Examination of Witnesses (Question Numbers
420-435)
MS LIN
HINNIGAN, MR
ALLAN BOWMAN
AND MS
ANDREA ROWE
12 NOVEMBER 2009
Q420 Dr Naysmith: Andrea, Skills
for Care is responsible for the post-qualification training to
a certain extent. What do you think of what has just been said?
Ms Rowe: It is shared. I just
wanted to say one of the things that employers say about the social
work degree is it is a case of one government policy being counterproductive
to another government policy, so the policy to increase the numbers
in universities to get a degree in social work is very attractive
but I know employers say the social workers going in lack basic
key skills.
Q421 Dr Naysmith: Are you talking
about previous to this change?
Ms Rowe: It has not changed. The
same evidence has come to the Social Work Task Force as previously
that there are people going into work who do not know how to write
reports and have those basic skills. Social care is always at
the bottom end, just as in the whole workforce we always get the
bottom strata of applicants because it is the lowest paid. If
you have got a low status workforce then you get the poorest applicants.
Sometimes that works to your advantage, as with the NEETs, because
they understand the people they are working with, but not always.
Employers really struggle. It is partly their fault because they
have not worked with the universities strongly enough. Our contribution
to the post-Task Force implementation would be to strengthen those
partnerships between the employers and the providers.
Q422 Dr Naysmith: Is personalisation
making any big difference to this?
Ms Rowe: As I say, I do not think
that is necessarily the biggest issue. I do not think employers
are saying the training is not fit for purpose in that sense.
That is not what we are getting back.
Q423 Dr Naysmith: There has also
been quite a lot of concentration recently because of the Baby
Peter case on children's services. Are we moving towards separate
training for children and adult social workers?
Ms Rowe: It seems to have shifted
away from that again. We always go into the reform of social work
thinking it is going to split and it does not. The strongest advocates
for keeping it joined up, of course, are Welsh, Scottish and Northern
Ireland colleagues because they are in Europe and see social work
as a European profession which is integrated.
Q424 Dr Naysmith: Why are they any
more in Europe than we are?
Ms Rowe: They just are. They get
more European funding than we do.
Q425 Chairman: I am watching what
is happening in the Chamber and we are likely to have a vote soon.
I have got a series of questions for Alan and what I am going
to do is get through them as quickly as I can. Your memorandum
says that research into "micromarket development" has
shown "problems due to growing regulatory, legislative and
other barriers and that the number of micro-providers is actually
falling". You say local authorities must address this "as
shapers of local care and support markets". Why is such a
role needed, and is there any evidence that councils are up to
the job?
Mr Bowman: The Audit Commission
has been critical to some extent of councils' capacity in this
area. To put a very straightforward analogy: the local authority
is the elected body responsible for the community that elected
it and, whether it is a social care market or other forms of employment,
part of its strategy has to be about saying, "What does our
community need? How do we put in place all of the things that
will make our community a good community with good quality of
life?" To bring that back to social care, the local authority,
with its partners in primary care trusts, in commissioning care
services has got to think a bit more economically about "If
we are going to invest, let's not just get the cheapest bed per
week. If we need a certain number of beds" and you assume
they have got some intelligence about the number of beds and projections,
"what do we need to put in there to ensure there are sufficient
numbers of beds, they are of high quality and have got properly
trained staff". It invites a changed approach to commissioning
services. You always use the old Marks & Spencer analogy.
If they decide that you are going to be a Marks & Spencer
provider they make sure you are a very good provider by investing
in you, but they also set quality standards on what can be sold
as a Marks & Spencer product. I do not want care reduced to
Marks & Spencer goods, but some of the ways that economic
markets are developed and shaped are what local authorities in
some cases are very good at already through local strategic partnerships
and other things. It is about helping local authorities to take
not just that role in relation to the care market but, if you
think about all the other things that we want, it is about free
transport for older people enabling them to get about and have
a quality of life, it is about free swims because you do not have
a local authority without public swimming baths. The issue is
we want to have a healthy community and the local authority, as
I do not need to tell you historically, was the big difference
between poor health and ill-health at the turn of the last century.
It is about looking at these things in the round and saying, "What
are the things we need in our community that will give our citizens
a good quality of life?" and then as they move with increasing
needs, "How can we make sure in our community they will have
the kinds of things that will give them that?" A lot of local
authorities have demonstrated they are capable of doing that very
well but what they need to do is translate that into the social
care market.
