Examination of Witnesses (Question Numbers
500-519)
MS SHEILA
SCOTT OBE, MR
MARTIN GREEN
AND MR
COLIN ANGEL
19 NOVEMBER 2009
Q500 Charlotte Atkins: No responses
from the chief executives of the PCTs.
Mr Green: I will not say we have
had no responses, but we have not had action. For example, there
seems to be no lever to say people in care homes should be able
to access GP services and somebody in the Department of Health
should have the capacity to say it is clear that everybody should
have access to primary care services, if it is not happening,
why is it not happening, and call somebody to account. Strategic
health authorities, I would naturally assume, would have a role
in that, and they have not responded either. So what we see in
the system is some people do not know that it is going on, and
that was quite shocking to me, that PCTs did not know that some
of their GPs were charging, but when it is brought to their attention
you get platitudinous responses of how terrible it is and little
action systematically through the system to ensure that it does
not happen again.
Q501 Charlotte Atkins: Can I suggest
that you perhaps follow it up with a letter to the individual
MPs covering those PCT areas.
Mr Green: Absolutely.
Q502 Charlotte Atkins: I would certainly
welcome such a letter if it is happening in my patch.
Mr Green: Certainly. Of course,
I also have followed it up by sending the reports to the Secretary
of State, to the opposition spokesperson; so it is not as if politicians
have not had these reports. The difficulty is that they seem to
know there is a problem and they seem to agree that it should
be dealt with. I do not know whether it is because there are no
clear levers in the system that they can pull. I think, increasingly,
what is becoming apparent is that a lot of the decentralisation
which comes with the desire of putting things closer to people
also has the effect, which is an unintended consequence, of taking
away any capacity to deal with issues from the centre when you
identify them.
Q503 Charlotte Atkins: With respect,
it is all very well sending it to the Secretary of State and the
Shadow Secretary, but I do think that where you have a local MP
who has a relationship with the PCT and, presumably, also has
a relationship with the care homes, that is where you are likely
to get a better response. As I say, if there are any in my patch,
I would like to know immediately, please.
Mr Green: It is a point well made
and I will certainly follow that up.
Q504 Dr Taylor: Could we ask for
a copy of that report to this Committee?
Mr Green: Yes.
Ms Scott: The letters are always
very carefully worded, in my experience, and many small businesses
just think this is something they have to pay. The letters are
usually worded suggesting this is for extra services, and so many
care homes, smaller cares home and, I suspect, larger ones too,
just pay it. It is only if somebody contacts me, you, other people,
that we say you do not have to pay, and you write back along these
lines asking if they are paid for NHS.
Q505 Charlotte Atkins: GPs have had
a significant pay hike in the last few years, and it seems to
me that is something which they should be covering. Can I move
on to something else now? Is personalisation a threat or an opportunity,
in your view?
Mr Green: I think it is a tremendous
opportunity. I think it will give us lots of particular opportunities
to diversify. For example, the way in which things were commissioned
was about commissioning block approaches to care. What we hope
we will be able to do through personalisation is start developing
innovative and creative new services; also to engage in discussion
with users about, for example, some of the trade-offs that people
might want to discuss. So I think it is a huge opportunity and
as a sector I think we are ready to meet that challenge if we
get supported through the commissioning process.
Ms Scott: It is an opportunity—I
think the barrier for us is the regulator—if the regulator
allows care providers to innovate, which is what we need to do.
Sometimes the regulation itself has stopped that innovation in
the past. I think we have a real opportunity now, with the regulator,
to allow places like care homes to become real resources within
the community—not just to be closed communities providing
services, but to look out towards the community as well so that
people might be able to come to care homes for other services.
In a village a care home might be the store service as well as
providing care.
Q506 Charlotte Atkins: So you think
that personalisation and independent living can be made possible
within residential care, not just within the home?
Ms Scott: Indeed. We would like
to think that we have always provided a personalised service.
This makes you rethink all of the services that you provide with
such a focus on personalisation that we are encouraging members
and non-members to rethink about the services they supply and
also look at the way they are supplying those services, particularly
around residential care. Because they have delivered services
to a particular person for a long time that does not mean to say
that they cannot delve more and more into what that real person
is to ensure that the services they are delivering are key, and
that particularly is true for people with dementia. The best dementia
carer knows as much as they can about the life of the person before
and then you can really personalise a service for people. One
of the keys is going to be able to find a large enough work force
to deliver.
Q507 Charlotte Atkins: Colin, did
you want to come in on that?
