Examination of Witnesses (Question Numbers
460-479)
MS SHEILA
SCOTT OBE, MR
MARTIN GREEN
AND MR
COLIN ANGEL
19 NOVEMBER 2009
Q460 Dr Taylor: Can I ask Colin if
he agrees with the chap who fired the Exocet missile yesterday,
who said that in Scotland the costs of care at home have gone
up by 74%; that if you go over 30 hours of care per week at home
it is much more expensive at home than in residential care? Do
those sorts of figures add up?
Mr Angel: On the intensity of
the service, yes. If services become very complex, often you need
two care workers present at the same time and that, inevitably,
doubles the cost of a standard hour of home care.
Q461 Dr Taylor: I am sorry to interrupt,
but if you need two care workers at home all the time, seven days
a week, how many staff—
Mr Angel: Not necessarily always
at home at the same time, but when care is taking place, two people
there.
Q462 Dr Taylor: How many people would
you need to keep a rota with two available when needed throughout
the week?
Mr Angel: That is too variable
for me to be able to answer, I am afraid.
Q463 Dr Taylor: But you would agree
that the costs of care at home over that sort of length of time
are absolutely exorbitant?
Mr Angel: No, I would not agree
with that.
Q464 Dr Taylor: I should not have
put it in that way. It is more expensive than residential care
for somebody with those care needs?
Mr Angel: That would depend very
much on the prices in their local area.
Q465 Dr Taylor: There is a proposal
to merge the Attendance Allowance budget into the social care
funding stream. What do you think of that?
Mr Green: When I was involved
in the consultations with a lot of older people and carers, this
was a very contentious issue with them, and it was interesting.
One lady said to me, if you look at the personalisation agenda,
which is about putting power back in the hands of the service
user, it was her view that probably the Attendance Allowance was
the only particular bit of the benefit system that was doing that.
She also raised a question, which was quite interesting, about
the issue of the equalities agenda in relation to this. For example,
we were having our conversation just after it had been announced
that Disability Living Allowance was not going to be taken account
of in this process, and she raised the question: why were people
having this different view? She also raised the question as to
why, for example, people who got child benefit were not being
seen as that being taken into the whole of the education system.
So it was about a conflict, in a sense, with Government policy
to take it into the mainframe budget, but also very much a feeling
that it was an equalities issue as well as an issue about care.
Ms Scott: I am absolutely opposed
to any changes to Attendance Allowance. If it goes into the government
pot it disappears, from my point of view. It comes out again,
I am sure, but Attendance Allowance is targeted at individuals
and it is not means-tested and, for the majority of the work that
we do, for self-funders, it is the one piece of help that they
get towards the cost of their care, and so to take it away, I
think, would be very unfair, because it certainly would not come
back to them.
Q466 Dr Taylor: That is very clear.
It would just go into the local authority's pot and that is the
last that is seen of it.
Ms Scott: Yes.
Mr Angel: Yes, I would agree that
the danger of it going into the local authority pot is very high.
However, UKHCA—as we do not represent the views of people
who use services—are very clearly here saying we do not
have a formal view on this.
Q467 Charlotte Atkins: I would like
to ask all of you, how should the different situations of older
and working age adults be addressed by a new funding system? Obviously
they have different needs. Do you think that the Green Paper properly
addresses the different situations for working age and older adults?
Ms Scott: I think the Green Paper
is focused on older people, but younger adults are mentioned.
The needs of younger adults are quite different and, so I do not
forget, I would like to say that younger adults with long-term
conditions, when they get to pension age, it goes—the support
that they get of any type, including funding, goes—and they
become a retired person and they frequently have to move into
another environment because the place where they have lived is
much more expensive. It has always seemed to me to be unfair that
those people, often who lack mental capacity, their lives change
so dramatically. I think we said in our evidence very briefly
that social care for younger adults and social care for older
people is so different. With younger adults, particularly with
learning disabilities, one is trying to move them from dependency
to independent living; whereas for older people their life is
usually going in the opposite direction as they are likely to
become more dependent. So I think it is difficult to combine the
two in the Green Paper. I certainly think that at the moment younger
adults are facing massive changes through local government about
where they live, how they live, money that is available and it
is more problematic for us. Our members may have supported them
from very heavy dependency, but when they go out into independent
living often the support and care that they need is not there
and so their lives are not as good as they should be. I think
there is probably room for a broader look at younger adults after
this Green Paper is finished. I know that there are tsars and
director generals, but I think that we need to have a proper look.
