Social Care - Health Committee Contents

Examination of Witnesses (Question Numbers 820-839)



  Q820  Dr Taylor: Sir Jeremy, I think you said there was an argument for local differences but surely the same package of care should be guaranteed wherever you are in the country, should it not?

  Councillor Sir Jeremy Beecham: No. The same basic entitlement to care should be guaranteed wherever you are, but it would be wrong to preclude the possibility of going above that level. You must have discretion to do that and also to innovate. I do not think you can simply lay down one model of care across the country. Certainly in my time, long ago, as Chairman of Social Services in Newcastle, we very substantially improved the range of services at that time. We had the discretion to do it and we did it. I would love to see local government doing that under a new system, but based on that very firm bedrock of basic entitlement. But you have to be able to deal with the situation that presents in your own locality. An inner city area is different from a rural area in terms of both needs and how delivery might be affected, for example; different social composition and ethnic groups and so on will have different problems. You cannot have a simple universal rule, particularly one which would be regarded as a maximum.

  Dr Taylor: I think you are right to use the word "entitlement" because in the first session "flexibility" was a word that came up very often. Thank you.

  Q821  Dr Naysmith: Good morning, Jeremy. Welcome to the Health Select Committee. It is good to see you again. The Queen's Speech included the policy of providing free personal care at home for those with the greatest needs. Do you think this policy has been properly costed and evaluated?

  Councillor Sir Jeremy Beecham: It remains to be seen. On the face of it, it looks as though the estimates may be fairly crude. They depend very much, of course, on precisely what is covered by the pledge, and there is some guidance. We are talking about critical needs. Most authorities have unfortunately had to pull back to that kind of level anyway under the financial pressures that have been experienced, but there is potentially scope for argument about what those measures would involve in terms of the care that would be available. I rather fear, speaking as a lawyer, that some of my professional brethren will be rolling up their sleeves with the prospect of judicially reviewing councils' decisions or whoever's decisions on how that is to be met. The costings and the numbers, I would say, are not robust necessarily. I am not saying they are definitely not right, but there must be a suspicion, given the short timescale in which all this has been developed, that the figures are not particularly robust. The estimated figure of £670 million may or may not be right, but it is really too early to say.

  Q822  Dr Naysmith: The suggestion is that councils will have to find £250 million in efficiency savings. Is this feasible?

  Councillor Sir Jeremy Beecham: We are already finding substantial efficiency savings. We would be finding those anyway, but there is something called the new burdens doctrine, which is a basic agreement between government and local government that, if new responsibilities are placed upon local government, local government will not be required to meet those out of its existing resources but that extra funding will be provided. One approach is to look at whether some of the other burdens that councils have to cope with can be relieved. The LGA has submitted some suggestions of around £700 million a year of other burdens which could be lifted from us, which would free up money to contribute towards this, whether it is £250 million or more. That seems to me reasonable. In other words, there would be efficiency savings, but they would be efficiency savings generated from reducing the superstructure of very largely otiose regulation and inspection, but other things as well, which government require to be carried out at the moment. I am saying that the £250 million should not come from current council activities, because already we are making improvements and efficiency savings of that kind. A burden of this kind has to be funded either directly by government's intervention or by reducing other burdens on us.

  Q823  Dr Naysmith: Another suspicion that people have is that there could be a lot more demand than the Government expects. Do you think that is true?

  Councillor Sir Jeremy Beecham: That may well be true. Of course, once you create the concept of free personal care—as Scotland have found, I think—it becomes difficult to turn people away who may feel that they qualify or who may want rather more than what may be a pretty basic provision in terms of personal care and personal hygiene or oral care or whatever, and things like companionship or shopping or help with household chores and so on may be very limited. It is opening up a bit of a Pandora's Box. Having said that, the concept of helping people stay in their home, contrary to the views of our political colleague Lord Lipsey, does seem to me right. The principle is a good one, but I am not yet confident and I do not think the LGA as a whole is confident that the figures necessarily represent the likely cost of this at this stage.

  Q824  Dr Naysmith: Could councils just end up increasing rationing and charging in respect of some of the other things that you have just mentioned?

  Councillor Sir Jeremy Beecham: If we do not get the resource one way or another externally, then such councils as are still providing care for less than the critical group will be even more under pressure to confine it to the critical group and charging of course is already an issue in a number of places. I am not saying that we necessarily will get into the Barnet "easy council" system, which may provide a basic service and then anything else is charged for, but councils will be obviously over the next few years under great pressure. There must be some risk of what you have described happening.

