Examination of Witnesses (Question Numbers
302-319)
BARONESS YOUNG
OF OLD
SCONE, MR
RONALD MORTON
AND MR
SAMPSON LOW
12 NOVEMBER 2009
Q302 Chairman: Good morning. Could I
welcome you to what is the third session of our inquiry into social
care. I wonder if, for the record, I could ask you to introduce
yourselves and the current positions that you hold?
Mr Low: Good morning.
I am Sampson Low; I am a policy officer with UNISON, the public
service union. We represent 300,000 members in social care in
caring, administrative and professional social work capacities
for a wide range of employers—local authorities, NHS, private
voluntary sector and agencies—across all 152 local authorities
in England and members in Scotland, Wales and Northern Ireland
too.
Baroness Young of Old Scone: My
name is Barbara Young; I am the Chairman of the Care Quality Commission,
the new joint regulator for health and social care.
Mr Morton: Good morning. My name
is Ronald Morton from the Care Quality Commission. I am a strategy
manager within the Commission.
Q303 Chairman: Welcome once again.
I have got a question for the first two of our witnesses to start
this session. Obviously we are doing an inquiry into the Green
Paper "Shaping the Future of Care Together", which is
concerned more with funding options for social care and with improving
the services provided. How widespread is poor quality social care
and could you give us some examples of that?
Baroness Young of Old Scone: Shall
I start off, as it is the heartland for us, I suppose. The latest
figures we have got are that about 79% of social care services
are in the good or excellent category, about 16% are in the poor
or adequate category, which is about 3,700 services, and that
is not acceptable, so there needs to be action on these poor providers
to get them further up the quality spectrum. Generally speaking,
performance has been improving for particularly residential care
services over the last few years and performance against the national
minimum standards has risen in the figures we will be launching
at the back end of this month for six years in a row, so I think
there are some real signs of improvement in some services. There
are some areas, however, that are unacceptable, particularly that
16% of poor and adequate services. There are some major questions
about domiciliary care, as opposed to residential care, where,
I think, there has been less focus in the past and there needs
to be more focus in the future. Of course, the quality of care
can be poor even in a good care setting, and there will be occasions
when things do go wrong, and one of the key features for the Care
Quality Commission is that we want to hear those accounts of poor
quality care, because if we can understand how people are experiencing
care, we will then adjust the way in which we regulate providers
of care in order to make sure that we are focusing more closely
on places where people feel they are experiencing poor quality
care. So we are very keen to get the views of the users of services
really at the heart of our work on regulation. Of course, a big
element of the quality of care is not just how the services are
providing care but also how the commissioners of care are commissioning
care, and we can talk more about that if you want.
Q304 Chairman: We will want a little
bit more detail, yes.
Mr Low: Obviously we can give
bad practice from the point of view of our members in terms of
pressure on pay and conditions, particularly in home care or domiciliary
care, but a classic example of bad practice in home care and social
care is the contracting system where the local authority is under
pressure to take the lowest possible price and bid for work regardless
of quality. Obviously, the contractor bidding is bidding to abide
by the Care Quality Commission's minimum standards, but often,
frankly, the contracts are awarded at unfeasibly low levels, and
that puts enormous pressure on the workforce and many providers
then do not complete their contracts, find that the cases, the
individuals and users have far more complex needs than they ever
imagined and start trying to hand back the more complex cases
to the local authority, or even finish the contract and hand back
to local authority who has the ultimate duty of care. So cut-price
contracting is, for us, perhaps a classic example of bad practice
in the social care sector.
Q305 Chairman: Baroness Young, you
did say that inspections show quality ratings are improving; I
think you said something like a six-year one. Does that reflect
genuine improvement? It does beg the question, are your inspections
any better than Ofsted's inspection of Haringey's Children's Services,
which were found to be, effectively, in a position where false
data was being used to say that everything was okay? Are they?
Baroness Young of Old Scone: Clearly,
I would not want to comment on Haringey other than to say that
the particular issue there was child safety.