Q426 Chairman: In relation to the
evaluation of Individual Budgets that has taken place, 13 pilots,
you say it "suggests that individual budgets have `the potential'
to be more cost effective" but "Reliable evidence on
the long-term social care cost implications is not yet available".
Are we putting the cart before the horse by rushing into personalisation
without even knowing whether it is cost-effective? Is it SCIE's
job to look at this?
Mr Bowman: Can I just say that
we need to develop an economic model. There is no point in me
saying this is the best way to provide care if I cannot tell you
what it costs. You cannot make an informed choice as a user or
a commissioner. SCIE is developing that economic role and it is
one that we need to have, a bit like the National Institute for
Clinical Excellence in relation to treatments and drugs. The issue
on Individual Budgets is I think it has been wise to pilot them
because the international evidence, while wholly positive, is
not overwhelmingly positive in the sense you would say that we
have got cast iron proof that this works. What we are seeing from
the pilots are issues around younger people certainly, better
outcomes, and potentially more cost-effective. For me, it seems
we need to take the lessons from the pilot very carefully. The
issue is once you begin to move from pilot to large-scale, how
do you make sure there are no unintended consequences that would
result in this system coming under pressure or simply not delivering.
There we have to look at the views of older people in the pilots
who, understandably, have often said, "I'd rather not have
the hassle of managing a personal budget, I'd like somebody to
manage it for me". How do you introduce this concept in a
way that improves outcomes? That brings us back to what investments
the local authorities make. Are they going to have the support
mechanisms there for people who have Individual Budgets? Are they
going to have the provision there for people to spend these budgets?
These are more critical points. I suspect from the limited evidence
available that the biggest saver from Individual Budgets will
be the National Health Service and that opens up the question
of how do you then manage to transfer resources from health to
local authority or health to social care.
Q427 Chairman: The Green Paper advocates
"an independent body to provide advice on what works best
in care and support" and to ensure that "services are
as cost-effective as possible and that they are based on evidence
... The independent body could be a new organisation, or we could
give the remit to an existing organisation". Does that have
any implications for SCIE?
Mr Bowman: It does, and they actually
mention SCIE as the kind of organisation they might use. The remit
of this independent body fits very well with what we already do.
We have the advantage of being a charity, so we are independent.
As I said earlier, we do cover the UK, the whole spectrum of children,
families and adults. We have a track record of producing reliable
guidance research and knowledge. We are developing the economic
model that I think has to go hand-in-hand with that because there
is no point in just offering the advice on what is best if it
is not what is best attached to "What can you afford and
what are the likely outcomes". I think we have established
the kinds of partnerships and relationships across the sector,
including with the National Institute, for instance, on the joint
guidance on dementia which is applied across the whole health
and social care sector. We have done other things with them on
child health, foster care and so on. Our capacity to work collaboratively
with others like NICE and, indeed, with our colleagues in the
care sector would suggest that we are well-placed to be that independent
body, and as an independent body to give advice that is not always
that which would be sought but at least to be able to give that
advice on the basis of rigorous research, rigorous road testing
of what we do and rigorous evidence that this works or this does
not work.
Q428 Chairman: I am going to tempt
you to give some advice now you have said that. Alongside this
emphasis on evidence-based services, we hear that people receiving
direct payments will be able to spend their care budgets on all
sorts of things that have not been rigorously evaluated as a cost-effective
use of taxpayers' money—from alternative medicine to football
season tickets. Is this a contradiction in Government policy?
Mr Bowman: No, because Government
policy is now focused very much on outcomes and if the outcome
you want is someone to have a decent quality of life, to remain
independent, to support themselves, then I think it invites a
lot more imaginative spending of money than probably people like
me would come up with immediately. We get the example quoted of
season tickets and it is always the extreme. Of course, when you
look into the particular examples that sound extreme and bizarre
there is generally a very good, logical and sound reason for that
and quite often a saving in terms of other services that might
have been used. The key issue is does the individual believe that
they are better because of this, do they believe they have got
a better quality of life and, in a sense, is it cost-effective.
You do not go away from, "Is this a good use of money in
terms of what we are trying to achieve by outcome?" Of course,
your choice of football team may determine whether it is a good
use of money!
Q429 Chairman: I would agree with
you.
Mr Bowman: We have a range of
examples at a smaller level, which I will not go into because
of time, but little things can make a tremendous difference to
some people's functioning at very little cost.
Q430 Dr Taylor: Coming to the funding
options, Mr Bowman you have given us some details about the future
funding arrangements and I am giving you the challenge to summarise
your evidence-based views on the advantages and disadvantages
of each option in about one minute each.
