UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 22-iiiHouse of COMMONSMINUTES OF EVIDENCETAKEN BEFOREHEALTH COMMITTEE
SOCIAL CARE
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Transcribed by the Official Shorthand Writers to the Houses of Parliament: W B Gurney & Sons LLP, Hope House, Telephone Number: 020 7233 1935 |
Oral Evidence
Taken before the Health Committee
on
Members present
Charlotte Atkins
Stephen Hesford
Dr Doug Naysmith
Mr Lee Scott
Mr Robert Syms
Dr Richard Taylor
In the absence of the Chairman, Charlotte Atkins took the chair
______________
Witnesses: Professor
Caroline Glendinning, Professor of Social Policy,
Q759 Charlotte Atkins: Good morning everybody. I would very much like to welcome you to the sixth session of our inquiry into social care. I want to apologise, first, for being a bit thin on the ground. You will also have noticed that I am not Kevin Barron, the Chairman of the Committee. Unfortunately, he cannot be with us today - he is involved with a government meeting - so I am filling in as a member of the Committee. Just for the record, I wonder if you could give us your name and the current position which you hold., starting with John first.
Mr Waters: I am John Waters and I am Technical Director for a Charity called In Control.
Professor Glendinning:
Caroline Glendinning, Professor in the Social Policy Research Unit at the
Professor Beresford: Peter Beresford,
Professor of Social Policy at
Q760 Charlotte Atkins: That is helpful, thank you very much. I will open up with some general questions first, and this is addressed to all you. What do you make of the funding options set out in the Green Paper? Which, if any, do you favour - and why?
Professor Glendinning:
From my experience of being involved in the consultation exercises but
also looking at the experiences of other countries, I would say that it is a
shame that the taxation-based option has been dismissed. In other countries
taxation-based funding for long-term care is common.
Professor Beresford: I was commissioned by the Joseph Rowntree Foundation to carry out a consultation on a national basis with a diverse range of adult service users in different situations using different services late in October this year. The key views of that wide, well networked group were, first, that there were problems since the options were not costed, and we still do not know what the costings are. It was felt that the sums identified were unrealistically low, like the first estimates for a new jet aircraft or aircraft carrier. People felt that none of those three options would offer a reliable, sustainable, inclusive equitable basis for social care for all groups. An underpinning concern of the people we consulted with was that the Green Paper was framed very much, going back to what Caroline has just said, in terms of seeing service users as a burden and dependent rather than recognising that by providing appropriate support they might be able to be better contributors, so there is a real concern. People were almost unanimous in the view (1) that general taxation should definitely have been included as an option, and (2) in thinking that it was the preferred, more viable option for the future funding of social care.
Mr Waters: I would echo much of what Peter and Caroline have said. I suppose there are two key elements to this. One is the issue that has been touched on in terms of where does any more money come from, but, secondly, how should that money then be administered, and some thought in terms of the fact there does not seem to be great logic to saying that it is unfair to just draw on the working age population for support to meet the social care needs, for the reasons that Caroline has said. But the issue in terms of where the money is administered in terms of the two main areas - either local authorities or the benefits system - if there is movement between those, that needs to be done with some thought in terms of the money that currently is in the benefit system, once it reaches people, is genuinely under their control and is in their hands and they can do with that as they determine. Local authorities, because of the historic pressures and rationing systems, tend to ration through service types. Thus that issue would need to be deal with very clearly if there was a move away from a national benefits system into a more local system.
Q761 Charlotte Atkins: Could you tell us a bit more about your organisation's ten-step plan for reforming social care funding and how that relates to the Green Paper options?
Mr Waters: There is a lot of overlap and there is a lot in the Green Paper that, hopefully, draws on some of these ideas. What we have tried to do with the ten-step plan is to identify some of the key issues that face local authorities as they move forward, to inform the debate with some of the progress that has been made and to try and give a practical model to say it is possible to get money into the hands of older and disabled people in a way that defines clearly the conditionality. Why is it that certain people should have a certain level of money and what are the restraints around the use of that money and to focus the restraints, not, as is currently the case, on paying for services, as maybe with direct payment, but in terms of greater clarity in terms of outcome. What is it that is being achieved here? It is a helpful shift to be able to say to people, "Here is a framework of a level of needs. These are your circumstances, the support you can draw from the family, and here are the outcomes that this money is going to help you achieve." That is quite a powerful thing to be able to do, and our ten-step plan really flows from that idea; that it is helpful to give people a clear entitlement to resources based on both their level of disability but also their social circumstances and, then, what you would need to do to make that a reality, and it begins to explore more fully, and with greater ambition than the Green Paper, some of the integration of funding streams that might need to be taken forward. For example, currently the focus of the rationing of use of the Independent Living Fund is around task and activity - I can spend particular money, but only in certain ways - and it kind of undermines the attempt to get control close to people when really the focus needs to be on the outcome here, and the outcome in that instance is that I get to live in my own home.
Q762 Charlotte Atkins: Caroline, you told us something about the conclusions of your studies into social care funding, but is there a particular system which you think we should copy?
Professor Glendinning:
No. I think it is very difficult to make
recommendations about a particular country, a particular approach, because
other countries have got their own institutions, their own structures, their
own cultures and traditions, but I do think it is possible, from looking at a
range of other countries, to draw some general conclusions about the principles
that seem to underpin care arrangements and funding arrangements in other countries,
and I just want to highlight four of them. The first is the principle of
universal access based on levels of need regardless of income or assets. Having
said that, that universal access dependent on level of need can be linked with
and combined with progressive means-tested co-payments; so you have a principle
of universality that people, nevertheless, can and do contribute where they are
able to. The second principle is equity. Across
Q763 Charlotte Atkins:
Professor Glendinning: It has been politically very popular, and it remains politically very popular. It is not clear that demand for services or demand for personal care has increased; there have been wider policy changes and demographic changes that have affected costs anyway. The research that has been done, particularly from the University of Stirling, has shown very marked variations between local authorities in the level of additional costs that they have had to bear but, also, there are some big weaknesses and shortcomings in the data that is available both at local authority and at national level that would enable the future costs of free personal care to be properly estimated. Indeed, the Scottish Executive has been criticised for introducing the policy without a clear understanding of the long-term costs. There is still a shortfall in the data that is available to help understand the current and longer-term costs.
Q764 Charlotte Atkins: You were suggesting that some local authorities had greater costs than others. What was that based on: the nature of their populations?
Professor Glendinning: It is partly based on demography, partly based on the number of people who were previously funding their own care who came into scope for free personal care. Of course, free personal care is offered to people in residential care as well as in their own homes. To the extent that local authorities are able to shift the balance of care into the community and away from residential care, there is the potential to contain some of the costs of free personal care.
Q765 Mr Scott: Perhaps I will start with John. What are your views on the policy set out in the Queen's Speech about providing free personal care for those with the greatest need? Could you see any unintended consequences of this policy?
Professor Glendinning: Shall I go first? You go first.
Q766 Mr Scott: Do not fight over it!
Professor Beresford: No, no, I think we are of similar minds on many issues here. The real concern that I have personally is if we have ruled out as an option considering general taxation in a Green Paper to which there have been 24,500 responses, a significant number of which have supported the idea of general taxation at least to be included, then it feels like it is policy being made on the hoof to introduce a new idea which contradicts that. We carried out our national consultation after the announcements had been made, both about the Government's proposals and the Opposition's proposals, and I think what people said is really the way I would feel about this. For example, what is "critical"? Who decides and how, and what if your needs fluctuate? I think it is difficult to answer. One of the things that concerns me is when you make an intervention in one part of the system, you can have unintended consequences in other parts of the system. I think if you say we are going to provide free domiciliary care, my question would be: what happens to the rest of the system? I think what people are saying is: does that mean that to offset costs fewer and fewer people will be seen as having appropriate qualifying needs, and would that mean that there will be perverse incentives, for example, for people either not to receive support that could prevent things getting worse or, alternatively, for people to be seen only as candidates for residential care? I think, unfortunately, if you do touch one piece you need to look at the whole, and that is the worry about this proposal.
Professor Glendinning:
I think there are some interesting lessons from
Q767 Dr Taylor: This is really addressed specifically to Peter. You have picked out some splendid words that service users want to be cared for by workers with vital human qualities, and you have listed them: warmth, empathy, honesty, respect and competence, which I think is a brilliant summary. You go on to say that too often they are not treated by these sorts of people. Why is that? What can be done about it?
