Session 2010-11
Publications on the internet

Oral Evidence

Taken before the Health Committee

on Tuesday 9 November 2010

Members present:

Mr Stephen Dorrell (Chair)

Rosie Cooper

Nadine Dorries

Grahame Morris

Mr Virendra Sharma

Chris Skidmore

Valerie Vaz

Dr Sarah Wollaston


Examination of Witnesses

Witnesses: Dr Hamish Meldrum, Chairman of Council, British Medical Association, Dr Peter Carter, Chief Executive and General Secretary, Royal College of Nursing, Allison Roche, Assistant National Officer, Local Government, Police and Justice Section, UNISON, and Guy Collis, Policy Officer, UNISON, gave evidence.

Q231 Chair: Good morning and thank you for joining us this morning. Will the witnesses introduce themselves briefly, so we know who we are talking to and where you are coming from?

Dr Carter: I am Dr Peter Carter and I am the Chief Executive of the Royal College of Nursing.

Dr Meldrum: I am Hamish Meldrum, GP one day a week and Chairman of the BMA Council the rest of the time.

Allison Roche: Allison Roche, Assistant National Officer for UNISON.

Guy Collis: Guy Collis, Policy Officer at UNISON.

Q232 Chair: I think it is fair to say, of the two representatives of UNISON, that Allison deals more with the social care side and Guy more with the NHS side. Is that correct?

Guy Collis: Correct.

Allison Roche: That’s right, yes.

Q233 Chair: I’d like to start, if I may, on the NHS budget, and then move on to the social care budget later in the session. Then we can conclude with exploring the interface between the two, which is obviously one of the big risks around this programme, but we have to deal with it section by section.

Can we start with the NHS? I would like to ask all our witnesses first of all how you react to the scale of the demand challenge that is faced by the NHS against the background of what is a very small realterms increase in its budget? Sir David Nicholson has said that this challenge represents one of the most substantial management challenges you’ll find anywhere in the wider economy. I would like to understand where the witnesses feel we are in terms of the effect that this efficiency challenge is likely to have on the services that are delivered to patients at the front line of the NHS. Perhaps we will start with Dr Meldrum and then move on.

Dr Meldrum: I would certainly agree that it is-I don’t think it’s one of-I think it is the biggest challenge. As you say, the settlement, although superficially saying that health is protected, will mean that it will be the lowest increase year on year that health has had over the history of the NHS. Then to try to identify 15% to 20% effectively of that budget to actually redirect into other areas in a fairly short space of time, particularly while the NHS is going through yet another of its reorganisations, is going to be very difficult. It is always a problem with a bigger organisation like the NHS in that you can identify individual areas of what might be called inefficiency and try to address them, but unless you look at how these impact on the service as a whole it may not actually overall increase the efficiency. In terms of what we spend in GDP compared to other countries and the outcomes we get, the NHS is probably a reasonably efficient system overall. We can argue about aspects of productivity and ONS statistics-and we may come on to that-but I think it is going to be a huge challenge.

We are already seeing that, in some places, the challenge is not being addressed in a terribly evidencebased or logical way, in that you are relying on happenstance of people retiring or leaving the service to try and make savings. What you will need, if you are going to try to achieve the sort of savings that are talked about, is a fairly massive reconfiguration of the way services are delivered.

Now you are trying to do that at a time when you are getting rid of PCTs, you are getting rid of SHAs, and the new groups that are going to replace, certainly, PCTs, have not come on stream. So one fears that there may be a degree of planning blight over the next couple of years which would mean you would have to always make all the savings in the last year, which I don’t think is feasible.

Q234 Chair: You used the phrase "massive reconfiguration". I wondered what you meant by that.

Dr Meldrum: In some areas, the replacement of PCTs with GPled consortia, whatever form they are going to take, may happen reasonably seamlessly, where there are already good relationships between PCTs and existing practices, where there are quite effective commissioning groups. There are many other areas, though, where, for a variety of reasons, these relationships do not exist and one really wonders and worries about the potential for these areas, which are often some of the more difficult areas in terms of providing healthcare. One worries how they are going to manage in the sort of timescale we are talking about.

