Examination of Witnesses (Question Numbers
440-459)
MS SHEILA
SCOTT OBE, MR
MARTIN GREEN
AND MR
COLIN ANGEL
19 NOVEMBER 2009
Q440 Chairman: Certainly we think
there is under funding of demand. We are not sure about costs—but
from what Colin has just said, it is quite clear there could be
pressure on costs—but there is a view that we are actually
panicking unnecessarily in terms of the future of social care.
What do you think about that view? It is not one that I hold but
it is one that has been put to us.
Mr Green: I think, in terms of
the agenda around things like personalisation, the increase in
expectations is quite significant. If you look at delivering bespoke
personalised care services, they are very much more expensive
than delivering baseline care services in a one-size-fits-all
scenario. I do not believe that we are underestimating the issues
for the future. I think there are issues about the numbers of
people who will be coming through and needing care, but there
are also issues about raising expectations but not having a clear
narrative about how you are going to fund that rise in expectations,
improvement in quality and more personalised care.
Ms Scott: I think the service
can be supplied—I have no doubt about that—as long
as we manage the workforce. The issue for us certainly is around
the funding of those people unable to pay for themselves, and
that is why I believe that this needs to be planned now. It is
no good us letting it run another 20 years: some very difficult
decisions have to be made about how that funding is going to happen
and because of the increasing numbers that are going to need the
service I think that the decisions need to be made right now.
Chairman: We are probably going to have
a look in some detail at what those decisions are, but let me
start with Doug.
Q441 Dr Naysmith: Sheila, you mentioned
a moment or two ago about demand varying across the country. Do
the costs of supplying the services you provide vary significantly
across the country?
Ms Scott: No, surprisingly, I
do not think they do. There are some variations, of course. For
our members primarily in the private sector the biggest cost is
the cost of the building and the land, and that can vary dramatically—so
in London clearly that has an impact—but the regular costs,
apart from London, are fairly static. The cost of the service
varies.
Q442 Dr Naysmith: Why does it vary
if the costs are much the same?
Ms Scott: Part of the reason it
varies is that there are some areas of the country where almost
all of the service is purchased by local authorities, and they
may use their dominant position to force the costs down—so
that is not a negotiated position by many providers, that is a
fee level that is set by a local authority—whereas, particularly
in the south, the percentage of people paying for their own care
is remarkably high, and I would say that they are paying the real
cost of care rather than that bulk purchasing price.
Q443 Dr Naysmith: Is there an element
of cross-subsidy going on, do you think—people who are paying
for their own care are paying more than they need to—to
subsidise local authorities?
Ms Scott: I would absolutely say
there is not.
Q444 Dr Naysmith: There is not.
Ms Scott: You would not be surprised
to hear, I would say that there is not, but it is true that where
there are people funded by local government and people funding
themselves there is bound to be some of that, but we always say
to our members: you must calculate what the real cost of care
is—that is the cost you declare and that is the cost that
you charge—and then your negotiations with local government
are a separate matter.
Q445 Dr Naysmith: You said there
is not much variation across the country. Do you agree with that,
Martin and Colin? Is that your experience?
Mr Green: On cross-subsidy, I
think I would divert slightly from where Sheila is, because I
do think there is a bit of cross-subsidy, though, of course, it
can be identified as for example people having larger rooms so
they pay more for more that service, et cetera, but if you have
a situation where you are not getting the true cost of care, and
it costs a certain amount to deliver on the level of care and
the quality of care, the only way you can make it up is through
some other source. So there is definitely an issue about how local
authorities sometimes pay below the market rate.
Mr Angel: I would not say that
the costs for us are similar. In the homecare sector the price
of an hour of homecare can vary by about 25% between the regions,
with the most expensive in London and the South East at between
£13.50 and £14.00 an hour and, say, the East Midlands
and the North West at £10.50 to £11.00. That is largely
made up, because the homecare service does not have property to
be concerned about, by weekly wage levels. Around the country
you could have a care worker in the North East earning, say, £6.20
an hour, while one in London may earn about £7.00.
Q446 Dr Naysmith: What effect do
you think this variation will have on the future funding of social
care proposals? You are going to have to have something that reflects
that, are you not?
Mr Green: Sheila mentioned the
issue about some areas being heavily reliant on local authority
funding. If, for example, I am the Chief Executive of a large
corporate group and I have significant under funding in one area,
I might decide that I am not going to develop new and innovative
services in that area because they are not cost-effective to deliver.
What it might do in the long-term is change the availability of
some services. So this notion of having a service that meets individual
need might be okay in some areas, but it might be skewing the
market in others because of the funding position.
Ms Scott: Before 1992 we had London
weighting. At that time I was a home owner in London. It was significantly
more expensive and that was reflected, and I think that it may
have to be taken into account—not just London, but maybe
some of the Home Counties as well. Of course, self-funders allow
you to do things like pay higher wage bills as well, but, I think,
if it is to be a universal care balance—
Q447 Dr Naysmith: Let us have a look
at another aspect. How reliant is the industry on migrant labour?
