr Taylor: I was grateful to
you for explaining your idea of projections, predictions and modelling
because I was quite confused. We were given an indication by the
Department of Health that your Unit is doing some modelling relating
to the funding options. Could you let us know how far advanced
the actual quantitative analyses of the funding models in the
Green Paper and of the free personal care policy area are? When
can we expect these to come to light?
Mr Wittenberg: May I start with
the Green Paper first? The Department of Health has commissioned
a whole programme of modelling from the Personal Social Services
Research Unit over an extended period and originally goes back
to the time of the Royal Commission. One block of modelling has
been published in the sense that the PSSRU published a discussion
paper, DP2644 actually, which describes the micro-simulation model
and it also presents some outputs from the model on the current
funding system. When I think about it, papers were published earlier,
in March of last year, which looked at aggregate projections for
old and younger people. In addition, the outcome of the modelling
at an aggregate level that PSSRU have done for the Department
appears in the impact assessments for the Green Paper which of
course are on the Department of Health's website. All of this
is actually available. The Department is continuing to commission
further modelling from the PSSRU and that is in progress. I understand
from colleagues the Department's plan is in 2010, next year, to
publish another block of output from modelling.
Q218 Dr Taylor: Twenty ten is rather
wide. Can you give us any more accurate timing? The consultation
on this thing closes on 13 November so we are not going really
to have any idea of the different costs of partnership insurance,
comprehensive, before we respond to the consultation.
Mr Wittenberg: There are figures
in the impact assessment on the costs that have been published.
If people want to look at the details, the impact assessment for
that purpose is useful reading alongside the Green Paper. You
asked me when in 2010. I am really sorry I do not know. I will
go back and ask colleagues or you may wish to ask the Secretary
of State when you interview him.
Dr Taylor: That would be the way forward.
Q219 Chairman: Do you think that
key features of future funding systems such as its universality
depend on some of the factors which have been mentioned this morning,
for instance unit costs or how unit costs will grow or the availability
of informal care? Are those and other aspects going to determine
the future?
Mr Wittenberg: They will clearly
have a huge impact on the expenditure but when it comes to choosing
between options, clearly there are value judgments involved. As
I see it, the projections are a tool, they give information to
decision makers but then in choosing between the various options
on which the Green Paper is consulting, clearly there are value
judgments and modelling alone is not going to answer questions.
What it is going to do is give one indications of probable balance
of costs really and then decision makers need to think about issues
of cost effectiveness and in particular issues of equity and whatever
other values they feel it appropriate to assess the options against.
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