Mr Angel: Yes. Personalisation
clearly has to be an opportunity more than it is a threat delivering
the most user centred services possible, doing those activities
that are important to the individual receiving the care and greater
job fulfilment for the homecare workforce. Yes, I recognise that
pitch, that many providers realise that personalisation is what
they have been doing all along or perhaps was what they were doing
until local authority contracts became more prescriptive, and
I do find myself saying personalisation is not the threat but
the current purchaser of care services is. We have seen very little
of the social care transformation grant going out to independent
sector providers who deliver 80% of state funded care, very little
explanation about what personalisation would look like as a service,
and we have created some guidance for our members, for lack of
anything else coming forth from the Department of Health, but
we also see some quite strange and, we think, quite deliberate
actions by councils in their current contracting business. The
other day I saw a contract that, despite being a contract between
the council and provider, tried to impose the contract terms on
any self-directing service user that the agency provided care
to, including somebody paying exclusively from their own funds.
We have also seen contracts where the council has to give its
express permission before a provider can deliver a service to
a purchaser who has exercised choice and decided to head off—
Q508 Charlotte Atkins: We would certainly
like to see some examples of that. If you could let us have that
evidence, that would be very, very welcome indeed.
Mr Angel: We certainly will do.
Thank you for that.
Chairman: I am conscious of the fact
that in a minute's time this session is nearly ended and we are
about halfway through our questions at this stage, so I will ask
for quick questioning and quick answers. You do not have to duplicate
it if it has already been said.
Q509 Dr Taylor: I would like Colin
to explain a little more. You say in your evidence you fear untrained,
unqualified, unsupported and unregulated personal assistants.
We heard last week the Care Quality Commission does not have any
powers to regulate these privately provided personal assistants,
so what regulatory changes are needed if we do not allow service
users to make their own decisions?
Mr Angel: Could you repeat that
last sentence?
Q510 Dr Taylor: What regulatory changes
do we need or should we just allow the service users complete
freedom to choose their own personalised assistants with no regulation
at all?
Mr Angel: I do not have an intellectual
problem with people choosing, making an informed decision not
to undertake any checks on workers that they may employ directly.
I do not follow the logic of a system that regulates the homecare
sector considerably onerously but then allows a grey market of
personal assistants with no checks being mandated whatsoever.
So, yes, the change in legislation would be that unless you had
a mitigating circumstance you would be required to check your
workers before you employed them directly.
Q511 Mr Syms: How would you view
the idea of council approved preferred providers for people using
personal budgets?
Mr Green: My view about that is
it would be absolutely fine if I had any confidence that councils
would not abuse their position on that, and that is going to be
the issue. So I think my view about it is I would like to see
councils out of the arena and the debate and discussion should
be between the provider and the user, and that will be the way
in which we would get to a much better position in terms of particularly
the personalisation agenda.
Mr Angel: We feel that many of
the approved providers at the moment are actually closed to application,
so that effectively they are a snapshot in time of those services
that the council had checked out at the time immediately before
the list closed, and often do not take into account new entrants
to the sector or services that add to their quality or range of
services. I do not actually think they are helpful.
Ms Scott: Both PCTs and social
services find it easier to deal with larger organisations. That
does not necessarily fit in with the choice of individuals, and
approved lists reduce the amount of choice that people have and
also penalises, in some instances, small business.
Q512 Charlotte Atkins: Last week
we had evidence from UNISON and they claimed that there is a lot
of poor quality care. Would you accept that, and, if so, are your
members at all responsible?
Ms Scott: I have worked in social
care now for almost 30 years and this has been a journey towards
quality care. Not every provider is there yet, but I believe that
we have seen a dramatic increase in quality care provided. We
have such a robust regulatory system that that drive towards eliminating
poor care must be continuing and, as providers and representatives
of responsible care, we do not want to see poor quality care because
it has an impact on all of us. I believe that the journey continues
upwards. I do not think we are seeing an increase.
Q513 Charlotte Atkins: We are seeing
a fairly dramatic staff turnover in social care, particularly
in the private sector—not quite so much, I think, in the
public sector—and that must have an impact on quality if
you are getting this staff turnover, because you just cannot train
the staff fast enough if it is going to be turning over. If that
is happening, you accept that you are having excessive staff turnover,
what is the best way of retaining staff: better salaries?