There seems to be quite a concern that there is a lot of migrant
labour. Why is this? First of all, do you think that it is really
happening (and most people think it is) and why is it happening?
Mr Angel: Yes, we do. UKHCA gave
evidence to the House of Lords two years ago and we found around
20% of the homecare workforce were migrant workers. This has been
further confirmed by COMPAS; Oxford University found broadly similar
findings. That figure increases significantly in London, where
estimates are between 40% (which is ours) and 60% from COMPAS.
It is clear that migrant workers are a vital part of our workforce
and we would not function without those people's work.
Q448 Dr Naysmith: Why is that?
Mr Angel: If you asked employers,
I think they would say that they have difficulty both in finding
people who are willing to work for the wages that employers can
pay and finding those who have the correct skills and aptitudes
from the local labour market—British nationals.
Q449 Dr Naysmith: You will be aware
of the recent Oxfam report that suggested that one in five care
workers are paid below the minimum wage and often have to work
long hours.
Ms Scott: I have asked to see
the evidence, and I have not seen the evidence yet. Our members,
like every other employer, are subject to visits by all sorts
of people checking on those sorts of things, and prosecutions
happen if that is the case. I certainly have not heard of any
of our members. I have heard of our members having inspections
on all manner of things.
Q450 Dr Naysmith: Are you suggesting
it might happen outside of your membership then?
Ms Scott: No. I cannot say for
sure, but I was really surprised by Oxfam's position. They have
never come back to us about the evidence that they have. I think
the issue of migrant workers is really critical for us. It is
COMPAS who we have worked with, as Colin has. Their report said
that up to 60% of all social care staff in London are migrant
workers. That is enormously high—much higher than I thought.
Of course, we are seeing a shift now because of the financial
position. There has been a slight shift and we have been employing
more local staff than before, but it is a huge challenge for us
because we need more and more staff. The homecare sector, residential
sector, the needs of the people we care for are higher and higher,
so we need more staff, and it is difficult, particularly in good
economic times, to recruit when for so many employers the wages
are not the best. However, we have other reasons that people might
seek employment with us. There is the flexibility of hours, we
are able to offer part-time work, we need to look at other added
value that we can offer around training so people that might be
unskilled finish up as qualified people, but it is never easy
during economic good times to recruit staff to social care because
of the current situation around wages.
Q451 Dr Naysmith: You mentioned earlier
about low prices, suggesting that in some places you were squeezed
by local authorities, and so on?
Ms Scott: Yes.
Q452 Dr Naysmith: Are homes closing
because of these low prices or not being able to get an adequate
return?
Ms Scott: We have continually
over the last maybe ten years seen a shift from the small providers
that I represent (and that is small and medium sized; I do not
just represent small providers) towards much larger organisations.
I truly believe that a wide diversity of provision and choice
is the best and, sadly, that the smaller unit, which suits some
people, is disappearing, and so, although I think the number of
beds is not going down as much as one might have thought, the
places where the care is being provided are certainly changing.
Q453 Dr Naysmith: Martin, you have
not had a chance to tell us what you think about migrant labour.
Mr Green: Linking to that point,
of course, I think it is really important that we do maintain
diversity because of the personalisation agenda, and the more
we have to deliver personalised care services the more we need
diversity in the sector so that it can respond to individual need.
I really reiterate all the points that my colleagues have said
about the issues around the importance of migrant workers and
some of the reasons why migrant workers are attracted and available
to our sector. The Work Force Strategy that the Department of
Health has looks at where we position this as a profession, rather
than just as a job, but, partly, it is not backed by any appropriate
response in terms of how we resource that. For example, if we
did go to a proper, independent cost-of-care exercise we could
then look at what it would cost to deliver that highly professional
work force. I am not using the term "profession" in
terms of saying people are not professional because they do incredibly
complex and difficult jobs, but I do think we need to see the
work force shift from being a paid-by-the-week, by-the-hour, by-the-session
work force and delivering a career structure within it.
Q454 Dr Naysmith: Do you see any
problems in the future for being so heavily reliant on migrant
labour?
Mr Green: Yes, I think we are
going to have problems in the future, particularly because of
the new points-based system, which is going to stop people who
have the requisite skills coming from non-EU countries. Part of
the issue is about how we select our staff, and they need to be
selected not only on the basis of their skills but also they need
to be selected on the basis of things like attitude and core value.
In terms of where the position around the EU staff is placed,
it might be that there is this flood of people who could come
in and do the jobs but the question is: are they the right people
and are they skilled enough and do they have the right attitude
to deliver the outcomes we require; and that is, for me, a debate
point.
Q455 Dr Naysmith: Finally, quickly,
for all three of you: do you think there is any future in technological
advances changing the need for reliance on migrant labour and
making the whole system a bit more efficient, because you are
very heavily reliant on labour wherever it comes from?
Mr Green: Yes, but I think we
should remind ourselves that we are in a people business. People's
quality of care can be added to and supported by things like technical
support but, at the end of the day, I have never yet heard a person
say that their quality of care is defined by whether or not the
computer at the side of the room beeps: it is about the interaction
they have with our colleagues and our staff. So I think we need
to remind ourselves that quality in this sector is defined by
personal care, and that is interactive care.