  Q825  Dr Naysmith: Jenny, I covered a lot of ground there. Do you want to comment on any of those things?

  Ms Owen: I will come back to the question of whether the modelling is robust. Of course it would be good to ask those people who did the modelling for the Department of Health. I am sure there was a range from low to high.

  Q826  Dr Naysmith: I think our advisers are listening.

  Ms Owen: Yes, it would be very interesting for them to be able to say. It may well be that the figures picked were at the lower end of the modelling and it would be interesting for you to know that. In terms of ADASS's position on this, we wrote to the secretary of state soon after it was announced and said we were very concerned, and there were a number of reasons for concern about the financial costs of this. One is that there are a number of people who are self-funding at the moment and I do not think we have any idea how many self-funders will come and say, "I want to apply for free personal care." It is very difficult to assess that and there could be many more people than the Government modelled. There will be a number of people who switch who are currently having personal care at home and they are being looked after by families and so on who will come into the system. It is again difficult to know. Some people who have very high levels of need, much more expensive than residential care, in fact, could well come and say that they want to be entitled. The second big area of concern—and I think even the biggest area for me—is the administrative burden. We have been trying through the work we have been doing on personalising social care, to take money out of bureaucratic systems and processes and free up more money to put into the care pots, and this takes us back into a fairly heavy administrative system. At the moment most of us would not be able to tell between people who had critical and substantial needs, so we would have to invest in systems that absolutely defined those only in the highest bands of need. We would then have to assess people on the four activities of daily living, if you look at the current guidance on how this is going to be applied, and there will then need to be, as Jeremy has said, a whole plethora of work to ensure that those judgments are robust because they will be challenged. There will be legal challenge. This is the next level down of people below continuing care, and we have all seen how difficult it is for people who want a challenge, believe they are entitled to continuing care, cannot understand why they are not entitled to it, and it is jolly hard to work your way through that system. This is now creating a system that is the next level down. Administrative burden is going to be very high. In terms of efficiencies, the very first question we were asked by the Chairman was how we are going to be managing in the economic downturn with the pressure on budgets. We already have efficiencies in our system, as Jeremy said. It is not a question of being able easily to find others. The budgets of course for next year were already set, so over and above that we are opening the books again and looking for additional savings that could be made. We are very pleased there is some Department of Health or NHS money coming into the social care pots, but there are real, significant risks around making this work.

  Q827  Dr Naysmith: I was interested particularly when you suggested that it might be more expensive to care for some people at home than in residential care.

  Ms Owen: Yes.

  Q828  Dr Naysmith: Do you think there is a danger of bouncing people into residential care to avoid paying for free personal care at home?

  Ms Owen: This is a really difficult question. Local authorities have two duties. One is to assess need and provide care and support to meet that need, and the other is to have a duty of value for money, to get care at the best value. When you look at the judgments that have been made, we absolutely have both those duties. If your care, the same sort of good quality care, can be provided at better value in residential care, you have a real dilemma. It is very difficult.

  Q829  Dr Naysmith: Irrespective of what Lord Lipsey says. Jeremy, what do you think?

  Councillor Sir Jeremy Beecham: Quite. I agree entirely with that. I am not at all convinced by Lord Lipsey's argument. I would just like to refer to the impact analysis that the Government has published about this. It is candid enough to talk about "inherent uncertainty" in estimating the costs, which is why they have only done it for two and a half years in terms of the free personal care. I do not know how they have done it, but they have estimated the cost of re-ablement, which is increasingly part of the development of adult care these days, at £1,000 a person. I do not know on what basis that has been brought forward or how many people receive this and, indeed, how many then leave the system having been re-abled, as it were, or how many may need further care. There are very big questions about all of this. I suppose in an ideal world you would pilot this first and see what it costs, but then we have said that so many times and for so many different policies over the years but it does not ever seem to catch on.

  Q830  Dr Naysmith: It is one of the regular recommendations from this Committee whenever we report on almost everything.

  Councillor Sir Jeremy Beecham: Exactly.

  Q831  Dr Naysmith: Will you please evaluate the pilot studies. They are being rolled out all over the place without evaluating them.

  Councillor Sir Jeremy Beecham: Yes.

  Dr Naysmith: Thank you very much.