Professor Beresford: This article in The Guardian was based on a report commissioned by the then Minister for Care, where we spoke to 110 or 112 service users, a very wide range, and over a quarter of them came from black and minority ethnic communities, across people with learning difficulties, older people, people who use mental health services, physically and sensory impaired people, and I think what you will notice, if you read the article, is the concern and support that people register for the workforce as well as their concerns about bad practice, and I think this is a complex issue. We carried out another consultation which was published earlier this year, again relating to the more recent agenda, again talking to about 100 people, and there are remarkably similar findings. The two things that people emphasise when they are trying to get to grips with why it is not working are (1) the issue of funding, which is seen as problematic, and (2) the issue of culture, which is seen as problematic. It is the wrong culture in place still. However, if we are talking about the quality of the workforce, there do seem to be negatives at work. We are expecting of a workforce (and amazingly we often get it) amazing levels of human skill and understanding, a workforce that is treated, in terms of their reliability and quality and rewards for the employment, very meagrely, at the level of check-out staff, as that article said, working in supermarkets. This is a very difficult occupation and it has been reflected, of course, in high rates of turnover, low retention and difficulties in recruitment in the social care work force which are expected to get far worse as the population needing social care support is expected to grow bigger. I think that is part of the problem, but there are other problems too. For example, the way in which commissioning is undertaken, the purchase of services. We know the Government understands that because the whole shift to personalisation expresses a concern to move away from that, but people so often talk about the fallibility and unhelpfulness of domiciliary care - repeated mantras from people that we talk to that you get a troop of people you do not know, one after another, always different, coming into your home who may not treat you with understanding, may not know you, may not treat you with respect, who will undertake very personal intimate tasks with you not necessarily in the best way possible - and we also know, of course, that there are real problems with that workforce. Apart from the poor conditions in terms of income, people may be expected to do a task within 15 minutes, no allowance may be made for the transport time that there is between one person and another, and people may be expected to pay for that time and the cost of travel themselves. We know from some further work that we have undertaken, again commissioned by the Joseph Rowntree Foundation, about person-centred support, a big national project which is reporting next year, that people may not receive training or supervision except in their own free time, and they will not be paid to undertake that, and so there are real essential problems in the work force which, I have to say, it feels to me that policy-makers are reluctant to recognise and face up to.
Q768 Dr Taylor: Thank you; that is very helpful. Bad commissioning: what should commissioners be doing about the quality of staff that they include and these problems with the staff?
Professor Beresford: I think there are micro issues and what you might call macro issues in relation to commissioning. You can see, as we have seen in the big project I have just referred to, the standards we expect where locally people make supreme efforts to make the very best of the resources that are available but, if there is only so much money allowable to pay, whether it is domiciliary care or residential care, and that does not match what it actually costs to provide good care and support, if there are cultural problems in terms of the kinds of people you are recruiting - and domiciliary and residential care is not an area which is constructed and envisaged in career terms as a positive role, although many people, nonetheless, carry it out in that way - then we have problems. There are essentially built-in problems at a macro level is what I would argue.
Q769 Dr Taylor: What can the regulator do? How can the Care Quality Commission going into a home pick up the quality of the workforce, whether they do have the empathy and the warmth that you describe?
Professor Beresford: I think there is a problem in seeing regulation as an appropriate means of dealing with a problem whose origins may lie elsewhere, may lie in problems of supervision, training and particularly of funding and resources, and, of course, regulation can sometimes be a blunt and crude instrument. I think it is very difficult to expect a regulator, especially a regulator like the new Care Quality Commission, which in a sense is required to have a less hands-on role than was previously the case, to compensate for other more substantial difficulties. If, for example, I say to you, checking out a residential service where one knows that the report from the predecessor of the Care Quality Commission was very positive but that when you speak to a resident there they do not even realise that they are permitted to go into the garden, you realise, of course, that there is a big gap, many a slip 'twixt cup and lip, between what it is possible to do by a regulatory system (and that too much is expected as such) and what needs to be achieved in terms of other change. One of the things that service users feel very strongly is that to rely on regulation and registration as a cure-all is not going to work. They recognise that there are problems of a more face-to-face fundamental issue than a regulator should be expected to resolve.
Q770 Dr Taylor: So low pay, poor training and time for doing tasks are really the vital things?
Professor Beresford: I think that they are, and I think also that there is a low value placed on such work in our society. I think it is interesting that very recently we have been able to read in The Guardian - and we know this is the case - the way that immigrants are being exploited to undertake such work. It is because it is not a job that, unfortunately, people can see as offering an adequate career for the future, it is an entry job, and I think for that to be true is an appalling indictment of our society; the value it places on the human and personal needs of people who are having difficult times or who are at difficult ages.
Q771 Dr Taylor: Certainly in my area at home, care workers in residential homes are Filipinos, and they do a splendid job.
Professor Beresford: Absolutely.
Dr Taylor: Thank you.
Q772 Stephen Hesford: Mr Waters, your organisation In Control claims to have conceived and developed the concepts of personal budgets and self-directed support. Can you tell us how you came up with these ideas and what shape they take?
Mr Waters: I suppose they have evolved over a number of years and they came from a recognition of some of the problems that we have been talking about this morning. The intention really has been to say how is it possible to fairly share resources that are available to local people and to place the decisions about how resources should be spent as close to people as possible, whether that is the person themselves or, if they do not have capacity, their family member or, in some circumstances potentially, a social worker or somebody advocating on the person's behalf. It was the intention to say how do we get control close to people when previous systems had struggled to do that. We have heard Peter talk about some of the difficulties with the way services and the workforce operate at the minute. We worked initially with six local authorities for a couple of years and we said here are some core ideas about what a personal budget might be and some ideas building on the work that then happened around person-centred planning to say, "Is it possible to get control close to people? What are the tensions in there? How do you solve some of the debates around what is good use of public money?" and we have done that by working together with families, people themselves and particularly with local authorities and challenging them really to change their systems within the parameters to which they operate. That work has moved forward over six or seven years now and we have produced a couple of significant reports that have said: this is the emerging model, this is the effect that we think this approach can have in terms of getting control close to people. The key issue, I think, is this idea of partnership - getting control of resources close to people but sharing out resources fairly to people using a transparent framework that allows people to identify their own level of need and what for them is a fair allocation of resources - and to tie into that a clearer idea of what is the outcome here. For example, one of the outcomes might be to maintain family relationships. Quite clearly, the Green Paper says one of the things that services should do is support maintenance of family relationships. We have taken a step back from that idea of services and said overall the system should be doing this and that the financial resources should be under the control of the person and, so long as they are used in a way that can be agreed to achieve those outcomes, then it should be the person who decides and not the commissioner or the local authority who decides.
Q773 Stephen Hesford: There is a term that we have got from you called "total transformation". Can you tell us a bit more about that?
Mr Waters: That is just the name that we gave to a piece of work that we took forward. This started off before the Green Paper had set out any of these ideas, before Putting People First had said that personal budgets were a helpful way to organise social care, but we had a lot of interest from local people and from local authorities, who were saying, "We recognise the value in this approach and we recognise that we cannot just operate in small-scale pilots. We cannot make it available to somebody with a learning disability but not to an older person, or somebody in this area and not in this area." So we responded to that and we said, "We will work with you and figure how do you begin to change your whole system" and we called that total transformation. We worked with about 20 local authorities to support them to begin to think through the bigger systemic changes they need to take through.
Q774 Stephen Hesford: One former government minister, in simple terms, described your organisation as being fantastic.
Mr Waters: That is very kind.
Q775 Stephen Hesford: What exactly is your relationship with government and to whom are you accountable?
Mr Waters: We are a charity, so we are accountable to a board of trustees. Our main funding comes from a subscription from local authorities and we provide a support service to local authorities, figuring out how to meet the demands that are being placed upon them. So we are accountable to a board of trustees but, also, we would not exist if local authorities did not think it was worth supporting our work.
Q776 Mr Scott: Direct payments have been made since 1996, but the take-up has been very low. Why do you think that is?
Professor Beresford: I think it would be helpful for us to contextualise the terms "individual budget" and "personal budget" with "direct payments". Direct payments were an idea that came from the disabled people's movement, and what they were crucially about was making it possible for people to have more control over the support that they had and more control over their life, and, sadly, this is still a problem for many service users, many people have not experienced. I can remember one of the first things that my organisation did was a project concerned with measuring outcomes and trying to develop user-defined outcomes. Not just what professionals thought outcomes should be, but service users. When we put that together in a video, we discovered that the only people who could talk about outcomes and for them to have any meaning for them were people who were accessing direct payments Only they were seeing appreciable change in their lives from the support that they were receiving. There is so much evidence to show how well direct payment can work, but we know that there have been obstacles, in the sense that their take-up has always been different in different parts of the country, different local authorities have been more or less enthusiastic, that many social workers have not had the support to understand them or have been able to implement them well, and, of course, what was the case with direct payments was that few promises were made that this would be a cheaper way of offering support. It was made very clear that this should be, and could be, a better way of offering support. One of the things that we have seen with the more recent discussions, which is why they have gained so much political support, has been claims made that they can be much cheaper, and I think that those claims need to be subjected to far more careful scrutiny. What was said about direct payments was that they could make it possible for people to live a fuller more contributory life, and that was in accordance with values of a philosophy that the disabled people's movement developed called "independent living", not meaning standing on your own two feet, but having the support to be a contributor - to be able to go to work if that is what you wanted, to get an education, to sustain relationships, to be a parent, rather than have someone coming in and getting you up at the time of their choice, putting you to bed at six o'clock, and so on and so forth. I think there were problems in the way the process was implemented, and I think disabled people have often felt that local authorities were not the ideal implementer, and I think many of the gains that we have seen come with individual budgets have been because there has been the opportunity to get back to the true spirit of direct payments, which was: you should know what resources are available and truly have control over them and, of course, have the support to run the system. That is what was seen as the most important: there should be an infrastructure of support - advice, guidance, management, knowledge - from local service user organisations, something which the Prime Minister's Strategy Unit said we need to go ahead and have a network of nationally in this country, but that has not always, unfortunately, been in place. I think we are seeing an extension of continuity and to some extent a rebranding and, I think because there is now more political will there is much more chance of this working.