Q306 Chairman: It is the quality
of the inspection, I suppose, that we are talking about. How do
we know that it is good quality as opposed to (I hate to use this
expression but I am afraid it does happen, certainly in health)
this tick-box exercise that organisations go through?
Baroness Young of Old Scone: I
have been very impressed, in the 16, 17 months that I have been
associated with the Care Quality Commission, with the quality
of the inspection of services, but, as you know, we have got a
new registration system coming in and we are particularly keen
to build on the expertise that has been developed over time in
inspecting services to make sure that the inspection process is
as effective as possible and focuses on the things that people
really care about—the outcomes, whether they are treated
with dignity and respect, whether their rights are respected,
as well as a whole variety of other issues—and we want to
very much focus on whether the care that people get is what they
should have the right to expect, in terms of what it does for
them, rather than simply looking at processes and policies, which
can lead to a bit of a tick-box approach. That has caused a bit
of a stir in the social care world, because in the consultation
we undertook on the compliance criteria that we are going to use
for the new registration system quite a lot of providers came
back and said, "No, no, please tell us what to do";
whereas we have been saying, "This is the outcome we want
you to deliver and we do not have strong views about how you deliver
it, but we will have strong views about whether you are delivering
it." So I think there is going to be quite a lot of discussion
about how we can make inspection as effective as possible, bearing
in mind that some of the bigger providers will have good systems
for managing their own quality and some of the smaller providers
will need more help because they have not got the internal capacity
to think through some of the issues of how they go about providing
the outcomes that we are looking for. The other side of the business
of assuring quality is, of course, the work that we do with councils
reviewing how they commission services and how they put in place
mechanisms to make sure that the range and quality of services
that are available for people, whether they are people funded
by the council or whether they are self-payers or people who top
up payments, whether they are a good range, whether they are accessible
and whether they are good quality. Indeed, I think we have an
effective process of working with councils to identify the ones
who are not commissioning as well as they should and whose range
of services across the piece, therefore, is likely to be less
good. We meet with them on a regular basis, we develop joint action
plans with them, we monitor whether they are achieving those action
plans and, I think, there has been a track record which CSCI,
our predecessor, developed and took forward of getting more councils
up the quality spectrum, as it were, in terms of their commissioning
role. So we can get at the services in two directions: both from
the commissioning point of view and from the service provision
point of view. Clearly, because we are not on every door step
all the time, there will be times when things go wrong in particular
care settings that we perhaps should have anticipated and did
not or that we could not have anticipated. One of the pieces of
work we are doing at the moment is what are the pre-conditions
for poor quality? What are the things that happen in services
that make you worry that they are going to be at risk of providing
poor quality? There is a good body of research evidence from other
regulatory fields that says that things like change of manager,
high staff turn-over, change of owner, major cost reduction programmes,
all those sorts of things, are likely to make a service more prone
to poor performance, and we want to try and identify those indicators
of incipient poor performance so that we can move in and help
nip things in the bud. There is a lot of work ongoing on our regulatory
processes at the moment to try and build on the very good work
that CSCI did and improve them further.
Q307 Chairman: As opposed to looking
(and this is your statutory responsibility) at what individual
councils do (and it is right and proper that you should do that),
does the CQC have features of what you believe is a quality service
as well?
Baroness Young of Old Scone: We
think a quality service is one that really puts the individual
at its heart, that is designed to meet the needs of that individual,
that has the individual in the driving seat with their carers
and their family and that really delivers the 16 criteria that
we have got in the new registration system, which range across
a whole variety of safety, well being and quality issues, but
the quality of the service is not the only thing: because there
has also got to be quality of access. If you cannot get at a service,
it is not a high quality service because you are not able to get
it. So we believe that access to services is as important as the
quality of the service that you ultimately get, but certainly
having people right in the driving seat of their own services,
for us, is a fundamental part of quality.
Q308 Chairman: Sampson, do you have
view about this?