  Q832  Dr Taylor: Doug and I were both at the meeting where Lord Lipsey made his comments. It was interesting that in, I think, the first session we had here after that, that several of our witnesses did agree that they were absolutely amazed that this proposal had come just at the moment when we were talking about the Green Paper. Would you agree with that amazement or do you think it was appropriate?

  Councillor Sir Jeremy Beecham: I think a modest amount of astonishment was probably felt in the Department of Health actually! So, yes, I suppose I would.

  Q833  Dr Taylor: Thank you. We have really covered the draft regulations that have come out. I do take your point, Jenny, that it is going to be critical people with critical needs and these are going to be the most expensive of the lot. Are there any other comments about the draft regulations and guidance that you would like to make?

  Ms Owen: We have said to the Department of Health we will work with them—because obviously we are in a consultation period on the regulations—and we will look at them in detail and try to work on a system, given that this is going to go through and become law. If this is a law, we have to look at what is the most effective way of making this work. I have to say that the four activities of daily living I think could wrap us up forever in arguments about what does it mean. This is the experience of Scotland. Let us just take one example: Help with eating. What does it mean? Does it mean cutting up the food? Does it mean help with putting the food in your mouth? Does it mean microwaving it? Does it mean cooking it? For lawyers, as Jeremy said, this is going to be an absolute minefield. I am also very concerned because we have spent the last four or five years, at least, trying to get continuing care to work well, and there has been now the second lot of guidance around how to improve the assessments around continuing care. I would like to see something that tries to learn from the experience of that, not to get us into a situation that recreates all of those difficulties. The other thing is that we have been spending the last two years working on personalising services, getting away from: "If you need this activity of daily living, then you need this" but having much more flexibility around the response. We must not throw out the personalisation of our services as we have to start looking at this.

  Q834  Dr Taylor: You have already hinted at the absolutely vast expense that this could be. I think you picked on the self-funders. We do not know how many there are of those.

  Ms Owen: We do not.

  Q835  Dr Taylor: Is there any way of estimating the proportion of existing service users who would qualify for free personal care?

  Councillor Sir Jeremy Beecham: The Government has produced some suspiciously precise estimates. The figure that they have come up with on self-funding and unmet need is £46,089. Residential care switches: £2,384. I just do not know where these figures come from.

  Dr Taylor: Thank you very much for pointing that out. That increases our enjoyment

  Q836  Mr Scott: Sir Jeremy, we have heard a lot recently of evidence and allegations of poor quality of social care. Is what we have heard about the exception to the rule? Is it the fault of councils? Is it possibly down to tendering and the lowest bidder getting the contract?

  Councillor Sir Jeremy Beecham: We need to keep today's news—on which perhaps your question is partly based—in perspective. Most social services authorities are good or excellent. Eight are adequate. The poor are no longer with us, so to speak. I think Jenny said to me before, "Adequate is the new poor." Perhaps we need to consult the editors of the OED about that. Obviously a service which is not good enough is not acceptable, but only eight councils' services are described as "adequate". Equally on the residential care side, The Times ran this scare story this morning about people living in squalid homes and so on. That would be entirely unacceptable. The numbers they talk about are 10,000 out of 440,000 people in care. 10,000 if they are not living in decent accommodation is 10,000 too many, but, again, it is a miniscule percentage. I do think there is a continuing challenge to authorities and the Care Quality Commission to ensure that standards are maintained and improved, but the general level is more than acceptable, it is good or excellent. In terms of the different providers—to come back to your outsourcing point—the figure is 87% of local authority residential places are regarded as excellent, 86% of third sector providers, and 74% of private providers. That is lower than the other two, although, as Jenny helpfully pointed out here this morning, it has increased from 64% last year, so it is on an upward trend. I do think there is a question about some of the outsourcing. I touched on it indirectly before, and there was of course that interesting television programme—and I cannot remember whether it was Dispatches or Panorama—in which they had somebody with a camera working in one of these organisations. It was worrying, because you do need properly paid, properly trained and properly supported people delivering care of this kind, and there is a danger, in the drive to keep down costs, in my view, that you can end up with the cheapest but not necessarily the best. There is another danger of a different kind slightly, which is in the provision of residential care. There was a huge shift to outsourcing this in the 1980s, with a very unlevel playing field in terms of the grant that was available, and many local authorities effectively withdrew from residential care provision which was left in the hands of, largely, the private sector, and then of course it became uneconomic for the private sector and there were capital gains to be made out of disposal and so on, and so you were left with contracting provision. I think you need a mixed economy of care across which standards should be maintained by proper inspection, and I would draw attention to the possibilities, both in that context and generally, of enhancing the effectiveness of scrutiny within local councils, including the participation of third sector people, carers and the like, in the scrutiny process. That is potentially a powerful tool to back up the statutory regulation.