Q777 Mr Scott: Caroline and John, would you like to say anything?
Mr Waters: My thoughts are that I agree entirely with Peter's comments. I think there is a significant issue in terms of direct payments have operated almost as a bolt-on to the main way that local authorities conduct their systems. A social worker supporting one of their clients to take up direct payments would have to be following a completely different set of processes and procedures. They would have to find the time in their work to sit down and develop a good person-centred plan with somebody, and that takes time; it takes energy. It is often what folk want to do and is the right thing to do but they are faced with the choice of saying there is a pre-commissioned, ready-made solution here where I can pick up the phone and I can move on to my next piece of work. So it is partly because it has been a bolt-on.
Professor Beresford: Could I add to that because I think that is a helpful comment and I would not disagree. I do not think that is a statement actually about good social work. If one looks, for example, at specialist palliative care social work - and there are cases of individual budgets and direct payments in specialist palliative care, where there is a much more informal, thought through partnership approach to assessment - you can see exactly what John has described taking place. I think what the problem has been is that the care management introduced in the 1990s has not sat comfortably with these ideas of self-directed support.
Mr Waters: The other difficulty, in terms of uptake, was clarity around the level of resources that any one person should have available to them, and that often was decided at the end of an assessment process once a service had been costed and, in order to control and manage and ration local resources, local authorities would place quite clear restrictions on the things that direct payments could and could not be spent on, starting perhaps down to a list of preferred providers, but then, even more tightly, down to certain tasks and activities, because there was a lacking of any sense of how much of a fair allocation should be made available.
Professor Beresford: Could I pick up on that one because again that is a very valid point. One of the troubles we are seeing now is exactly the same happening with local authorities interpreting personal individual budgets in just the same way. I could point to an inner London borough which has made it clear to people that if they want to spend some of their personal budget on cleaning, it will deduct that amount from their personal budget, and it has only been in the case of some people who have taken that to all forms of complaint and appeal that they have managed to reverse that decision. There has been a cultural problem, which continues, of local authorities' understanding of an open menu, I think, here.
Professor Glendinning:
I would add one point, and it is drawing on evidence from the
Mr Scott: I think employing family members is something that Members of Parliament can relate to!
Q778 Stephen Hesford: Professor Glendinning, can you summarise briefly for us the findings of the individual budget pilot?
Professor Glendinning: Yes. To some extent this supports the points that have already been made about the difficulties and the challenges of transforming a system. I think all the pilot sites extended the scope of their pilots during the two-year pilot project and, indeed, some of them had decided to introduce individual budgets across the whole of adult social care during the course of the pilot. They found it was very difficult to run the two systems in parallel so the pilot sites were beginning to move towards this kind of total transformation. The outcomes for older people were not as positive as for other groups of people. The outcomes for people with mental health problems were very positive and there was actually some suggestion there that people with mental health problems were opting for personal budgets, or individual budgets, where they had previously refused to use or not been willing to use conventional day care services, day centre services, and so on. There was some evidence of increased demand there and people with mental health problems tended to use their personal budgets, individual budgets, for leisure activities - adult education classes and those kinds of things. Part of the reason, I think, for the less than positive outcomes around older people was that ---
Q779 Stephen Hesford: I think we have got a question on that, so if we can just park (a rather inelegant phrase) older people for a second, we will come back to that.
Professor Glendinning: Okay. I think one of the important points and one of the important findings of the evaluation that I do want to highlight was the failure to really tackle the issue of integrating funding streams, and this is where individual budgets differ from the personal budgets that are now being implemented by local authorities. Individual budgets were intended to bring together the resources.
Q780 Stephen Hesford: If there was a quick, for our benefit, definitional relationship between individual budgets and personal budgets, what is it?
Professor Glendinning: Individual budgets were intended to bring together multiple funding streams - resources from Social Care, Access to Work, Disabled Facilities Grants, Supporting People, Independent Living Fund - so resources from DWP funding streams and DCLG funding streams. The personal budgets that are now being implemented and are putting people first are social care resources only, and I do want to emphasise that this was probably the most disappointing element of the pilots. The proposal that individual budgets should include these different funding streams came from the Prime Minister's Strategy Unit report in 2005, and it was an attempt to try and reduce the complex set of multiple assessments, multiple eligibility criteria that disabled people and older people have to go through. The pilot sites were very excited at the prospect of being able to try and bring together funding streams, but they found it very, very difficult, largely because of restrictions at central government level on what the different funding streams could be used for and accountability for how they were used. That was one of the really difficult areas. Of course, the other really difficult area was the fact that although all these funding streams were included in individual budgets NHS resources were not. So there were major problems at the NHS social care boundaries, particularly around continuing healthcare and mental health services, where people very often used both health and social care resources. So, individual budgets, multiple funding streams, personal budgets and social care resources only.
Q781 Stephen Hesford: I think you have probably answered this, but was there anything that came out of the pilots which still seems to be hanging in the air?
Professor Glendinning: I think the funding stream issue is one, and, of course, since the IBSEN evaluation has been completed, the Department of Health is now piloting personal health budgets. We are still very unclear about how they will interface with social care personal budgets and the Department for Work and Pensions is discussing the piloting of right-to-control projects, which will include some of those IB funding streams - it will include Access to Work and the Independent Living Fund. I think the whole issue of cross-departmental working to try and simplify all the different resource streams and the assessment processes that go with them is a major issue that remains to be addressed and it links to the Improving Life Chances strategy. I think there are some other issues we have touched on already about what it is legitimate to spend public resources on. What are the boundaries on what people can use their personal budgets for? I think we need a much bigger debate around that, and I think it is something that government needs to lead on, because the uncertainty about what people could spend their money on really restricts creativity both in terms of frontline staff and personal budget holders and I think we also need a bigger debate on how we actually allocate resources to people. The resource allocation process that In Control pioneered and was very, very influential with many of the pilot sites, in a sense, by-passed a bigger question about what criteria we should use, what levels of resources we should allocate to which groups of people, and, of course, it revealed big inequities. It revealed very clearly that older people get far lower levels of resources than other groups of service users. I think those are some big debates that still remain.
Professor Beresford: Can I add something to that. I think it is very helpful to hear set out in a very clear way things are that are not always set out very clearly at all, but we need to remind ourselves that the Government made a commitment 18 months ago to transforming social care services, and one of the findings from the preliminary work we have completed in the national project supported by the Joseph Rowntree Foundation is just how many things need to change and be got right systemically at local and central level if you are being serious about actually transforming - and I think that comes across very strongly also from what Caroline has said - and, therefore, it is a worry to service users who have been long-term service users, who have experienced wave after wave of policy change which has not been reflected in positive change in their day-to-day experience, but the same might happen now, because we are using very large words like "transformation" but not necessarily recognising that if we are talking transformation it actually does mean that, and it is an enormous thing to be aiming for. On the ground, service users and, of course, practitioners are concerned.
Q782 Stephen Hesford: Can I come back to you, Professor Glendinning. The Government have moved towards personal budgets. Am I right in thinking that what you are saying is they were driven to that because of the complexity of operating individual budgets, or is there some other explanation?
Professor Glendinning: I do not know. I do not know the reason for the decision. The decision to roll out personal budgets across English adult social care was, of course, made before the findings of the IBSEN evaluation were available. I do not know. My own personal view is that it was a political decision. I am not aware of any clear evidence underpinning that decision.
Q783 Stephen Hesford: Is it a done deal, or is there a way back, or should we move on?
Professor Glendinning: I think certainly the experience of the individual budget pilots (and I am sure John would reinforce this) the processes of developing different ways of allocating resources, different ways of agreeing with people what they might use those resources for and accounting for them, the issues about risk and safeguarding that are related to it, and there are some very big issues as well around service commissioning that we have not touched on - I think the changes that are involved in all of those things would make it very difficult to go back because I think it is a total transformation. It is a transformation in culture and in operating systems throughout adult social care.
Mr Waters: Can I take a quick opportunity to add to what Caroline has said in terms of clarifying the issues in terms of a resource allocation system. Quite clearly, it was the work around the resource allocation system. It caused a lot of folk to realise some of the differentials across different social care groups; it was not the innate cause of those. The system had been operating and older people had got, on average, significantly less than other groups, but it was not the shift towards personalisation or personal budgets that caused that, that was already part of the system, and I think our work has demonstrated some very practical and simple solutions to some of these key problems and a much greater focus on outcomes around a fair deal. Added into that a capacity to begin to begin to define how much support is it reasonable to draw from those people around you, from your family; how do you define that? There were some very practical problems that needed to be solved to move on. In terms of the funding integration, a lot of the difficulties and issues there were very predictable and were predicted. A colleague of mine, Simon Duffy, and I prepared a paper predicting some of these difficulties and there were attempts to solve or to ask local people to solve problems that should have been solved centrally. Where there needed to be an alignment around the means-testing arrangements or the charging arrangements, the restrictions, these were set in statute or in trust deeds that quite clearly needed to be removed and flexibility given to local authorities and to local people. So these things were predictable. They are not massively complicated. You can quite clearly say, if you begin to set out a way of measuring need, if you begin to set out what a fair deal looks like, if you begin to set out some clear outcomes for people, they can then bring on and draw from their own resources and their own creativity. If you help people plan and focus, not just on the money, we begin to see some better outcomes, and a lot of the feedback that I have when I talk to folk nationally is the emphasis often is in the wrong place around personal budgets and ignoring that actually it takes a lot of effort and a lot of time to sit down with somebody and figure out a decent plan that will work for them and their life. The focus often goes on to how we manage the budget, and that is only part of a bigger system.