Mr Green: Yes. You talk about
the fact that there is less turnover in the public sector. There
are reasons for that, and they are down to some of the benefits
and salaries. I agree with Sheila: I cannot sit here and say there
is no poor quality care going on, of course there is not, but
the reality is that we are on a journey. We are improving things
all the time, but we are doing it against the backdrop of some
of those real difficulties that you outline around, for example,
the staff turnover and how that impacts on the quality of care.
Ms Scott: The recession has had
an impact and increased stability levels.
Q514 Charlotte Atkins: Is increased
salaries the way for you? You were suggesting that you have less
high turnover in the public sector because of salaries and other
benefits.
Mr Green: I think increased salaries
is very much a part of it. There is also a bit about training,
but when we talk about training I really wish we would stop throwing
that out in terms of it being a tick in the box because for all
this money spent on training nobody does very much analysis of
how it impacts on the quality of the care. I also think there
is a real issue about recruitment and getting people into the
sector around their core values as well as around their skills.
I think this is a sector where a lot of the people who work in
it are very much driven by the values rather than the salaries,
obviously, so I think there is a big job to be done to get all
those things in line in ways that will help us to move to this
being very much a career rather than a job.
Mr Angel: We had a very quick
look at UNISON's evidence yesterday. They did not present a picture
that we recognise for the home care sector. I also looked at the
quality ratings from the regulator of home care services yesterday,
and if there is a difference, it is between local authorities
having more `excellent' rated providers than the independent and
voluntary sector but both have almost identical numbers of `good'
services, which are by far the highest proportion of all ratings
offered, so that changes the difference between `good' and `excellent'.
Q515 Charlotte Atkins: What about
`poor' ratings?
Mr Angel: 0.3% of local authority
services, of which there are far fewer than independent sector,
and 1.1% of `poor' services in the independent and voluntary sector.
One does not feel happy about any poor grading but that is still
a fraction of the entire supply.
Q516 Sandra Gidley: A question for
Martin Green and Sheila Scott. There was an example of a care
home whistleblower who wrote that in the care home where she worked
they budgeted 70 pence a meal for each resident, the food was
"mostly grey slops" and the staff had to "have
a whip round to buy some decent food". Could you tell me
how much your staff members budget for meals?
Mr Green: I cannot. It varies.
Q517 Sandra Gidley: What would be
the range?
Mr Green: I would not know.
Ms Scott: Two things. When I was
a home owner I could not see the point of not feeding people,
my customers properly. It just seems extraordinary to me that
you would purposely do that. I do not ignore what the whistleblower
said. Up to £5 per day, from the quick ring round that I
did to be up-to-date, is what I think is the norm, and I tried
to do a wide section of places. It is just extraordinary to me
to think that would happen. I hope that that was an exception
rather than a reality because the three high points in the life
of a care home are mealtimes, so to think that you are eating
porridge at every meal is just nonsense to me. Certainly when
I was a home owner I treated those three points in the day as
the key parts of each day.
Q518 Sandra Gidley: Is there not
a danger that as the residents get a little older and frailer
and probably less likely to complain that the standards could
drop and cuts could be made?
Ms Scott: I truly believe that
the NHS has a role to play in this in supporting care services
on how to encourage people to eat techniques, et cetera, so that
even if it is pureed it can be nicely presented and people can
be helped as best as possible to eat a wide and varied diet.
Mr Green: There are some really
good examples of good schemes within the sector. For example,
the Anchor Trust has a catering scheme, Barchester have done a
lot of work on for example the presentation of food and particularly
for people who are very frail and have problems with appetite,
et cetera, presentation and particularly portion size can be really
important. I go out and about to care homes and one of the delights
is that I go and I eat with the residents, so my experience is
that things are good, but obviously that whistleblower's experience
was different and that is something that needs to be investigated.
Q519 Chairman: How widespread is
the practice of local authorities operating "Dutch auction"
e-tendering processes, and what impact does this have on the service
quality?
Mr Green: It has been something
which we have identified as being a real problem within the sector
although of course we did identify it and we got some good support
from people like Baroness Young, the Chairman of the Care Quality
Commission, who condemned it, and likewise some people in local
authorities and in the Department of Health. It seems to me absolutely
outrageous that you would set the goal of delivering high quality
care, go through a tender process and then do a Dutch auction.
I can understand why you might do that if you are buying a commodity
like a pen for a local authority but certainty not in the arena
of personalised care services. I think it sends all the wrong
messages and it also will not deliver the right resources because
if you tender for a service at a given level then that is the
level that you expect and need to deliver that quality service.
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