The other area, of course, is the move to universal foundation trust status. Again, one worries in the secondary care sector how that process will be managed, having seen some of the problems of hospitals striving for foundation trust status in the past.

Q235 Nadine Dorries: Just quickly. That cosy relationship that you just described between the GP consortia and the PCTs is perhaps one of the reasons why the GP consortia want to break away and, therefore, it is the converse of what you have just said, isn’t it? It’s not a case of if they have got a good relationship it might work with a seamless transition. We actually want to break away from that relationship.

Dr Meldrum: No, I wouldn’t call it a cosy relationship. I would call it effective working, where PCTs have been doing what the coalition’s plans intend them to do. They have actually been listening to clinicians, they’ve been bringing clinicians and patients on board in terms of design of services and working effectively together. The area I think you may be referring to is where PCTs have not been listening to clinicians and other people involved in the design of services, where there aren’t these good working relationships. There, I think, you may have a point, but you are starting from quite a low base and you are expecting GPs, or groups of GPs, and others to get up to speed very quickly from, as I say, a very low base.

Dr Carter: I think this is a question of semantics. It is true that, from one dimension, the NHS has done better than many other departments that have had to endure significant cuts. But the financial reality is that there is not going to be enough money in the system to go forward in the way that the NHS has done over the past few years. So the painful reality is that you have got to decide how you manage that change. The figure that has been used for about 12 months to 18 months by Sir David Nicholson is that £15 billion to £20 billion has to come out. The first thing is that we would like to see the methodology. How was that £15 billion to £20 billion arrived at? It is a perfectly reasonable question.

The second thing-there’s a range of things I could cover, but this is what I would wish to share with you at this point-is that that £15 billion to £20 billion, which, as I say, has been around for nearly 18 months, predates the Chancellor’s announcement that there would be a twoyear pay freeze. So when you consider that over 80% of the NHS expenditure is on pay, has the reduction or the pay freeze now been factored into that £15 billion to £20 billion, because we would suggest the consequence of that is that that figure should be dropped?

The second thing to refer to is that currently-and these are figures from David Flory-foundation trusts are carrying a surplus of at least £2.5 billion to £3 billion. That is 129 foundation trusts. Our intelligence and reconnaissance tells us that many other trusts, PCTs and health authorities equally have significant surpluses. So in this austere financial climate we believe there should be a further examination of just how much money is in the system and whether that level of reserve, that surplus, can be justified in this difficult time. Having run large organisations myself, of course in any organisation you carry a surplus for the rainy day. The reality is that that rainy day is here. We find it hard to understand the justification for carrying that level of reserve when frontline clinical services are being cut. We are not for one moment suggesting any financial impropriety, I want to be crystal clear about that, but there is a whole range of techniques that you can use when running NHS trusts, and it is to do with accruals and provisions. In relation to provisions, the NHS traditionally has, at one level, a prudent approach to provisions. Some other people might say it is a very pessimistic approach. But the reality is that, currently, we believe there are billions of pounds within the NHS that should be the first port of call rather than frontline clinical services.

Q236 Chair: Can I just refer you to one paragraph in your written evidence that caught my eye, and I quote: "We have evidence that NHS Trusts are making shortterm ‘slash and burn’ cuts, which have historically been made to battle financial shortfalls, which are leading to the erosion of effective, safe and quality patient care in the NHS"?

Dr Carter: Would you like me to comment on that?

Chair: I would like you to comment and substantiate that.

Dr Carter: I am sure it is going to be frustrating for the Committee, but this Friday we will be publicising that evidence. I am only sorry that this meeting isn’t next week. The reason I can’t give it to you is that it is still being refined, because we need to be clear that everything we publish on Friday has to stand up to scrutiny. We will be publishing evidence of thousands of job losses, of significant cutbacks in services, and evidence, by way of example, of specialist nurses being cut. We believe that specialist nurses actually save the NHS money. Hamish referred to it. What we are seeing are very blunt instruments, such as recruitment freezes, which are simply illogical. How can you possibly think it is a sensible way forward to make socalled efficiency savings when you simply have, "The next person that resigns, we’re not going to replace"? It just doesn’t stand up to scrutiny. That evidence will be out. As I say, it is very frustrating for us that we are not able to give you the details, but I can assure you that by Friday-and we will be sending this evidence to all MPs-you will be getting the detail of that. So it’s short term, it’s ill thought through.