Professor Beresford: I would like to get back to some basics because I think it is very helpful. I think there has been a problem with this debate more generally in that there has been a tendency to focus on means, not ends. There has been an enormous focus on individual budgets and personal budgets, and we know that they offer good things and they also have serious and continuing problems. I think what we need to remember is that if there is not enough money in the system, as there does not seem to be (and, do not forget, what you get is ultimately bound by your role and your place in the eligibility criteria system) it means that what it is, apart from being top-sliced for its own administration, is points for prizes, as people call it, which ultimately is a rationing system, and what distinguished the newness of the idea of direct payments was that there was an independent criterion, which was how would this make it possible to live your life independently, and I do not think that is strongly there. I think the issue was never that moving to cash should simply be a financial transaction. We know that the group of people who do that routinely - self-funders - is the group most vulnerable, often unnecessarily, to institutionalisation, to moving into residential services. It was intended as a shift in power, and I think a lot needs to be in place, not least some of those things which have been talked about by Caroline: the idea of a system of infrastructural support, advice, guidance, of local organisations of service users, neither of which is truly in place, both of which have financial implications.
Q784 Dr Taylor: This is your cue, Caroline, to come back on the older people and why they do feel so much less comfortable. Is it just because they are not confident, they do not get the advice and the guidance that has been said, and what can be done about it?
Professor Glendinning: I will come back to that, but what I want to do, first of all, is to spell out that you can use personal budgets in different ways, and I think this is important to my part of the answer. In a personal budget you do not necessarily have to take the cash option. A personal budget: you can hand it back to your care manager and say, "Please commission the purchase of services on my behalf." You can give it to a service provider and, in a sense, call off packages of care as and when you need them. You could ask a third party, a carer or a trust to manage it for you. Those deployment options are very important because what all the research on direct payments has shown is that older people are not necessarily comfortable with the cash and being an employer, and I think that is an important issue. Certainly looking at the individual budget pilots and the evaluation and the evidence from that, older people were often very frail by the time they became eligible for social care, perhaps had fluctuating and deteriorating health problems, even if they were already receiving services, as Peter said. You have picked up the issue of the relationship with the people who provide your care, and, I think, certainly with the individual budget pilots, some older people may have experienced the pilot as a threat to that stability and the trusted relationship - it did not have to be, but that is how they perceived it - and, of course, they received lower level of resources, the bulk of their personal individual budgets were used for personal care because that was an absolute priority, and they had less scope within the resources they were given for those more creative things, using the money for social activities and improving other areas of their lives. This picks up the question about service commissioning because, for older people in particular, they may well want to hand the budget back to the local authority to say, "Please purchase services on my behalf", and what some local authorities are now beginning to do is to commission, for example, home care services with a greater degree of flexibility, and I think it is absolutely vitally important that older people who want the care manager to manage their personal budget, nevertheless, have opportunities for choice and control, because the contract with the provider allows some flexibility - for example half an hour a week that is unallocated and the older person can say, "Okay, I would like to go shopping this week. Next week I would like to go to the garden centre" - that kind of choice - but that involves changes in commissioning practices as well.
Professor Beresford: One of my other
roles is to be a trustee of the newly established
Q785 Dr Taylor: One of your big criticisms is lack of training and instruction and how to access and decide upon the services?
Professor Beresford: It is not a criticism; it is a statement of one of the essentials we need to have in place to make this transformation really work. People need to have help - whether they are someone with learning difficulties or an older person - and we cannot assume that the family can do it. Lots of people are old and do not have that family, some people are isolated, some people do not want to turn to their family. There needs to be some option of exterior support. One of the recommendations of the Hampshire Commission was that there did need to be this infrastructure of information, advice, advocacy and support for it to work well.
Q786 Dr Taylor: Caroline, turning to the
Professor Glendinning:
At the moment you are not usually able to employ a close co-resident
relative. That is the current regulation. Obviously, exceptions may be made for
people, for example, in very rural areas where there is nobody else, but it
particularly prevents older people paying a spouse. I think we need to bear in
mind that as the population as a whole ages, carers age as well, and there are
increasing numbers of elderly spouse carers. So that is probably the main
restriction. Having said that, it is not the answer for everybody. Certainly I
have come across anecdotes where real problems have arisen through the
employment of family members. So it is not an answer for everybody, but it does
seem to be popular with older people in the
Q787 Dr Taylor: I think that is great. Should it be one of our recommendations that there is flexibility for the use of personal budgets? If it is right for a certain person to employ their spouse, they should be able to do that?
Professor Glendinning: I think that could be a useful recommendation, so it is about being more flexible in who you can employ and how you can use the personal budget, but I do want to emphasis the other options as well - giving your budget over to the care manager who can purchase a flexible range of services on your behalf, giving the money to a service provider and calling off packages as and when you need them - and local authorities are beginning to work with their local service providers to support the providers in delivering these more flexible options, and I think that is essential as well.
Q788 Mr Syms: Should people have the right to choose not to choose and just keep the services they have got if they are happy with them?
Professor Glendinning: I will say very quickly that at the Social Policy Research Unit we are doing a major study into how people experience and respond to choice over time. It is very clear that different people want different choices about different things. Choice may be very important in relation to housing options but much less important in relation to health treatment. I think it is a very individual choice.
Professor Beresford: I have noticed that government does talk a lot about choice, service users talk a lot about control, and they are different, and there are tensions. For example, in relation to day services (and I can speak particularly in relation to mental health service users) mental health service users are seriously concerned about the disinvestment closure of day services. There have been day services, day centres for mental health service users and people with learning difficulties that have not been good, which have just been, as it were, waiting rooms, but what they can be (and some are) is places where people can feel safe, have relationships, get support and have a springboard to other things. If you talk to mental health service users - I have heard this so many times - people say, "It is not often safe outside. If I behave in a way or am seen to be different or weird, people may not be nice to me. I like to be somewhere where it is not like that. I would love to go to a café, but it is £2 for a cappuccino. I would like to go somewhere where I can feel reassured." The worry is, of course - and I think Caroline referred to this - how do you sustain two different systems at the same time, but the bottom line is, if we are talking about personalisation, we must be offering the kind of choice that is implied in your comment.
Q789 Mr Syms: Should day services for a centre be ringfenced?
Professor Beresford: I do not see how you can ringfence one service and not another. I think, assuming, in simplistic terms, that the move now has to be to pushing people into employment and disinvesting from services that seek to enable people to have a chance for that and for other things is crude and does not recognise the complexity of mental health issues, the capacity for people to be able to move on but the needs that some have at any time to be somewhere safe.
Mr Waters: It is important to recognise that choice operates at both ends and that just by identifying a particular service model to say, well, if some folk choose to take their personal budget and spend it on other things that will destabilise what is there and, effectively, not be a choice for some of the existing service users - that is very much an issue that needs to be borne in mind by commissioners. Equally, though, the opposite is true. I have managed many, many services over many years and known that the large numbers of people who go there, given a genuine choice, would not be there and have, with increasing choice, seen people vote with their feet. You need to say that this is a double-edged element and it is not a simple thing. Clearly, there are some things that you would say should be ring-fenced. You do want an infrastructure - and those would be the things that Peter and Caroline have talked about - and you need to make sure that there are good advice, support, planning and advocacy systems available to people.
Professor Beresford: User-controlled services, user-controlled organisations.
Mr Waters: There is an infrastructure that works for a new system that enables people to make informed choices and to take control, and those would be the sorts of areas that you would say that, if you want to protect something - the protection of vulnerable adults - you would need to have a system in place to see that there is an independent, most probably, local authority led body that takes that forward. You would not want to let that disappear. So there are clearly things in the system where you would say a helpful infrastructure is helpful. When you start getting into direct service provision, you need to bear in mind that choice is not an all or nothing for the folk who end up in systems. If the local authority has pre-purchased a bed in a home, they are going to use that and somebody is going to end up in there, so if that is committed, then that person's choices are restricted.
Q790 Mr Syms: Do you think it would be practical for individual service users to collectively commission services, whether it is a day centre or a dance class? Do you think that would be practical or do you think that would be local authority led?
Mr Waters: There are examples in the traditional system for many years where local families of people with learning disabilities potentially will have gathered together and set up a service. There is nothing to say that that cannot happen. There are some pilots under way exploring this issue more formally, in terms of personal budgets, with a housing association piloting some work in this area, but it is fairly early in terms of the idea of personal budgets and collaboration.
Professor Beresford: Coming from the other end, for at least 20 years there have been efforts by service user organisations to establish collective services run by service users, and a major piece of research by the National Centre for Independent Living and the Centre for Disability Studies at Leeds University reported an evaluation of that and those services were particularly valued. What worries me, though, is that we have a Government, and I am sure an Opposition, which is committed to a plurality of supply, yet we know that so far enough attention has not been given to supporting service users and their organisations to establish the kinds of different and valued services that they have been able to initiate but not develop far enough.