  Q837  Mr Scott: Thank you. Jenny would you like to add anything?

  Ms Owen: Yes, I would. I would like to make reference to the headline news as we woke up this morning. There are two reports that the Care Quality Commission have published this morning. The first one is about the performance of local authorities. Now we know that it was the wettest November ever since records began. Today, since records began, the performance in local authorities is the best ever. There are now no poor councils for the first time ever and 95% of councils are good or excellent. That should have been the headline but it was not. There are eight adequate councils. If CQC were very worried about that performance, there would have been some very significant work going on between the Care Quality Commission and those local authorities from the time that they were assessed in that way, which was back in the summer, and now, and that absolutely has not been the case in most of those councils. I think there is a bit of an issue there which I will just park. The bigger question was about the quality of the care provision. As Jeremy said, it has varied depending on the type of provider. It raises questions about the commissioning of local authorities. They commission just under half of the places in the country; the other half is paid for by people who are self-funders. Obviously, whether you pay yourself or whether you are paid for by the local authority, the quality of those homes and the home care is incredibly important. I directly asked the question of CQC: "Should we stop commissioning places in those poor and adequate homes?" Of course the answer to that has to be, "No, you cannot say that. You must not stop, because there is a whole series of reasons and complexities about this." For a start, homes go in and out of these ratings. One of the main reasons why homes go in and out of ratings is because they might lose their home manager or the domiciliary care manager, and the manager has a very big impact on the quality, and it can be temporary. The job of the local authority is not to stop commissioning those places, it is to work with that home to bring the standards back up again. Let us take, for example, a residential care home with 90 residents. You cannot have 90 residents moving out of a home—and this would happen very frequently with the ratings going up and down. It would not be what residents want, it would not be what their families want, and it would not be the best way to run a system. We have to work on improvement. Some of that is about our workforce development. Sometimes we help put managers alongside, sometimes we look with the providers to see whether they have a good manager somewhere else. There is an enormous amount of detailed work that goes into improving the performance in residential care and domiciliary care services. As well as that, there could be reasons why somebody has chosen an average rated home: because that is closer to where their son/daughter/family live. They know it is not the best rating, they can see the ratings, but it is where they want to be and they like the particular aspects of that residential care service. Then we have a responsibility again to try to drive up those standards. It is a responsibility local authorities take very seriously. It is quite interesting to look at data. There is a jargon for this data: it is called CRILL. I cannot even remember what it stands for. It is something about regulatory information in local areas, but I cannot remember. Council Regulatory Information—

  Q838  Mr Scott: It is a great shame that people do not use language that everyone understands.

  Ms Owen: CQC CRILL data is very recent in the scale of data returns and it is now what we can work with. The thing that will work most effectively is when councils and CQC can work together, look at that data, understand what it means and the questions we need to ask, and then a programme of work with those authorities. I think the scary headlines today belie the significant amount of work that is going on.

  Mr Scott: Thank you.

  Q839  Stephen Hesford: Jeff Jerome, the National Director for Social Care Transformation, came to tell us what he is doing, a sort of parallel system on personalisation and the transformation agenda. How are councils doing?

  Councillor Sir Jeremy Beecham: I think personalisation is being developed. We are moving on from direct payments—which are, I guess, one potential aspect of that. As Members of the Committee heard earlier from the previous witnesses, there are a number of aspects to that, including the need for authorities to help people navigate the new systems. Whilst taking the point that one needs to avoid over bureaucratising it, it does necessarily involve, to a degree, first of all trying to establish that there is a market there and encouraging providers, whether it be a local authority itself or third sector or private sector providers, and quality assuring what is available, and then helping people make the choices that will suit them best and securing some value for money. It is relatively early days but it is beginning to develop in most authorities. I suspect it will not be too long before we see Daily Mail headlines, as there has already been one case when some chap got a season ticket to see Rochdale Football Club as part of his personal care package. It might have been thought to have been depressing rather than otherwise, but apparently it was not.

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