Examination of Witnesses (Question Numbers
340-359)
BARONESS YOUNG
OF OLD
SCONE, MR
RONALD MORTON
AND MR
SAMPSON LOW
12 NOVEMBER 2009
Q340 Sandra Gidley: When we have
personalised budgets it is going to be even more disparate.
Baroness Young of Old Scone: I
think there are huge issues about regulation in a personalised
setting, because obviously many of the services that will be provided
in a personalised setting might not be subject to our regulation
at all. So I think there are some big issues that we are working
through at the moment on what the role of the regulator in the
personalised world is going to look like for the future.
Q341 Sandra Gidley: You have powers
to shut down but, in effect, are they not limited by the fact
that if you shut down a home there is often no capacity in the
system to relocate the residents? Is it not the case that it is
not really a power?
Baroness Young of Old Scone: It
is a power, and it is a power that we use on not infrequent occasions.
I think it is a useful power as a backstop to demonstrate that
if people do not take strong action to remedy services, we can
put them out of business, but the reality is that if we came to
the conclusion that a service was so poor and had not responded,
what we do is work with the users of the services and the commissioners
of the services to look at what alternative provision there is
and how the users of that service can be transferred to alternative
care provision, or, if it is the sort of service where there is
a reasonably fast turn-over, how we can move at a reasonable pace
towards the closure of that service. Indeed, I was present at
the closure of a service last week where we had worked with the
local authority over a period of about four or five months to
find alternative placements and for the local authority to get
its head around the question of how were they going to ensure
there was an adequate range of services for their population without
that care home being in existence.
Q342 Sandra Gidley: So for four or
five months people were in a substandard care home. Is that what
you are saying?
Baroness Young of Old Scone: Obviously,
if there were a care home that was so dire that people were hugely
at risk or being served so poorly that we feared for their safety
or their well-being, their health, we would take faster action,
as, indeed, the local authority would, because they would need
to find alternative locations for them. Where a care service is
just consistently poor and we are not seeing any signs of improvements,
we can move at a slightly slower pace, but, obviously, the aim
has got to be to get a planned and careful movement of the individuals
concerned because it is their home and their life that we are
talking about.
Q343 Sandra Gidley: How many care
homes have been closed down in the last year?
Baroness Young of Old Scone: We
will have to provide you with that information.
Q344 Doug Naysmith: Barbara, your
organisation's predecessor, CSCI, made some recommendations about
revising the eligibility criteria for social care. Can you tell
us about them and how they differ from the changes that the Government
is now recommending?
Baroness Young of Old Scone: I
think the model that CSCI was promoting, and which we support,
was very much that the concerns about the existing eligibility
criteria are that they are being used simply as a rationing mechanism
and, in many cases, not only are they being used as a rationing
mechanism, but individuals who have got sufficient funds, who
are likely not to be eligible for local authority funded care
(and, indeed, in many cases, it is only those with the highest
level of need that are funded by local authorities) were screened
out immediately and, as self funders, were not getting access
to the fundamental core of the system that we want to see in place,
which is that everyone, irrespective of their ability to pay,
ought to be getting an assessment of needs with the local authority
where they play a full part in it, ought to be getting advice
and information about services that are available and ought to
be being supported in making choices about the services that are
available, even if they are going to be paying for them out of
their own pocket. That was what CSCI wanted to see as the fundamental
element of the system, and then the criteria for whether you would
get funded or not would come into place at that point, rather
than funding acting as a screen that prevented you from getting
the universal access to assessment and advice and signposting
and support.
Q345 Dr Naysmith: Do you think the
Government's proposals cover what you intended and what CSCI (and
you say you now support it) and what you want, as opposed to merely
what is in the Green Paper now? Do you think there is sufficient
in the Green Paper to cover that?
Baroness Young of Old Scone: I
think the Green Paper, at its most radical, would change that
completely, because, obviously, there are elements there that
are looking at what the universal level of service is that everyone
should have a right to and how that should be funded. So to some
extent that would take the place of the access criteria, but there
is going to be quite a long time between then and now.
Q346 Dr Naysmith: Absolutely. This
is a long-term vision, is it not, really?
Baroness Young of Old Scone: Yes.
Q347 Dr Naysmith: You are running
an organisation which will want to do something about it sooner
than that.
Baroness Young of Old Scone: Absolutely,
and there is a requirement already that local authorities provide
this universal assessment and it is simply not happening. So,
in our work on assessing the quality of local authority commissioning,
we will be banging away at that one, because we think that that
is a fundamental piece of service that everyone should have access
to. We are doing some work at the moment, a review.
Q348 Dr Naysmith: I was going to
ask you about that. You say in your submission that you fear more
rationing of services will not take place because of the economic
circumstances that we are in now and that access will get worse
before it gets better. Can you tell us about the review that you
are undertaking to look at this?