Professor Glendinning: I just want to add a reminder that older people are the biggest group of social care service users and reiterate my earlier point that people, by the time they become eligible for social care, are often fairly frail, may well have health problems, and the notion of organising your own services is, I think, not always realistic, nor should it be assumed that carers will do that for them.
Q791 Mr Scott: It seems widely acknowledged that brokerage, advocacy and advice are an essential part of putting people's own care packages together. Who do you think should provide it and how should it be paid for? Could I perhaps start with John?
Mr Waters: In terms of the total transformation that we have been talking about, there is clearly an issue. Large sums of money go on the transaction of the system already, and one of the dangers is that if you suddenly invent a new profession of brokerage, you end up saying, "Well, how do we fund that?" and you take money out of the hands of disabled and older people. Clearly, in terms of funding, one constraint will be you do not want to add to the transaction costs here. In terms of the idea of brokerage, we found it very helpful to think of it as a series of tasks and functions that need to be carried out rather than a role that any one individual can carry out and, also, to make the systems as straightforward as possible. Often it serves people's interests to create an industry around brokerage. There is a danger that you could make the whole process so complicated and planning so difficult: "That is something that I can do and needs to be paid for". One of the things in terms of opening out control needs to be where people themselves or their family members want to help people sit down and figure out, "How do I use a personal budget to achieve the outcomes that I want to in my life?" that there are systems there in terms of information and there are things there that people can draw on and can use. Rather than thinking of brokerage as something that has to be done by paid professionals, there are questions to be asked around how do we make the whole process as easy to navigate as possible, and then, when people themselves (and we see lots of examples of this) have sat down and developed a support plan, they often think, "I want to help somebody else", and the idea of peer support and enabling people and organisations to support each other around some of these aspects of brokerage.
Professor Beresford: I would want to add to that. I think that John is right to caution us against the over-professionalisation of the role of service broker, but if we go back to comments that have come from several of us, being able to make meaningful choices, being able to give informed consent can be very difficult when you have no track record and experience of doing that in relation perhaps to a crisis, a changed circumstance in your life and the need to turn to social care. I would refer people to the work that has been undertaken by the National Development Team for Inclusion, who have given a lot of very careful thought to the role of service brokerage, for example; and I think what they and I would agree with is that we need to have service brokers who are not over-professionalised but who are skilled and qualified - we need some form of qualification - and who are independent, and that needs to be accommodated in costings. One of the points that they have made is that the management of such independent service brokers should very much be including people who come from service user perspectives and service user organisations. I think that would offer a real corrective to over-professionalisation, but, whatever we call it, people will need some kind of help in getting the best out of new arrangements for choice and control.
Professor Glendinning: I would add two points to that. First, I think it is important not just to think about the initial sets of choices around services but it is about ongoing support, ongoing support as your condition changes. As your needs change, you may want to make changes in the services and kinds of support arrangements that you have. So I think people need ongoing support; it is not just that initial thing. The second point is your point about the expertise that brokers have. I think that achieving good professional brokerage or advice services requires financial stability, and I think it does require investment by local authorities.
Q792 Dr Taylor: Peter in What Service Users Want you say that direct payments should not be "framed in narrow consumerist terms of individualised purchase of care." You are just getting at the flexibility that we need with that, are you not?
Professor Beresford: Partly, but I think we need to accept that having help when things are difficult to be able to live your life under what may be changed circumstances is not the same as buying a fridge or going on holiday. It really is not. Of course when you do go on holiday and you do buy a fridge, there are set up quite a few systems and organisations to safeguard and protect you. The whole crux of this is about enabling empowerment in a meaningful way, so that you could take back control over your life. One of the wonderful things about good social care, whether we are talking about people at end of life or when they have sustained through onset of impairment, mental or physical, some major change, is the way that it can enable people to make the very most of their life and have a positive life, and that is not, again, like buying a fridge or buying a holiday. You need help, you need support, as well as the flexibility you have just mentioned.
Q793 Dr Taylor: But empowerment is vital.
Professor Beresford: In a meaningful way, yes.
Q794 Dr Taylor: Steve Cohen wrote an article in Community Care magazine: "Personal budgets remove choice." What do you make of that?
Professor Beresford: I wonder where Steve Cohen is coming from. I think the Government is getting it right. The Government started off with a bit of a preoccupation with means, and now, because it is talking much more not only about individual personal budgets but about personalisation, it is talking about goals and desired ends, and that is what it has to be. It is a weird word "personalisation." As I heard someone say the other day, it has taken us until the 21st century for social care to realise it is about human beings and enabling it to be in accordance with their unique rights and needs, but the truth of the matter is that we do have the potential for more change if we see this as a whole spectrum - Caroline has emphasised that - of different ways that you can get what will work best for you to maintain your unique aims in your life but your shared rights in our society.
Q795 Dr Taylor: And goals and ends are the crucial, important things.
Professor Beresford: Get the goals right, get the outcomes in your head, and let us spend a little less time just looking at technicalities.
Q796 Stephen Hesford: Should the Vetting and Barring system apply to personal assistants? Should PAs be regulated? If they should, how would it work?
Mr Waters: As Peter says, if you are taking control, you are making decisions in your life, there is a range of systems, are there not, that we can put in place to regulate the service we are getting? The key thing here would be in terms of access to that information and how you make it feasible that an individual who chooses to invite somebody into their life - because effectively that is what you are doing when you are acquiring a personal assistant - has appropriate and ready access to relevant information. It is a relevant safeguard.
Professor Beresford: I was interested in the comments that I think Caroline made about the Dutch experience, about making sure that there are in place the usual sorts of control and regulatory arrangements that there would be for any kind of employment. I know that service users have big qualms, and have long had, about simplistic assumptions that regulating and registering of personal assistants will sort it all out. They worry that it will be registered and regulated in accordance with old-style approaches to supporting people rather than regulated and registered in accordance with what they want out of personal assistants. But something sticks in my mind from being a member of the Commission in Hampshire: one service user who gave evidence, who also supported many other people in relation to PAs, said, "I have to say the fact that someone has been CRB checked and had all sorts of other kinds of formal acknowledgement never convinces me and has never worked. What really works for me is my gut feeling about them as a human being." We are talking about very complicated judgments here. If we make sure that we have an occupation that is better understood, better valued and better rewarded, we are more likely to get a better quality of person doing it and then we might want to review, in association with service users, what kind of regulation and what kind of registration.
Q797 Stephen Hesford: You are arguing, in some ways, for a sort of free-for-all kind of anarchy, because there would be potentially no control over people's exercise of whim. It would all be down to some personal whim of a user, and the system on each and every occasion would have to respond to that and would have no defence to it. That seems to be to be the logic of what you are saying, Peter. We have heard about councils running banks of PAs and having lists of preferred providers for people with personal budgets. Logically, from what you say, that would be just rubbish, because people's gut reaction could completely cut across that, even if it was some kind of attempt to make the system work.
Professor Beresford: When it comes down to who we would want to have involved in our
life, undertaking personal and intimate tasks, it will be down to the most
sensitive kinds of choice, and I am not suggesting that. I have heard people
say who use personal assistants that they are concerned about systems of
regulation and registration giving people a false sense of security. I also
know of service user organisations who operate and support direct payment
schemes which have developed the equivalent of banks of PAs because there can be
problems when people are having holidays or people get ill. You need more
systemic arrangements which we do not have yet. We are at early days still for
personal assistants. It is a massively expanding occupation. We need to put in
place - and I think the
Professor Glendinning: We also need to think that personal assistants are only a part of the social care workforce even under personalisation. There are still, and will continue to be, very large numbers of care workers who work for agencies as well. We have to be careful that we do not concentrate on the personal assistant end and allow some of the provider agencies to become destabilised. They are having to respond to very different kinds of market situations, and some people will prefer an agency because they will see that as offering greater protection than being an individual employer. We also need to think about the other areas, ways in which people seek and obtain social care support.
Mr Waters: Very practically, that range of options can increase choice. As Peter says, if you take the role as an employer directly, you have responsibilities. This is not all about rights; it is about responsibilities and you are tied into that. As an employer, if you choose to draw your support from an agency, then you have potentially greater flexibility in saying, "We didn't quite get on, I would like my support from another person, please," so that keeps that choice open. In terms of the idea of preferred provider lists, an interesting question arises, to which I think Peter was alluding, in terms of saying, "Whose preferences are these?" in the measures that local authority commissioners use to assess the quality of those providers and how we listen to the experiences and voices of people who need support in that process and then share that out appropriately. One of the areas of innovation that we are taking forward with a number of local authorities is exploring a form of eBay for social care, where there is a reporting system where people can vend a rate and people can draw down and offer comments back. A range of options here give different levels of choice to people, but at the end of the day we really need to figure how we listen to people and how we share that information and make use of some of the developments in technology that open up those opportunities to us.
Q798 Charlotte Atkins: Thank you very much for that. That ends the session. Thank you very much for coming along. It has been a very interesting session this morning. Thank you very much for helping us with our inquiry.
Witnesses: Ms Jenny Owen, President, Association of Directors of Adult Social Services, and Councillor Sir Jeremy Beecham, Vice-Chairman, Local Government Association, gave evidence.
Q799 Charlotte Atkins: Good morning. Welcome to our sixth session of our inquiry into social care. Could you for the record give us your name and current position you hold, please?