Can I also say that we have consistently said that we accept that the NHS has to examine itself in terms of its efficiencies, and there are areas where clearly it is inefficient? We have, equally, no problem at all looking at skill mix, looking at where you need nurses, what grade of nurses and what the ratio should be of qualified to unqualified. Certainly there are many tasks that are carried out where you do not need to be a registered nurse. The RCN has never shied away from that. We ought to work with employers. There are too many examples of being "done to" rather than taking us with them.

When I spoke earlier I mentioned about the pay freeze. It is very interesting that health workers-I go all over the UK-by and large have accepted the twoyear pay freeze. They know that the country is in an economic mess. What they are saying to us is that they would rather see the preservation of clinical services and jobs rather than some major confrontation to try to get a pay award which they know is unaffordable. But, equally, they see some of this shortterm thinking that they know will stack up longterm problems.

Guy Collis: UNISON would certainly endorse those opinions expressed by Hamish and Peter. We would also agree with David Nicholson’s statement that this does represent a massive and substantial financial challenge. This is clearly the lowest growth the NHS has ever seen in its 62year history. Even if you take into account the small increase, this is likely to be massively outpaced by the rise in what is generally termed health inflation, when you look at things such as the ageing population, the increase in drug prices and other issues around public health such as obesity and alcoholrelated illness.

Something else I think worth bearing in mind is that the NHS budget is also being used to help subsidise some of the other areas, with £1 billion to social care, and also some money to help out the Ministry of Justice with secure units. So the figures aren’t exactly as they might first appear.

UNISON is slightly more fortunate with the timing of this meeting today, because we publicised the evidence of a survey of 8,000 NHS staff yesterday. This will be going in as part of our submission to the NHS Pay Review Body tomorrow. This is the current situation rather than what people are expecting in the future, and it found that 80% had reported an increase in workload, it found that half of staff had experienced staff shortages and it also backs up the points made by the other speakers about the impact of recruitment freezes.

There is also a massive morale issue at stake here, not just the cuts-the efficiency savings, depending on how you see it-but the question of how these interact with the White Paper and the huge structural upheaval and the people who are getting ready to experience it, particularly those staff who work in PCTs or SHAs. We are going to see a situation where health managers are not only having to plan for huge reorganisation, which could involve the loss of their own job, but also having to find these massive savings. The White Paper makes it clear that there will be a 45% reduction in management costs as well.

Finally, I would just like to return to the question of where the £15 billion to £20 billion figure came from, which I think Peter has already referred to. UNISON is also concerned that there has never been any detail as to how this figure was reached. Certainly the leaked McKinsey report from last year suggested figures something around this level, but it seems to have become the accepted wisdom and certainly we are not aware of any detailed or adequate breakdown of how this figure was reached.

Q237 Chair: I am going to bring others in, but is it not the case-could I just ask you to comment-that actually £15 billion to £20 billion is simply a pounds value attached to the fact that there is a stable realterms budget and there is a 3% to 4% demand rise going on in the NHS, which we must expect to continue through the planning period as it has done over a long period of history? If you have a stable realterms budget and you have a continuing demand rise of 3% to 4% per annum over four years, what you have got to do is to achieve a reuse of between £15 billion and £20 billion of NHS expenditure. What is wrong with that presentation?

Dr Meldrum: I would accept that to an extent, but then it begs the question, not only where is it coming from but where is it going and, therefore, what jobs do you need to actually use that and to plan for those rises. It makes this idea that you have this rather illogical shortterm approach to just cutting jobs, when everybody says it is going to be reinvested, but part of that reinvestment will be reinvestment in jobs.

I think we really need to see a much better narrative than we have up till now: not only what is the rationale for actually making it that amount but actually where are these moneys going to be reinvested, what jobs are going to be needed in order to do that and, therefore, both locally and nationally, having much greater detail about the whole flow of funds and resources over the next four years.