Mr Low: Yes. Just on the inspection
and star-rating system, while we appreciate the CQC move to monitoring
outcomes and quality rather than processes, the stipulations they
make in minimum standards on staffing ratios and NVQ qualifications
are particularly useful for the workforce and we would not want
to see that dissipated, because we feel that that is a useful
pressure point for trade unions, and others, to intervene to try
and encourage workforce training and safe staffing ratios. So
in some respects we do like the process elements of the current
inspection system.
Q309 Dr Stoate: Baroness Young, we
have already heard this morning that funding is a big issue and
driving costs down to the minimum is bound to have an effect in
some areas, but 16% of adequate or less than adequate is pretty
alarming. How much of it is just down to funding and how much
of it is due to other factors, such as poor commissioning or inadequate
training of staff? What other issues do you think are involved?
Baroness Young of Old Scone: I
suspect that all those issues that you have mentioned play a role,
and others as well. I think, generally speaking, poor quality
services can result from either chaotic and not very well managed
services, of which there are some, it can result from huge pressure
on resource as a result of councils and individuals not having
as much money as a result of the recession and of downward pressure
on fees. One of the big questions for me is, if you have got a
local authority that is commissioning services at a very low fee
level where you have got somebody being looked after for £400
a week, or something like that, is it possible to provide a quality
service at that level? That is a big question for me because,
obviously, that starts to bear down on issues like the amount
of money you can pay staff and the skill mix and level of staff
that you can provide, and these are very fundamental, important
issues in terms of the quality of care. Taking the staffing issue,
if we do not have well-trained staff, well-motivated staff, who
see looking after people as a valued part of society and as a
profession, we will end up with some of the poorest paid, least
motivated staff looking after some of the most challenging and
important folk in our society. So there are big issues about the
downward pressure on costs. I think there is also an issue that
is about inappropriate behaviour that starts to grow up if there
is real pressure on finance, with cost shifting between health
and social care and people inappropriately placing individuals,
inappropriate, for example, domiciliary care, because it is cheaper
when, in fact, some other setting that is more expensive might
be a better setting for that person, and, of course, there will
be pressures on people who self pay, and they have got less money
at the moment. There are some real opportunities, however. If
you look across health and social care, there are some real opportunities
to try and re-engineer the way in which the pathways of care operate,
to try and get more money into the prevention and promotion end
of the care and into the least expensive parts of the care pathway
and try to avoid inappropriate admission into secondary care,
inappropriate re-admissions, inappropriately delayed discharges,
to try and make sure that health and social care are working together
to get the most effective pathway of care for an individual that
is at the most cost effective level. That, in itself, I think,
means that joint commissioning and pooling of budgets is a fundamental
part of the future. I just do not see how, in an economic squeeze,
we are going to be able to provide effective care unless local
authorities and PCTs start to jointly commission and start to
pool budgets to avoid the boundaries between health and social
care locking folk into the wrong part of the pathway.
Q310 Dr Stoate: That is helpful.
We have established—it is well-known—that your members
are amongst the lowest paid of any group of workers in the country.
How much do you think that poor quality of care is down to, effectively,
very low wages, or do you think there are other issues, such as
poor management and poor training?
Mr Low: Often it starts with under
funding and, as I said earlier, some cut-price commissioning,
and that puts pressure on wages and conditions, but also managers'
pay and conditions and the resources for training. Our home care,
domiciliary care staff say that they are often, over the years,
taking on tasks previously done by the district nurse, but they
are having to do this in shorter and shorter time slots—15
or 30-minute time slots—and building a relationship with
the users is often the thing that gets squeezed. It is the sort
of thing which, I know, is hard to quantify, but I am sure members
of the Committee appreciate that having continuity of care—regular
home carers who can also build a relationship, ask about family
relationships and check on other things as well—provides
early warning for public services. Daily contact from a home carer
can alert problems with not being able to pay fuel bills or other
problems, and some of the unofficial side of the social care job,
frankly, gets squeezed and, they say, it is difficult to do dignity
in 15 minutes.