Ms Owen: My name is Jenny Owen. I am the President of the Association of
Directors of Adult Social Services and the Director of Adult Health Community
at
Councillor Sir Jeremy Beecham: Jeremy Beecham, Vice Chairman of the local Government Association.
Q800 Charlotte Atkins: Thank you. You both say in your memos that social care is underfunded. How much is it underfunded and how do you calculate that?
Councillor Sir Jeremy Beecham: We can start with Alan Johnson's prediction that by 2020 there will be a £6 billion gap in funding. That was predicated on the current level of needs, but as we all know demography and medical advances are likely to increase that. Another way of looking at it is that an LSC study forecasts that we need over 3% real terms growth every year to keep pace with those trends. There does seem to be a very significant gap, and of course that covers both the health and adult social care services provision within local government.
Q801 Charlotte Atkins: What proportion of local government spending currently goes on social care?
Councillor Sir Jeremy Beecham: It partly depends on how you define local government spending. Taking the totality it is about 13% but it is a much higher proportion of what local authorities have discretion over because within the total expenditure there are vast amounts of direct grants, particularly in education. Adult services in social care would be the largest item in the expenditure of most upper tier authorities (unitary and county authorities) by a considerable margin.
Q802 Charlotte Atkins: Obviously you will have heard that the state of public finances are going to be heading into tough times. What will that mean in terms of preparations for budgets for social care?
Councillor Sir Jeremy Beecham: In any event councils are having to, and are succeeding, in generating efficiency savings. Many councils are re-engineering the way that services are provided, including adult care services. One of the necessary features to bear in mind here is that we have to move to a more "whole systems" approach, so we have to look at both health expenditure on social care and local authority adult services expenditure. Local authority adult services expenditure is only about one-seventh of the NHS total budget. In addition however, to, as it were, direct provision through adult services, local authorities also of course support a range of services which impinge periodically upon the clients in question. Whether that is housing, leisure, transport or education, there is a range of services which apply to that group, and of course that group itself is two-thirds people of pensionable age like me and one-third of younger people, so it is a very diverse population that we are looking at.
Q803 Charlotte Atkins: Jenny, would you like to come in.
Ms Owen: I would obviously agree with that, but perhaps I could add a couple of points. First, the Green Paper The Future of Care and Support talks about a £5 billion funding gap that we are going to be looking at in the future, and I think it is important to state not what the funding gap looks like now but thinking about what we are going to be heading into with the big demographic changes that are clearly coming into place. £5 billion is a round figure, a big figure, so look at that. In terms of the local authorities funding of social care, it is also worth noting how much of that can come from local council tax. There is a big variation but, on average, 39% of social care costs are funded by local government through council tax, and in some places it is up to 80%, so there is a significant amount of money that comes from local funding, from local taxation. Your final point was about how we are managing with the economic downturn and the squeeze on budgets.
Q804 Charlotte Atkins: Yes, the preparations you are making for the tough times ahead in social care budgets.
Ms Owen: I know from my colleagues nationally, colleague directors across the county, that we are all looking at very significant budget gaps between what we are looking at and what the current costs are, and looking at the demographic pressures. There are very significant gaps that we need to be managing and there is a whole range of activities going on in looking at every bit of efficiency that we can find, looking at how we can do things differently, integration, taking money from back-office costs, lots of work which is broadly labelled "Transformation activity" but which is really trying to do things in a more cost-effective way, because there are very significant concerns about that.
Q805 Charlotte Atkins: You were talking about a big variation across councils for the cost of social care. What is that down to?
Ms Owen: I was talking about the very big variation between the costs that are funded through local council tax. There is a number of reason for the variation in terms of costs between councils. Clearly there are differences between regional variations, the costs in the market, the costs that you have to provide care, the amount of costs for staffing and wages and so on, and we know there is a very big variation between how we spend our money.
Councillor Sir Jeremy Beecham: There is a slightly worrying trend in terms of commissioning, because there is a temptation in commissioning to look to reduce the costs of, for example, domiciliary service. I know in my own authority significant moves have been made there and the outcome of that is that the outsourced staff are being paid at or just above minimum wage to quite a significant degree less than they would have enjoyed with the local authority, and it does raise questions about workforce planning and whether you can attract and retain people with the right skills. That is a concern, but councils are often being driven in that direction.
Charlotte Atkins: Thank you.
Q806 Stephen Hesford: The Green Papers sets out funding options. Which, if any, do you favour?
Councillor Sir Jeremy Beecham: The LGA does not have a position on which of the options it favours, but personally I lean towards the compulsory insurance model. We have not really taken a view about at. Our prime concern is that which Jenny and I have both touched on, pointed to by the Chairman, which is the totality of funding.
Q807 Stephen Hesford: Can I ask why the LGA does not have a position?
Councillor Sir Jeremy Beecham: Because our concern is primarily about the totality of the funding. There will be further debate about how it is to be provided. For us, the main thing is to ensure that the quantum is right, and particularly, as I say, that we look at the whole systems approach, which involves the NHS funding. One of the great gains in the proposals around free personal care, about which there are of course still numerous questions to be answered, is that this does get the NHS firmly into the game of effective partnership with local councils in a way that perhaps we have not seen since joint finance projects expired sometime in the 1980s, I think it was. It has not really happened to a significant extent since then and it is potentially a very important step forward. After that, how it is funded of course, in terms of the balance between tax and contributions, is a wider issue, but from the service perspective, the crucial thing is to get that effective partnership and NHS resource into the provision.
Q808 Stephen Hesford: Jenny, which model?
Ms Owen: ADASS does not want to rule out entirely the tax-funded option. We thought it was ruled out too soon and that it needs a bit more looking at.
Q809 Stephen Hesford: Are you lobbying us to put that back in?
Ms Owen: I think it should be looked at again and not be dismissed. If, once you have done that, you dismiss it and it is a range of the other options, the most important thing for us is that enough money gets in the system, and the model that we think will get enough money in the system is the comprehensive insurance model. That is what we are supporting, for that reason.
Q810 Mr Scott: The Green Paper proposes either a fully national model or a part local/part national model. What would your response to that be?
Ms Owen: You are not quite touching on this, but perhaps I could first of all say that we absolutely support the notion of a national assessment, the portability of assessments. That is one part of a national system: that if you have an assessment it should be consistent nationally and people should be able to move with it.
Q811 Mr Scott: That is the next question. We will be coming to that.
Ms Owen: Okay. On the second part, which is about how the funding should be delivered - Should it be nationally determined? How much money there should be for that assessment? Should it be locally determined? - we have a position here where you can see the advantages and disadvantage of both systems. We are saying that there are significant advantages in having a part local system. As I was just saying, in some places 80% of social care is funded through local government tax. There is a demographic accountability. You can tie it in and work closely with your partners in the locality; you can work closely with the NHS, primary care trusts, GPs; you can work very closely with other services provided by councils that are really important to people's lives: transport, universal services and all of those things. It is very hard if you do not have that locally driven. However, we know that a lot of people find this inconsistency between what you get in one place and what you get in another, what you are allocated in terms of the funding, is very difficult. We would say that if the Government was going to introduce a national system of funding - so that there would be this amount of money, an entitlement, and it would be nationally determined - then the risk about how affordable that is should be held nationally. We have seen this before, in the past, around residential care and social security payments. Local government is very good at getting a finite budget, a determined amount of cash and working within that budget. We take the risk of demands and the amount of money not working terribly well - the demands are much more than the money we have - and we try to make that pot work. If you have a national funding entitlement, then there is a risk that the control of that money is nationally held.
Q812 Mr Scott: Would it not be, at the moment, that there could be accusations, depending on where you are in the country, that it is a postcode lottery.
Ms Owen: Yes.
Q813 Mr Scott: You will get a great service on one side of the high street and not such a great service on the other side because it is a different council. A national system would in theory stop that, would it not?
Ms Owen: That is exactly what people say and what they do not like about a locally determined level of funding, because it will be different. That is absolutely clear. However, nationally there is a level of funding available, and the costs escalate. The costs of residential care funding, because it was held nationally, escalated over ten years tenfold because there was no cap on it. It is a very interesting question that the Government are considering doing this. There is an issue about that. However, on the other hand, there is another issue which it is important to consider. It is not jut the funding that would go into somebody's personal budget or their care allowance, you also have to provide funding for preventative work, for those universal services that need to be delivered locally. I think it is quite a complex system when you start thinking about national.
Q814 Mr Scott: Sir Jeremy, what in your view would be an ideal balance between local and national funding?
Councillor Sir Jeremy Beecham: The concept is best described by looking at a national care guarantee rather than talking about a national care service, so that you have that basic entitlement wherever you are. How it is delivered will depend on local circumstances and local choice, of course reinforced by local accountability. After all, we have had the National Health Service for 60 years and, arguably, we have not eliminated the postcode lottery there. Sometimes I have been tempted to form a society for the preservation of the postcode lottery because I do think you have to respect local differences, not only in demand but how you meet that demand, and so you need a system which is flexible enough to allow you to engage with other partners, the third sector perhaps, in particular, to commission appropriately and to offer choice. You cannot do that in a monolithic bureaucratic structure, so you do need to have the framework of a national care guarantee and then that is delivered locally. As to the balance of funding, there is an issue here too, because if the funding were to go national, that would have a significant effect on the gearing that would affect local authorities. Already it is 75% central funding/25% local funding, so a 1% increase in a council's expenditure translates at the moment, on that gearing, into a 4% increase in council tax. The more you push towards the centre, the greater the impact on local council tax of any other decisions that you might be making, including those on services which are not within that national funding: housing, transport and the other things that Jenny and I have both referred to. There is an additional potential downside to, as it were, nationalising the funding in the way that has, for example, happened to the funding of schools, but I do not want to reopen that particular argument. The system, basically, would be a national care guarantee, locally delivered, locally accountable, and based very much on local authorities working in partnership with NHS carers and third sector and, indeed, private sector organisations.