Q456 Dr Naysmith: You are not writing
off technology.
Mr Green: No, no, I think it is
very useful, and it should be, hopefully, the thing that allows
us to have more staff time facing the service user so that the
gains that can be made would, hopefully, deliver more quality
interaction between staff and service user.
Mr Angel: In the homecare sector
we do not anticipate that technology is going to make an enormous
reduction in the amount of services used. For example, there will
be some reduction in overnight care and perhaps a reduction in
the number of very short pop-in type visits to just check on people's
wellbeing. However, I think we would probably say that home care
can be the response to telecare alerts where actually you need
human intervention after the data has been generated.
Ms Scott: I think it has made
a real difference already and I think that will continue. If I
look now at the sort of people that are being cared for in residential
care and in home care, their needs are much more complex and much
higher than they were because technology is able to deal with
some of the people that 20 years ago might even have been in a
care home. I think technology has made a difference. I recently
went and looked at some lifestyle homes where people will be able
to live for a very long period of time before they might need
to think about the next phase of their life. I think we will continue
to see significant developments but, as Martin said, I am afraid
it is never going to be able to replace (unless, I guess, it is
some grand robot) that personal care that is so important to people.
Q457 Dr Taylor: Can we turn to the
funding options. Briefly could each of you go through the three
options and say which you prefer and your views of them?
Mr Green: What I would say is
I did a lot of consultation exercises with users and they came
up with a fourth option, which was about whether or not it should
be funded by taxation; though, interestingly, it was not an option
where they said we want people to pay more tax; it was an option
where they wanted you to go back and reprioritise the budget and
put social care higher up the agenda. So, I think, as I went out
and about and I talked to people about the options in the Green
Paper what people were saying was, I guess, people are confused
as to why they think they should be paying for something that
they consider they have paid for. That said, in terms of the options,
I think my organisation's position is the co-payment option, of
the three that are on the table, is probably the most sensible,
as long as it gets real clarity as to how much the individual
is expected to pay.
Ms Scott: We have worked with
all sorts of organisations over the years. We have worked with
insurance companies and others. We have seen so many schemes launched
and fail; so I think the first thing that we think is that, whatever
system is introduced, it will need to be compulsory. I am afraid
it will need to be compulsory because, particularly for older
people, social care is something that they never think they are
going to need and we meet so many people who never expected to
be in this position. We are with Martin. The co-payment system
seems to us to be the fairest.
Mr Angel: At UK Homecare, representing
providers, we did say that actually it was not really our job
to have an opinion on the balance between the individual and the
state, which was a good cop out!
Q458 Dr Taylor: You did go on in
your paper to give us a lot of detail.
Mr Angel: We did. I think my summary
would be that, like Martin, we are not keen on the three models
proposed in the paper. I would certainly agree with Sheila that
whatever method is chosen there needs to be an element of compulsion.
Certainly, when we see eligibility criteria for homecare increasing,
we do not see a similar increase in private purchase by those
people who are no longer qualifying for state-assisted care and,
indeed, I guess, our thinking just at the moment was that a tax-funded
option or a more generous partnership model would be the route
we go down.
Q459 Dr Taylor: What are your views
about the recently announced policy about free personal care at
home to individuals with high needs? What are your comments about
that? No doubt you have seen the front page of The Times
and the talk about Exocet missiles. Where do you come in on that
idea?
Ms Scott: I thought we were in
the middle of a public consultation about the whole issue, and
so it was quite a shock, in the first instance, to have the announcement
made. It is easy to understand, being fair, but one wonders where
it leaves the other parts of the service. This is a large amount
of money that has been dedicated, and we truly believed that we
were having this major public consultation which would make these
sorts of decisions. So this large amount money that is being allocated
to one part of the service makes us think that other parts of
the service may not be so fortunate.
Mr Green: There is another issue,
which is how are you going to define this notion of people in
critical need? If you look at local authorities, for example,
the majority of them are giving services to people in critical
need. If you identify that as being the criteria that accesses
this new approach to the funding of care, you would, in effect,
have the majority of people who are currently paying something
towards their social care being freely funded. I do not know whether
there has been any analysis done of people who, for example, are
paying for that through their own resources who might want to
come forward—interestingly, there might be some people who
are currently residing in residential care who would think to
themselves, "If I can get that funded free in the community,
I might buy a flat and go back into the community"—and
whether or not that has been taken account of. In terms of the
overall headline, which was about free personal care, I think
we would be supportive of that, but I do think it seems a bit
strange to have announced this in the middle of the consultation
and, also, to have announced it at a time when there seems to
be no coherent back story about how this is going to be funded,
what the criteria are going to be; how it interfaces with other
aspects of the health and social care system; whether or not,
for example, the money that is allocated, as Sheila said, will
be enough and, if it is not enough, what is going to be the price
that is going to be paid in other parts of the health and social
care budget—because it does not seem to be if you go over
and above the amount that has been headlined as the amount extra—but
if the cost is significantly more, it is the question of where
that money comes from. So I think my view is it needs a lot of
proper analysis before we get to a view on it.
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