Q311 Dr Stoate: I entirely agree
with you. Baroness Young, you mentioned earlier that the quality
of the service is largely dependent on whether or not you can
actually access it. In other words, if you cannot access the service,
it is difficult to call it a quality service. What do we know
about levels of unmet need? Is there anything that we can say
about people who do not even receive a service at all?
Baroness Young of Old Scone: There
is not really a clear estimate of unmet need, but CSCI, our predecessor
body, in its State of Social Care Report 2007, reporting on the
year 2006-07, reported that shortfalls of care were particularly
high in that group of people with moderate to low care needs but
also that a number of older people who receive no services but
have no informal care to compensate for that, despite having high
care needs, were at risk. There were about 6,000 people in that
category, about a quarter of a million people not ostensibly in
receipt of any care at all, with less intensive needs, but, nevertheless,
real needs. So there is a sort of informal estimate of what the
unmet care is. Our summary really would be that for people who
do get over the threshold and into care, the quality of care is
improving, but the folk who do not get over that threshold are
in a worse situation.
Q312 Dr Stoate: How can you then
say that, effectively, 84%, or whatever it is, of services are
good or better if there is at least a quarter of a million people
who are not receiving anything and should be, by your own standards?
Baroness Young of Old Scone: Which
is why we have now developed a model of care which has got six
parameters to it, one of which is access: because though you can
be, if you get access to services, in receipt of a good service
in terms of our inspection of its quality, nevertheless, if you
are not getting access (and there are too many people who are
not getting access to services), that is not a good quality of
care.
Q313 Dr Stoate: Without a really
good model of unmet need, you cannot possibly know the answer
to that.
Baroness Young of Old Scone: Ronald
may want to comment on this, because he has got more knowledge
of what CSCI in the past did to look at this area. Certainly that
is the most recent information we have got in the State of Social
Care Report 2006-07.
Mr Morton: There is no clear or
systematic estimate of the level of unmet need, and I think something
would need to be done to explore what the levels actually are
out there.
Q314 Dr Stoate: I thought it was
rather basic. Should we not be doing that automatically?
Mr Morton: I think that is a very
good question and a good challenge. I am not sure if it is the
role of the regulator necessarily to look at that particular aspect,
but I think that piece of work does need to be done to find out
how many people are out there whose needs are not being met. Certainly,
in the context of personalisation, there are needs which need
to be met and people do not necessarily have the funds to pay
for them, where they are screened out of eligibility to care.
Q315 Dr Stoate: I would say it is
very much the role of the regulator. It is easy to provide care
to a few people; it is whether there are a lot of people that
ought to be getting it and are not?
Baroness Young of Old Scone: Some
of the modelling that the Government ostensibly has done to establish
the basis of the Green Paper is where that whole question of future
needs, and future funding to meet future needs, needs to be addressed,
I think. It is a much bigger issue than simply regulating the
quality of care. Certainly, we will happily take on board the
question of whether periodically in our State of Social Care report
we should try and make an estimate of the unmet need, though I
have got to make the caveat, I think, that Ronald would agree
with, that the figures in the State of Social Care Report 2006-07
were so much hedged around with ifs and buts because they had
to be assessed. They were guesstimates really.
Dr Stoate: Thank you, Chairman.
Q316 Mr Bone: I apologise to the
witnesses; I have to go after the question. It is not the result
of what you are going to say that is making me leave, though it
might be! Mr Low, you talk in the memorandum about poor quality
partly being about under funding and also about the profit motive
in the private sector. Is that not just union claptrap and your
pre-ideological views on this? What hard evidence is there that
the profit motive in the private sector is driving down care?
Mr Low: The evidence is that it
is cut-price contracting which is driving down quality. The profit
motive is one factor of many—underfunding, I think, being
the principal one—but, put plainly, the profits for shareholders
are funds that are simply not available for care and if services
are further sub-contracted, as they often are, to other providers,
agencies and others, then there is a sort of second and third
tier of profit margin that has to be found. So it is simply really
that this is money that is not available for care.