Q815 Dr Taylor: Before I move on, I am delighted to hear you say, Jenny, that the tax-funded option should perhaps remain. That was very much the message from our previous witnesses. They disagreed with the assumption that we cannot ask for more cash from the working age principle, provided people can trust that they will get help when they need it, which I thought was absolutely crucial. To move on to the nationally-uniform assessment, ADASS says that "The Single Assessment process has not been fully embedded across the Health and Social Care System and needs to be in order to underpin [this] agenda." Why will a new model work when this has been in place since 2001?
Ms Owen: The Single Assessment System is a single assessment across health and social care. Although there were different models that you could use, you would work on your single assessment in every locality between health and social care. It was not a single national assessment that worked across the country; it was different in every place, depending on what kind of system you used and the basis for it. The reasons that single assessment between health and social care has not worked very well across the country are many and varied but one of them is not having compatible IT systems. We still do not have IT systems that talk to each other.
Q816 Dr Taylor: As basic as that.
Ms Owen: It is really basic stuff, yes. There is a specific thing about that, but the principle about having a single assessment linked to a national assessment really is the same. If you have a national assessment, you agree that assessment criteria. You are still going to have people completing that assessment, and those assessments are between the social care professional and the individual. You would not have a scientific absolute correlation - and I cannot believe that will ever be the case - but you can create a national assessment system where the same questions, the same criteria are used, in the sort of way that we have the FAC (Fair Access to Care) criteria at the moment.
Q817 Dr Taylor: Do you see computer systems becoming compatible at any time?
Ms Owen: Between health and social care?
Q818 Dr Taylor: Yes.
Ms Owen: I hope before I die!
Q819 Dr Taylor: Presumably you would be in favour of something this Committee has suggested for a long time, that there should be some merging of social care and health budgets.
Ms Owen: I think we all would agree there must be greater integration of working between health and social care. How that looks? I do not favour, personally, just structural solutions - I think it is more complicated than that - but greater integrated working and the systems and processes that underpin that are important.
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
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
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 and were 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 good councils. That should have been the headline but it was not. There are eight adequate councils. I would be 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 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.
Q840 Stephen
Hesford: You are not a
Councillor Sir Jeremy
Beecham: I do not know that there are many
Q841 Stephen Hesford: Jenny, obviously you can add anything you want to what Jeremy has said, but in terms of levers to get this thing done, what are they and how are they working?
Ms Owen: I do not recognise the parallel working question.
Q842 Stephen Hesford: It is more that Jeff Jerome's organisation, as I understood what they told us, did not seem quite to fit. It seemed to be bolted on.
Ms Owen: Perhaps I could address that part of it as well.
Q843 Stephen Hesford: Yes.
Ms Owen: Rather than seeing this as parallel activity, I see it as absolutely essential and the whole of the work that we do in local authorities at the moment in adult social care is a huge transformational programme. It is cultural change, it is process change, it is operational practices change. It is fundamental. When we brought in the community care changes in the early 1990s, that was fundamental change. This is bigger, in my view, and it will take just as long. I think that was underestimated when it started. I would say a very, very significant programme. It was set up by government as a three-year programme, funded for three years. We are halfway through, so we have some idea about progress which I will come on to. In terms of what we did in order to help the sector, one of the things that has been very, very good about the way this government policy has been implemented is that it has been done in co-production with local government. That means we have sector-led improvement, the sector driving the agenda. We set up a consortium to manage that. It consists of the Association of Directors, the LGA, and the IDEA. That group of people, with Jeff Jerome as National Director, provide leadership for us around the work. So not parallel but actually providing some leadership and driving forward. In terms of where we have got to, one of the problems we had to begin with is that one of the soundbites, one of the easy ways of describing personalisation, was "personal budgets," but of course the changes are much more significant, much bigger than just personal budgets. They range right through from looking at prevention, looking at information, looking at market development, looking at social capital in the way our communities are organised. It has fingers in each of those areas. We did a self-assessment back in April and May, and in May we were able to set a benchmark of the progress that had been made. We knew from that piece of work that there was progress being made in every authority. Most councils had dedicated teams to lead the transformation agenda and it was funded by the reform grant; most had active engagement with their providers and were planning for development in the markets; four out of five authorities were saying that provision had already become more flexible; 23 authorities felt that their local information services were going to provide good information, advice, potentially advocacy. When we did this survey - so the latest figure then we had was 31 March - 93,000 were receiving personal budgets. We were asked to estimate how many we would have by March 2010 and that was estimated at 206,000. You can see, starting from a fairly low base, that the trajectory was fairly significant. There are big variations, everybody started from a different place, but everybody is working on an aspect of the transformation. In terms of levers, because this is co-production and we are driving the improvements ourselves, we have put our own feelers in place. There was a letter that came out from the LGA and from me as President to say: "These are the milestones" and we set five milestones that we expect everybody to have achieved. I could go through those with you if you like, but they are around how you engage people, the people who use services, what you are doing around prevention, what you are doing about information and advice.
Q844 Stephen Hesford: When did that letter go out?
Ms Owen: It went out in September, so a couple of months ago. Everybody is
now working to that. They have to do returns next March, and we are looking at
how we do the collection. The work that is currently going on is on what bits
of support local authorities want to help reach each of those milestones. We
had our national conference in
Councillor Sir Jeremy Beecham: It is interesting that quite a number of councils are now using people who have been through the system and benefited from it as advocates to spread the word. That is partly leading to this more than 100% increase in people on the personal budget side.
Q845 Stephen Hesford: Personalisation, it is suggested in some quarters, is an excuse for budget cutting. Is that fair comment?
Councillor Sir Jeremy Beecham: It should not be. When we talk about personalisation we should not be thinking of it purely in terms of adult services either; we should be thinking of it in terms of health generally. Of course that is part of the Government approach. Obviously efficiency is important. I suspect personalisation may be more costly rather than less, given the need, as I say, to help people through the system, but it is undoubtedly the right approach, and we have to offer people more choice and tailor the service to their needs and aspirations
Ms Owen: I think it will be better value for money. My experience locally in
Q846 Stephen Hesford: The 5,000 of your total responsibility, the number of people accessing adult social services, what percentage does that represent?
Ms Owen: At the moment, any new referral, referred in since last October, is
being offered a personal budget. Some people are taking the money. Some
people are saying that they want a managed service, but it is very
transparent how much that service is costing. About half the people are taking
a bit of both. Overall in
Q847 Stephen Hesford: Is the 5,000 a good sample to give you a good idea of where this thing is going?
Ms Owen: It is giving us a very good idea of what people are choosing in their support plans, of ways in which their care and support needs can be met. Some of the most interesting things that are coming out of that are the different ways in which people's support plans look from their old traditional care plans.
Q848 Charlotte Atkins: Jenny, could we have a copy of the letter you mentioned.
Ms Owen: The milestone letter.
Q849 Charlotte Atkins: Yes, please.
Ms Owen: Certainly.
Q850 Charlotte Atkins: I would be grateful if we could have a copy of that. I am going to move on to talk a bit about direct payments. Direct payments have been available since 1996 but the take-up has not really been very high. We are now moving very much towards individual budgets, personal budgets. Is this an attempt to repackage direct payments which in some people's view would be seen to have failed?
Ms Owen: I think it is a bit different. Direct payments historically were aimed at younger physically disabled adults. They did not have very big take-up with older people, and so they were very much more focused I think. They were used and allocated to help people organise their own care. The personalisation agenda is much more wide-ranging. One of the differences with personal budgets should be on what you can use it for. Direct payments were quite strictly ruled around that. There were rules about what you could use your direct payment for.
Q851 Charlotte Atkins: Yes, you were not able to use it for local authority services, for instance.
Ms Owen: No, and it was very difficult to use people who were in your close family circle and so on. This is opening all of that out. Because it is about whole system change, it is not just about repackaging direct payments. You can see from the take-up of 93,000 straightaway that it has much wider appeal. I think we now know that something like 40% of the personal budgets are going to older people. That was not the way in which direct payments were used in the past. I do not think it is just a repackaging; I think it is a transformational change.
Q852 Charlotte Atkins: Older people are claiming it more and younger people are continuing to do so.
Ms Owen: Yes.
Q853 Charlotte Atkins: One other thing that seems to be changing is that rather than having individual budgets which combine several funding streams, we are now moving to personal budgets involving just social care funds. Why is this happening? Why is the reason for this? Does it matter or is it just part of the transformation process?
Ms Owen: That is a difficult question. In
Q854 Charlotte Atkins: We are already seeing personal budgets in the NHS. Would you like to see personal budges integrated right across health and social care?
Ms Owen: Yes.