In the same way as we are looking at older people really with
the Green Paper, I think that perhaps we need to look at young
adults too to see what it is we aspire to, what we can afford
and what the National Care Service could offer to them.
Mr Green: My view about that as
well is that, if we are moving towards personalisation and if
we are doing everything in an equality and human rights framework,
what we should be doing is trying to define what the needs-based
response is, so that we are not categorising people in terms of
age groups but we are categorising people in terms of their need
and how we respond to it. It is a moot point but, for example,
an adult with a learning disability might have a significantly
higher level of resource for their care compared to an older person
with severe dementia but the need may be the same in terms of
the amount of support required, and it will be very interesting
to see how, when we get to an equalities framework, that is justifiable
across the system. I think Sheila's point, though, was very well
made, that a lot of the changes that are happening to adult services
are, in a way, catapulting some people into situations where they
are not very well supported. Part of the problem is that a lot
of the policy around particularly learning disabilities is predicated
on people with lower level needs and not on people who have multiple
needs. So a one-size-fits-all approach is being developed in the
Department of Health which is very much saying no more residential
care, and that is absolutely the right thing for some people,
but it might not necessarily be the right thing for others. People
need to know that if their policy direction is developed on the
basis of resource allocation needs—we all need to know that—but
to have a debate and a discussion about personalisation, about
choice, autonomy and independence on the one hand and then for
people in the department to sit back and say, "You cannot
have this, this or this service", seems to me totally incompatible.
So I just wish, on some of these issues, people would get their
language in line with their policy.
Q468 Charlotte Atkins: Colin, do
you want to come in?
Mr Angel: In the homecare sector
by far our largest service user group is older people, so that
balance does not seem too incorrect from our take on the Green
Paper. I would certainly agree that younger disabled people generally
get far greater funding, and that balance needs to be addressed
in the debate following the Green Paper. I guess there is also
the fact that younger disabled people generally have a greater
appetite for directly employed personal assistants rather than
services arranged by a homecare agency.
Charlotte Atkins: Thank you.
Q469 Mr Syms: Martin and Sheila,
why do you believe that hotel costs should not be part of a social
care package?
Ms Scott: I think I was responding
to that suggestion within the Green Paper. That was the suggestion
within the Green Paper that the funding of residential care and
nursing home care should be managed in the future. It is something
that I and the National Care Association have thought about in
the past, because this is an ongoing discussion/debate. I have
always thought that people want to make a contribution. I do not
think that they do not want to pay at all. I have always believed
that they wanted to make a contribution. I think that they would
think—this is just my opinion—their living costs they
would be responsible for wherever they are. I do not think they
expect the state to pay for everything. I think they expect the
state to pay for what they see as part of the Health Service responsibility.
Mr Green: One of the reasons I
think it is a good idea is it gives a bit more equity in the system.
At the moment, for example, the like-for-like calculations that
are done around whether or not somebody stays in the community
or goes into residential care, If you stay in the community a
lot of the costs inherent in you staying there are being met by
the individual through housing or, indeed, by other government
agencies. So if you then compare what people are paying for residential
costs, people think that is very expensive. Well, it is partly
because there are a whole raft of things incorporated in that
costing model that are not incorporated in other costing models.
Q470 Mr Syms: What data do you have
on the split between hotel costs and care and nursing costs? One
of the things I noticed when I went round the homes in Poole was
they all told me that the age profile was going up, so people
spent more time in their homes, they came in several years later
and, therefore, were frailer. So, apart from the split in costs,
are nursing costs rising at a faster rate because of this, Martin?
Mr Green: Yes, the increased dependency
is certainly having an impact, because people need far more support.
For example, a lot of residential homes that were built 30 years
ago have lots of car parking spaces outside because the older
people who lived there were driving themselves there. If you look
at the critical criteria now, nobody would get a publicly funded
place unless they had not one but several conditions that meant
they required ongoing support. So that is, obviously, going to
be much more expensive. In terms of where the split is, I think
that is more difficult to quantify, and I certainly have not got
figures around that, but if you develop an independent costs of
care model, then you could clearly identify what the splits on
accommodation were and have some kind of formula that would make
it easy to do across the country.