Q238 Chair: You might find your phrase "a better narrative" recurs. Would either the RCN or-

Dr Carter: We read the evidence that Sir David gave to you, and he was absolutely explicit that the whole of the £15 billion to £20 billion is coming back in. We don’t see the evidence of that, and there is something illogical about it if on one hand you say we have to make these savings because there is insufficient money in the system, and then you say that every penny is going to be ploughed back in. The two things, for us, are just not coming together.

Q239 Grahame Morris: I think all three organisations are speaking with one voice in relation to the scale of the challenges, meeting the £15 billion to £20 billion productivity savings. I wanted to explore your views. Clearly you think it is going to impact on frontline clinical services, but have you made any assessment of what that will mean in terms of staff numbers? The RCN has said specialist nurses might be at risk, and you mentioned you have done some surveys amongst your own membership. Are you able to share that with the Committee in broadbrush terms of what sort of numbers we are looking at in the sharp end in the delivery of clinical services?

Dr Meldrum: It almost gets back to what I was saying before. Without knowing what this money is being freed up for and where it is going to go, it is quite difficult to assess. I am particularly talking about the impact on medical employment, but we are seeing areas where there is obviously pressure on consultants on their SPA time-their supporting professional activities time-for research, for teaching and for other aspects of their work. We are certainly seeing pressure on junior doctors’ hours and rota gaps and suchlike too. Until you know where the workload pressures are going to be there doesn’t seem, to us, to be any real effective planning. Whether we will see medical unemployment in lots of medical redundancies I’m not so sure, but I think we will see-and I am particularly concerned-that people at the more senior end of the profession may decide to retire early because of various problems that they perceive, the threats to their pensions and suchlike. Certainly in our cohort study of junior doctors, about half of junior doctors have expressed a wish to spend some time working abroad. I think both the numbers will increase and the time they spend abroad might increase, so we will lose quite a lot of the investment that we have put in to train these people.

Dr Carter: Yes, we do have real fears on this. We launched our Frontline First campaign in July. By July we had already identified 10,000 posts that were going. We will be able to demonstrate over the next week or so that that is now significantly more, but we will be able to give this Committee the absolute detail, by employer and by post, as to where they are. If you go back to 2006 when Patricia Hewitt was the Secretary of State and there was a socalled financial crisis, which, relative to this, was absolutely minuscule, that year alone 5,000 newlyqualified nurses couldn’t get jobs. The vast majority of those nurses went overseas. 80% of newlyqualified physiotherapists couldn’t get jobs. What a huge waste. We would predict, if this carries on the way that it appears to be going, there will be record job losses and cutbacks in services. The impact of that, we believe, will start to show very quickly in things like waiting times going up.

Whatever people think about what happened over the last decade or more-if I could go on, Mr Chairman-people forget about some of the real progress that was made. In 1997, all health authorities every month had to submit data on how many people were waiting 24 months and more. That was a shocking state of affairs. Within a decade, that was down to 18 weeks. I remember Alan Milburn, who many of you will remember, talking about 18 weeks and cynics saying, "You’d be very lucky to get it down to 18 months." The 18 weeks has been, in our view, an outstanding success. That is the sort of thing that will very quickly be eroded. We think it is being eroded in different parts of the country, but the returns are not being made. We would predict, if this carries on, that the progress that has been made will very quickly be lost. That is absolutely no good for the public and it is a huge waste of all of the effort that was made to bring those times down.

The second thing is in relation to, say, the fourhour target for A&E, which has a mixed press. Overall we think it has been a very good thing. I was at a large teaching hospital very recently, and they were really under pressure. The chief exec of the NHS in London has written a letter, which is in the public arena, saying that there are many areas that are now really struggling with the fourhour target. This sister was saying to me that she dreaded the day, which was only 10 years ago, when she used to go off duty and come back two days later and there would be the same people waiting on trolleys that had been there when she went off duty, and these were predominantly elderly people. This is the effect we think is already beginning to happen, and that is before, actually, the real effect of these cuts, which is supposed to kick in on 1 April next year. So this stuff is real.