Q317 Mr Bone: So it is, in fact,
your pre-disposed anti-private sector pro-profit motives, which
I think devalues your comments. Many of the comments you say are
very good, but in the world that I live in there is a family care
home which wants to look after its employees, wants to pay them
a decent wage and wants to look after the people in the home:
the problem is that the wretched council is not increasing the
funding to them. If you have no funding increases, how on earth
do you keep the quality up? Is not that the problem? It is nothing
to do with profit motive. You talk about cut-price contracts.
Is not that the basis of it? If the council is saying, "We
are not going to pay you any more this year", how on earth
can they even maintain the current level of quality?
Mr Low: It is principally the
contracting process which we have the objection to, but our tendency
is to find that voluntary sector providers do have better pay
and conditions than private providers and that there is not quite
the same pressure on pay, terms and conditions and time slots
and other issues. On balance, that is the background, but we do
share the point about under funding, and the Low Pay Commission
share it too. In their last report they express concern about
social care commissioning processes not taking account of the
rate of the minimum wage or their annual uprating. The social
care sector is incredibly diverse. There are small-scale providers
who are struggling, medium-scale businesses, but also large providers,
who are owned by multinational companies and even by private equity
firms, who are making healthy profits.
Baroness Young of Old Scone: Could
I break the habit of a lifetime and support UNISON slightly with
some figures that we have got from our inspection processes about
the comparative quality between council-run services, voluntary-run
services and privately run services? I do not think the gradient
is huge, and this is an art rather than science, but council services
have got the largest proportion of good and excellent ratings
at 87%, voluntary sector services at 86% and 74% for privately
run services. So it is not a huge gradient, but it is a notable
gradient. That is from our inspection work on the quality of services.
Q318 Mr Bone: It is very interesting
that the inspection showed a different quality between whether
they are council, voluntary or privately run, but the serious
point I was just making is that I did not think, in reality, that
it is this profit motive that is the problem; it is the fact that
if you are not funding properly at the beginning how on earth
can you in any sector? In my area there are very few council-run
units. So when you are talking about comparing like that, it would
be interesting if that was because you were in different parts
of the country, because different parts of the country get better
funding. There is a lot more to it than I think just saying that
these nasty people are trying to drive down wages because they
are in the private sector. Thank you, Chairman.
Baroness Young of Old Scone: Chairman,
I know that you are pressing on, but I have now deciphered the
piece of paper that I was given about the issue that we dealt
with previously on unmet need. Just one sentence. Of course, local
authorities should be doing joint strategic needs assessments
for the totality of their population, which is where the issue
of unmet need ought to be quantified, down at individual local
authorities working with their health authorities and other authorities.
Chairman: We had this debate last week.
One of the major issues is, if they cannot provide, are they going
to make these types of assessment, but we may look at that further.
Q319 Dr Taylor: Good morning, Baroness
Young. In your memorandum to us you have expressed surprise that
regulation does not really figure largely in the Green Paper.
What should the Green Paper have said about regulation?
Baroness Young of Old Scone: I
think what we would very much be looking for is an endorsement
in the Green Paper of the kind of model that we believe regulation
focuses on, ie, that regulation has a strong role to play in not
only making sure that services are centred on the individual and
focused on outcomes but also that in the process by which we assess
local authorities, ie, are they doing a good job assessing what
the needs for their population are and are they doing the job,
not only the way that they procure services, but also in the way
that they encourage the market in services to develop and, also,
signpost people towards services even though they are not funding
them—that they have this broader overview role to make sure
that needs are met, however they are met, whether it is by public
funding or by self-payment or by a whole variety of informal care
means. I think that second point is one where the role of the
regulator is overlooked completely. People see us as a bunch of
folk who go out and inspect services; whereas I think our best
contribution is really assessing the performance of local authorities
as commissioners of services and as holding the ring in this sense
of place that local authorities have to make sure that there is
a range of services for everybody, even if they are not being
paid for by the local authority.
|