Ms Scott: There is one expense
above all others for care home providers, and that is the cost
of the staff. It is between 55 and 70% of all expenditure. The
majority of that will be care staff. If you think that is the
majority of the expense then, on a very rough and ready basis,
you would think that 60% of the costs might well be care because
of the staffing element.
Q471 Mr Syms: Sheila, you say accommodation
costs should be funded from the benefit system. Why and how should
this work?
Ms Scott: I am sorry; I did not
make myself clear. At the moment a significant amount of people
are funded by the state for their social care. A chunk of those
will be on benefits—older people with substantial benefits
to support their state pension—and that was what I meant;
that they should still be able to have those benefits to pay—I
was just making the point—otherwise they might be left without
a service. I think it goes without saying, but I just wanted to
make it quite clear that there are a significant number of people
who from their own income alone would not be able to afford to
pay the hotel costs.
Q472 Dr Taylor: Coming back to the
disparity in unit costs that we have touched on, we have been
given figures from Laing and Buisson in 2007-08 about average
unit costs for a place in a local authority care home: £716
per week compared to £420 per week in an independent sector
home. Why is this? You have already mentioned bulk purchasing
by local authorities commissioning very hard and driving costs
down. Are there other reasons for this, or is that the reason?
Mr Green: Public sector pensions,
enormous amounts of money spent in training, back office functions
provided by local authorities that are part of the support to
an in-house provision—so a lot of extra costs which are
incurred because of the background support that people are given
have been public sector rather than independent sector.
Q473 Dr Taylor: Are they paying their
staff, did you say, £6.20 an hour to £7.00 an hour for
care staff?
Mr Angel: That was the homecare
sector.
Q474 Dr Taylor: What is the sort
of average in the residential care homes?
Ms Scott: A similar amount for
a basic care worker.
Q475 Dr Taylor: It is similar?
Ms Scott: Yes.
Q476 Dr Taylor: Would you agree that
these wages are so low, in the words of one of the people at the
seminar I went to yesterday, that to work in this you have either
got to be altruistic or desperate for work?
Mr Green: I would say they are
far too low. If we were benchmarked on a £720 per week income,
we would be able to make them much better. There is a real issue
about the way in which, for example, the structure of pay in the
public sector and also the access to pensions and other benefits
deter people from staying in the independent sector. Often people
are entrants to the care service in the independent sector and
then go on and get jobs in the public sector. So in order to get
some kind of level playing field, we need to level up to where
the costs of the public sector are.
Ms Scott: There is something else.
A significant number of people that work in social care are women
looking for flexible hours, often unskilled, and their education
has not left them able to walk into an obvious career and, actually,
social care does give them some significant opportunities because
they are offered training. Training is available. They can go
up the vocational route. It is possible to make a real career
from an unskilled start. I am not saying this is perfect. It is
work that is always available for people, but we still manage
to get a significant workforce, and this is a workforce that we
train. So there are some advantages for working in social care,
and it is not always just the money, is it?
Q477 Dr Taylor: Absolutely not. These
figures of £716 compared with £420: are self-funders
paying nearer the £716 than the £420?
Ms Scott: Yes.
Q478 Dr Taylor: I think you mentioned,
Sheila, if people want to buy an enhanced care service they should
be allowed to do so. What is the role of these top-ups for enhanced
care at the moment? How important is it for the businesses and
the income?
Ms Scott: The statutory directive
says that people should have choice, and the only criteria attached
to that is around cost. So there will be some people who the local
authority will fund, but their parent wants to go into a more
expensive home and they pay the difference. That is one way. Many
local authorities accept top-up, providing they can see what the
extra service is. So it might be gold taps and a sea view. It
might be that. It often is.
Q479 Dr Taylor: Better food; does
that come into it?
Ms Scott: No, absolutely not.
I think that is one of our big fears: that there would be this
differential in service. Within a care home everybody would get
that same service—the same food, the same service—they
would be paying for some sort of extras, or the cost of the service
is that much extra where it is above the local authority limit.
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