Q855 Charlotte Atkins: I can understand you, coming from the Director of Social Services, wanting to get your hands on that big pot of money at the NHS. Inevitably, I know that at local level many local authorities think that, for instance, primary care trusts should be contributing much more towards social care budgets. Do you think you will get resistance from the NHS locally, or do you think now that local authorities are working in a much more partnership-led way with commissioning services together?
Ms Owen: The issue about health personal budgets we still have to play out and see how they are going to work. The pilots will help us to see that. The pilots are going to focus on people who have long-term conditions. In my authority we were going to look at one around mental health needs. We are spending money on the same people. This will not be able local authorities getting their hands on the NHS money; this will be about the NHS community services, who are currently supporting somebody, the same people we are supporting, putting that money together, so that package can then be flexible and controlled by that individual. That will start to make a big difference. The money is already going into that person but not in a co-ordinated way.
Councillor Sir Jeremy Beecham: Benefit sharing is really the name of the game, is it not, as opposed to cost shunting which is a traditional feature of the relationship between local government and the NHS. It has to change and in many places it is doing so. There are doctors who are now using part of their budgets to send people on what would be regarded as leisure type activities, dancing or swimming or whatever, because it is conducive to their health. That is a more sensible view because, ultimately, that becomes a preventative measure, either preventing illness developing or certainly making it more bearable. I think there is a willingness. We are speaking largely of PCTs and what I am not sure about is the extent to which the acute sector is engaging with this agenda.
Q856 Charlotte Atkins: I think PCTs might agree with you.
Ms Owen: Interestingly, when you think about the acute sector, one of the things we know is that too many people end their lives in a hospital. They do not want to be there but the alternatives are not there to support. End of life care would be a really good example, where if you put the personal health budget and the personal budget from the local authority together, people could make choices about how to end their lives with the right care and support where they want it.
Q857 Dr
Naysmith: Jenny, one of the risks of
personalisation that we have heard about from previous witnesses is that some
collective services, such as art classes or music classes or dance classes,
normally held in day centres, have closed down as a result of personalisation. You
must still be running them in Essex - quite a number of them, I suspect, with
the size of
Ms Owen: Yes.
Q858 Dr Naysmith: Does it matter if that happens?
Ms Owen: It is very difficult to say that that cannot happen. If you are giving people choice about where they want their services and they are choosing not to use the services we currently run, then I think it says something about the services that we currently run and whether they are fit for purpose. For those collective services I think there is a risk, and it is one that we are considering as we are thinking about developing the range of services.
Q859 Dr Naysmith: What can local authorities do about it?
Ms Owen: There are two things we can do about it. One is that we must be very flexible and make sure our money is not just tied up in services so that people cannot get a choice because they cannot access the money more flexibly. The second is that, by looking at what people are choosing to do with personal budgets and listening to what people want from those services, you can re-orientate them and make sure they are exactly what people want. We have not seen, at the moment, huge numbers of people leaving our day services, but we do have some very interesting conversations going on with our services, where people are saying, "Let's think about this. If people wanted to buy this what we would give them that is different?"
Councillor Sir Jeremy Beecham: There could be a bit of an analogy here between this area of policy and, say, parental choice in schools. The exercise of some people's choice, which will suit them, may restrict the choice and availability of services for others. It is a difficult line to tread, I think. We have to be able to protect those who do not necessarily want to do a different thing, who may still want the day centre or luncheon club or whatever even though others may not. All we can really do then, as Jenny says, is to listen to people, listen to the organisations that represent them too, which are very often helping to make the provision, but we must protect those who are not willing or capable of making the choices that some will find easier to do. There will be a cost to that. It is part of the total costs that one has to meet.
Q860 Dr Naysmith: There are things like brokerage and advocacy and advice which are widely seen as essential to help people put together fair packages for themselves. One or two social workers have said, "This is great. It takes us back to being real proper social workers." Is that right? Is that the role of a social worker? If not, who should be doing all these things?
Ms Owen: That is a good question. When I was saying: "It is wholesale change." We are now in a position in all our local authorities of thinking, "What is the role of social workers and of other people in the local authority and of other people outside the local authority, in the voluntary sector, in our user-led disability organisations? Where do these new responsibilities and roles fit." That is why I was saying that it is big operational changes as well as just what you think about personal budgets.
Q861 Dr Naysmith: Who gives the advice in your authority when someone undertakes to go personalised?
Ms Owen: At the moment we have a range of things. Because we were an
authority that had a lot of direct payments, we have built on a service that we
buy from our disability organisation, the Coalition of Disabled People in
Q862 Dr Naysmith: You presumably are paying for it as an authority.
Ms Owen: Yes.
Q863 Dr Naysmith: Should that come out of the payment that is made to them or should it be from council tax and local taxes?
Ms Owen: There is an argument that if you want an ongoing social work service, that is a service, a care management service, and that is a service you should pay for. There is an argument that you could pay for a support plan. At the moment we are not charging people for a support plan. We believe that it is part of our responsibility for the authority to get right.
Q864 Dr Naysmith: Switching hats, in other authorities is it different?
Ms Owen: I my ADASS hat. As far as I am aware, in terms of support planning, that is not a service that has a widescale charging system of being charged through your personal budget. How it will evolve in the future if it goes into brokerage is a question we will have to look at.
Q865 Dr Naysmith: Jeremy, do you have anything to add to that?
Councillor Sir Jeremy Beecham: Not really, except that it could be counterproductive to start charging people to help to the system. Because if they do not take the help, it may end up that something that does not suit them ultimately leads to greater cost on the public purse if the system does not work properly.
Q866 Dr Taylor: I have a series of questions about personal assistants. Remembering that personal assistants might be, as it were, employed by banks of PAs, remembering they might be just privately engaged people, should the new Vetting and Barring system apply?
Councillor Sir Jeremy Beecham: I suppose you could regard it as an aspect of safeguarding in some respects, could you not? Obviously we do take that seriously. Without getting too close to Mr Cameron's views about health and safety and regulation and that kind of thing, one wants to be balanced about this. The important thing is that councils will ensure that there is adequate training available for people and an expectation that those who are assisting will have undertaken some training and on a continuing basis, and that this is a factor that people will be encouraged to take into account when they are making their choices. How formal it has to be, I am not really qualified to say. Certainly on the training side there needs to be some investment in ensuring that people have the necessary skills.
Ms Owen: There are risks and balances here. If you regulate the PAs through the Vetting and Barring system, then you may have some risk diminished but you will also lose flexibility. You may have a range of people at the moment who would want to help you with your PAs, some of your neighbours and so on, and if you have to go through a whole system that might be expensive and certainly would be administratively burdensome. Would people say, "I don't really want to be bothered to do that"? You could lose on the flexibility but at the same time you might be able to safeguard against risks in a certain way. We are still looking at it in terms of a position. We do not know how many self-funders there are who are living at home, but let us just say that half the people who need social care services are self-funders who do not get any of the regulation that potentially we are talking about, then it is really important that safeguarding systems are built into the normal way in which we do our business. Things around how we make sure things are legal, trading standards, and all those ways in which you can diminish risk to us in the community are the things that we need to be looking at. There is an overarching general way in which we need to make sure that there is safety in services, and then there is something about do you get into Vetting and Barring, which has checks and balances.
Councillor Sir Jeremy Beecham: There is also a role presumably for general practice here. Obviously there should be contact. Given the fact that people are clearly in need of support anyway, there ought to be contact with their GP. One would hope that there would be some attention paid within the practice by doctors or other staff to keep an eye on how people are faring under the system. Without getting that too formalised, there needs to be liaison obviously with those with responsibility for care, whether it is a personal assistant or the GP practice, or, I guess, hospitals if they are involved as well. They would not just be standing on their own as personal assistants; there would be other people around with an interest who in that way able to keep an eye on the situation.
Q867 Dr Taylor: That is almost an ideal world, is it not? We all know GPs are rather pulling back from watching people in their homes.
Councillor Sir Jeremy Beecham: Or visiting people in their homes or doing anything very much, it seems to me sometimes - but that is perhaps another story.
Ms Owen: Of course local authorities still have a duty to review people who are having care and support, so we will continue to have that.
Q868 Dr Taylor: Even self-funders.
Ms Owen: Not self-funders. People who are paying through their personal budgets to have a PA, we have a duty of reviewing.
Q869 Dr Taylor: Would it be preferable for future people hiring personal assistants themselves to be able to call on the banks of PAs that councils hold? Because those would be approved people, is that what we should aim for really, that everybody should have access to a bank of vetted people?
Councillor Sir Jeremy Beecham: They should have access to it but not necessarily be required to use it is probably the way to put it.
Q870 Dr Taylor: Access but choice.
Councillor Sir Jeremy Beecham: Yes.
Ms Owen: Yes.
Q871 Dr Taylor: The very last question you have partly answered. Are there any restrictions that should be put on what people can use their direct payments for?
Ms Owen: They should not do anything illegal.
Q872 Dr Taylor: That we have heard before. That is the only restriction we have had so far.
Ms Owen: The most important thing is that it meets the care and support needs.
Q873 Dr Taylor: That is right. They have to be able to choose, do they not?
Councillor Sir Jeremy Beecham: Yes.
Dr Taylor: So only that they should not do something illegal.
Ms Owen: Yes.
Dr Taylor: Thank you.
Charlotte Atkins: Thank you very much for coming along today and helping us with our inquiry. It has been a very useful session. Thank you.