Baroness Young of Old Scone: Looking
at the access criteria and how they have tightened over time,
basically, in 2005-06 of the 52% of councils restricted their
access to that the two highest levels, which is substantial or
critical need. As of 2007-08 that has gone up to 72% of councils
only fund services for those at the two highest levels of need:
substantial and critical. So there has been a tightening of the
accessibility thresholds over the last few years. Last year it
flattened out and did not change too much, and the indications
we are getting from councils now are that they are not going to
change them for 2009-10. We will be able to assess that at the
end of the year, but you cannot help but feel, with the tightening
the economic situation and all the pressures that there are of
demography and costs, that the reality is that the only way local
authorities will be able to cope is by tightening these accessibility
thresholds even further.
Q349 Dr Naysmith: Is this what your
review is going to look at, whether the 72% stay the same, or
get lower or higher?
Baroness Young of Old Scone: Our
review is going to look more widely than that. It is going to
look at the experience of individuals on their first contact with
the council. So, across a whole range of individuals, whether
they are eligible for state funded services or not, and what experience
they have. Did they get proper assessment, were they given support
in assessing needs, in being signposted to the right sorts of
services, in being given help and support and advocacy in choosing
those services. So that is the sort of thing we will be assessing
as part of that study.
Q350 Dr Stoate: Baroness Young, how
much actual personalisation of care is currently taking place?
Baroness Young of Old Scone: I
think the personalisation process is moving, but it is very, very
slowly. More people are actually getting services that are focusing
on their individual needs and where they are at the heart and
in the driving seat. Indeed, there are some great examples. As
I have gone round the country I have seen some people whose lives
have been revolutionised by being able to decide how and when
and where they got their care.
Q351 Dr Stoate: The question is not
that that is not a good thing—it is a good thing—but
what I am saying is how much of it is happening?
Baroness Young of Old Scone: It
is patchy. Some councils are at a very early stage. It varies
between different groups of people. I think it is being addressed
with vigour by groups of people, for example the younger disabled
groups, but for older people and older people with dementia or
anybody who has got a learning disability or communication issues,
we have really got to make sure that, though they may not want
to take direct payments, nevertheless, ways are found of helping
those folk become the driving force in their own care.
Q352 Dr Stoate: I understand that,
but are you collecting any data or evidence on how it is rolling
out: rather than what is happening, how much of it is happening?
Baroness Young of Old Scone: I
do not know the answer to that.
Mr Morton: The information we
collect will explore how many direct payments, for example, are
being given. There has been a growth in trend of direct payments.
The latest figures show there are around about 90,000 people with
direct payments. It is small but growing in the field of services.
People who use services are reporting to us that the quality of
services is better than it was. Indeed, Baroness Young referred
to the better quality of care services, particularly home care
services, people directing their own support.
Q353 Dr Stoate: That is fair enough,
but in your evidence you said that the one-size-fits-all model
is still particularly prevalent amongst the self funders, those
under 65 and those below the eligibility criteria. What can we
do to try and bring things into line with a more personalised
set up?
Baroness Young of Old Scone: There
is a strong requirement being laid on local authorities to move
towards more universal personalisation, but we think that they
need to put in place a whole range of measures to make sure that
that happens successfully: for example, support and advocacy services
to allow people to get support as they work through the process
of putting together an individualised package and making sure
that they are getting the right range of services, because that
is quite taxing for an individual with a disability or with a
health problem.
Q354 Dr Stoate: It is clearly very
taxing, but it all depends on information, and reliable information.
So what are you doing to ensure that people making these decisions,
particularly individuals making these decisions, actually have
access to reliable, good quality information?
Baroness Young of Old Scone: Certainly
we will be providing information about the services that we regulate.
I think this is one of the areas where, quite frankly, the role
of the regulator in a personalised world is very unclear at the
moment, because for many of these services that are informal,
as it were, and more diverse, they will simply not be within our
regulatory remit, and that is an issue that is increasingly going
to be of concern. So I think the work that we are doing to look
at what our role in a personalised setting is needs to happen,
as, indeed, right across the regulatory field, but, of course,
the main avenue we have for tackling this issue is through the
work we do with local authorities as commissioners of services,
because they hold the ring on the personalisation agenda, their
responsibility is to drive that forward, and we can assess, as
part of our assessment of local authorities, how much progress
they are making on personalisation.
Q355 Dr Stoate: But you understand
why we have been be pretty alarmed by something you have said
then, which is that people on personalised arrangements making
their own arrangements, you are not able to have much of a handle
on that. That is very alarming.
Baroness Young of Old Scone: It
depends very much what services they choose to use. If they choose
to use a very informal set of services that are not currently
part of the regulated process, we have no regulatory role in that.
Our only role is through the work that we do in assessing the
quality of commissioning and the local authority's role as the
driving force in taking forward personalisation and, hopefully,
providing support and advocacy services that allow people to develop
personalised services safely, and to help them with some of the
nuts and bolts issues associated, for example, with direct payments,
if they choose to take a direct payment.
