Examination of Witnesses (Question Numbers
820-839)
MS JENNY
OWEN AND
COUNCILLOR SIR
JEREMY BEECHAM
3 DECEMBER 2009
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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