Mr Bowman: I am going to do the
classic here and say my organisation's and my concern is not which
is the best form of funding, it is what is the best form of care
to provide with whichever form of funding is available, and that
is our role and remit. I would be like any other human being.
I might have a view about what I would like for myself in terms
of cost of care, but we have got to be realistic and say the focus
for us would be the development of a national care service and
something that ensures you get the same deal whether you live
in Northumberland, London or Cornwall, and how do we then help
achieve that.
Q431 Dr Taylor: What about the differences
with older and working age adults?
Mr Bowman: I think we are going
to have to be very careful with that in the Green Paper. The first
thing that was welcome was that it tried to address older people
and those of working age, but there are clearly very significant
differences. The big funding issue is clearly for older people.
When we begin to look at people of working age we do need to look
at the whole system in terms of what incentives are there to work
and what disincentives, which is a separate debate. There is a
whole range of issues that need to be addressed specifically in
relation to people of working age. In some ways, once you have
made your decision about the funding model for older people that
may be more straightforward. If we try to have one simple unified
system for both we will be in trouble.
Q432 Dr Taylor: Do any of the three
options give you a better chance of this unified system?
Mr Bowman: The insurance model
provides certainty, which is welcome for all, but it would need
to be a compulsory insurance model because a voluntary one would
be very unlikely to work effectively for either older or people
of working age. To be frank, the issue of how you fund the care
of adults draws on many other sources of funding for older people.
You may end up potentially with a very good system predicated
around adults but the risk would be do we get to another watershed
of 65 and you enter a different system. Whatever we do, we need
to make sure a transition from whatever system we develop for
adults does not result in you being worse off as an older person
simply because you are older. There are all these traps that have
to be addressed in terms of bringing forward a White Paper.
Q433 Dr Naysmith: Mr Bowman, in your
memorandum you talk home care solutions offering much more scope
for co-production between relatives, neighbours and formal services.
You also talk about the possibility of a no-claims bonus as an
incentive to provide more informal care. I am interested in that
word "co-production" because it is an unusual word to
use in this context. We will leave that for the moment. What you
are talking about there is dumping responsibility onto unpaid
informal carers, are you not?
Mr Bowman: No, I am not. This
is where I think the evidence shows that unpaid informal carers
are very keen to do their bit by their family but they do not
want to be abandoned. They are likely to do more when the necessary
services are coming in from home care, and that can be something
like meals on wheels. All of the evidence that we are getting,
and some of it is international evidence, is that people are willing
to do their bit but they want the state to do their bit as well.
Co-production has got many meanings, it is a dangerous term, but
essentially it is about working with people to make sure they
get the service they want, but into that equation you have to
bring the carers and the family and the informal carers. I do
not like to use personal experience too much but a member of my
family in Scotland is in exactly that situation and I can see
the benefit that has come from the provision of good personal
care by a local authority against the range of things other people
are happy to do around her, which I think would have been jeopardised
had that care not come from the local authority. It is about that
balance. We must guard against anything that abandons informal
carers or relatives.
Q434 Dr Naysmith: A few years ago
in my constituency there was a chiropody service run out of the
local health centre which said to elderly people who needed their
toenails clipped, "Have you asked your neighbour first? Go
and ask your neighbour and if your neighbour will not do it, come
back and we will see what we can do". Is there not a danger
of moving into this kind of area?
Mr Bowman: That is a danger, but
I come back to what I was saying earlier: if I were the local
authority and the primary care trust I might invest in Age Concern's
chiropody and toenail cutting service and make it universally
available for people who want to access it. That would probably
be more cost-effective than having to use the NHS chiropody services,
for instance.
Q435 Dr Naysmith: The very last question:
is this not a way of overburdening already overburdened carers,
asking them to do more?
Mr Bowman: That would be the unintended
consequence. I come back to where I started a wee bit earlier.
Most carers want to continue to provide care, but they do not
want to be left to do the whole job. You have to give carers quite
a big say in helping people work out the best form of care packages
and things they want. There are simple things like timing. You
have got to take account of where the carer is and what they can
do. This is where I come back to what is a very good job for a
social worker with adults, to facilitate and organise that and
help people achieve a package that satisfies them all and does
not overburden anybody.
Chairman: A simple thing like timing
has worked wonderfully well for us. We have now got a page that
the vote is imminent. Could I thank all three of you very much
indeed for coming along and helping us with this inquiry. Thank
you.
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