Dr Stoate: I am sure we will look at
that in more detail later on. Thank you, Chairman.
Q356 Charlotte Atkins: UNISON and
the Care Quality Commission, obviously, both support personalisation.
Both organisations have raised issues around the sort of personalisation
agenda, saying that service users want to be in control but do
not always want to be an employer and control a budget. Would
you say that the only way for service users to be empowered is
when they actually control the cash? I will ask Mr Low to respond
first to give Baroness Young a little bit of a break and let Mr
Low get a word in edgeways.
Mr Low: Thank you. We do, for
the record, yes, support personalisation, it has many benefits,
but in the current under funded system it does over promise and
under deliver, and often the amounts available through personal
budgets, either those with the local authority personal budgets
or the direct payment system, are too small to make an effective
difference for people. What we would like to see is the in-house
services and local authority commissioned services to be given
the resources to be more flexible, and then people who wanted
personalisation, but maybe did not want to take on some of the
responsibilities and challenges of direct employment through direct
employment of personal assistants, would have some options. We
quite like, also, the option where some authorities are allowing
a hybrid system where some can have a partial direct payment which
they can self-direct but they can also have a partial personal
budget where they can buy in off the local authority menu of commissioned
services or direct provision, so they could keep some day care
centre provision. So that flexibility is good and we would like
more councils to do it. We would also like to draw to the Committee's
attention that our local authority and our disabled members of
UNISON did a joint trip to Sweden to look at personalisation and
found that the Swedish system is that the local authority employ
themselves a pool of personal assistants who can be directed by
users of the service, and that takes care of the registration,
barring and vetting, pay and conditions issues and takes on a
lot of the risk of covering sick leave, maternity leave and other
issues, and we would be very keen for the Committee to investigate
that further, if they have time, and possibly, if interested,
to recommend to the Department of Health that that would be a
suitable area for a further pilot.
Q357 Charlotte Atkins: Does that
also help with the issue of continuity of care? Obviously, one
of the concerns is that if you are dealing with someone with disabilities
or someone who is vulnerable in another way, continuity of support
is quite important in that context.
Mr Low: Yes, a local authority
pool of personal assistants would help with continuity of care
and information sharing, and you would not have a multitude, possibly,
of agencies, different providers, providing care and cover. So
continuity of care is very important, and turnover rates are a
lot higher. I think, CQC and the other regulators will confirm
that turnover rates are a lot higher in the private sector, at
about roughly 24% and about 10% in the statutory sector, and turnover
rates do impact on quality of care too.
Q358 Charlotte Atkins: Mr Low, do
you have any evidence within UNISON that service users are actually
being pushed into direct payments rather than selecting that particular
option themselves?
Mr Low: Not so much pushed into
direct payments, but if they have chosen direct payments they
are often unsupported, as I mentioned earlier. Some good local
authorities will commission advice services for local voluntary
sector groups to help those with direct payments, but it is often
not done with a package of available support to call on for those
with direct payments, but, also, the earlier stage before direct
payments are personal budgets. We do find some pressure to hit
targets for personal budgets, which is where a user of services
can cost and itemise the care they receive from a local authority
and can choose within the local authority menu. Elderly people,
often with only two 15-minute time slots a day in the morning
and the evening, are being encouraged to shift from the local
authority arranged services to a personal budget, which on paper
would mean that they have gone through this assessment process
and have chosen to do that but, actually, they are getting exactly
the same service through the personal budget as before but it
sort of actually hits a target. So there is a pressure particularly
on the personal budget area. Also social workers informally and
anecdotally tell us that there are some quick wins to hit targets
to be made by shifting elderly users of services on to personal
budgets. That is slightly different from direct payments though.
Q359 Charlotte Atkins: Baroness Young,
did you want to come in on the personalisation agenda. Are there
any concerns that the Care Quality Commission has?
Baroness Young of Old Scone: One
of our concerns would be that, because of the practical difficulties
experienced by some people and inadequate services in support
provided to some users by some councils, it gets a bad name. We
do believe that personalisation and putting the individual at
the heart of their care and in control of their care is a good
thing, but it needs these support services to be provided in order
to make sure that people, particularly those with more difficulty
than others, are coping with that (particularly elderly people
and people with dementia, people with learning disabilities) and
are able to deal with it and do not feel that they are being pressurised
into it without the right sort of support for them to actually
make sensible decisions and be safeguarded in the process, and
that is part of the work that we will be doing with the assessment
of local authorities. Have they got these services in place? Are
they taking the right steps to balance the opportunity, the choice
that that gives to people who live in their patch versus the risks
that it poses to them and, also, how are they going about making
sure that the right range of services does exist, not just the
direct care services, but the support services to allow people
to choose the sorts of employment services that Sampson talked
about that allow people to not be overburdened by the fact that
they are employers.
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