Guy Collis: In terms of putting an exact figure on the likely number of job losses, I think that is very hard to do at the moment, but I don’t think that diminishes the sense of uncertainty and concern there is out there. In fact, uncertainty is probably the key watchword with both the efficiency savings and the reform programme.

In terms of the type of job that might be particularly affected, there has been a lot of talk, which certainly UNISON considers artificial and divisive, about removing socalled backoffice jobs, socalled support services, which really ignores the importance of "the team" in healthcare. I don’t think anyone, whether as a patient or as a member of staff, wants their doctors and nurses to be spending all their time filling in forms. Admin staff have a role, so do the catering staff and IT staff. So there has tended to be quite a focus on, "These staff can be taken out of the system without any great loss," and UNISON would certainly dispute that. I think already there are reports coming through of hundreds of jobs being threatened across the country. Certainly UNISON would be happy to provide a further note on this if that would be helpful, because we are in the process of collecting things as they come through.

Q240 Chair: I think it would be helpful. Dr Carter has spoken in fairly emotive terms about what is going on, and I guess the question to the RCN is, given the pressures that are on the public sector in general, is there a way of handling the present situation in the Health Service that would mitigate some of the effects that you describe?

Dr Carter: Yes, absolutely. Look, I have just extolled some of the virtues of the previous Government. I think they did some really good things, and there is no doubt they tripled investment. The problem was that they didn’t get into service redesign and so much of the money was poured into the existing way of working. What we have said is that you have to be prepared to change ways of working and where you work, with a greater emphasis on primary care. We also think there are huge tranches of expenditure that are very difficult to justify. I have already mentioned the surplus, which, David Flory himself says, just on FTs runs into £3 billion. We would question the excessive use of management consultants, which we believe is probably knocking on now for the best part of a £1 billion industry per annum. There are also issues to do with the IT scheme Connecting for Health, which started off with a budget of £4 billion, which by anybody’s standard is a huge amount of money. We now understand it is up to £12.8 billion, but we still don’t have an information system which is fit for purpose. How much longer are you going to go on pouring that level of money in?

Then there is a whole range of other areas. Last year, the McKinsey report was published and eventually was made public. What McKinsey said in that report was that they have evidence that in some hospitals at any given time up to 40% of the patients don’t need to be there. What we say is, rather than cutting specialist breastcare nurses or diabetic specialist nurses, let’s get into McKinsey’s data, because if that is accurate-and they published it-let’s say to those hospitals, "Why is this the case?". Is it because of inappropriate admissions? I very much doubt that. It is probably because people are becoming ill, because there is a lack of community infrastructure, and getting into hospital. There’s probably a fair amount of people that are in hospital but, because of lack of resource in the community, they can’t get out. I could talk more about that, but that is what you should be looking at. The three organisations here today have consistently said that we are prepared to look at new and different ways of working.

Q241 Chair: An admission can be unnecessary without being inappropriate, is the key point.

Dr Meldrum: Yes.

Dr Carter: Yes.

Q242 Chair: Those are the kinds of issue, I suspect, without asking you to repeat it, Dr Meldrum, that you had in mind when you used the phrase "service reconfiguration"?

Dr Meldrum: Yes. There are two things. One is about running the present service more efficiently. As I say, I still do some work as a GP, and one knows that people end up being admitted or their discharge has been delayed because there aren’t enough resources-some of these may not be healthcare; they may be more social care, which I know we are coming on to later-in the community to look after them. Also, if you ask most patients what they want, they want highquality care as close to home to possible. That is not necessarily cheaper care. I think we have to make that point. Also there is a problem in trying to do anything like that at a time of financial stringency, in that until you have got these resources set up it is very difficult to close down or reconfigure the other ones. Of course, the other big barrier to reconfiguration, which we haven’t mentioned so far, is PFI, which not only has a lot of inbuilt costs in it for existing trusts but also can restrict the freedom for reconfiguration because these are built into very longterm contracts which are almost impossible to unpick, it seems. One can unpick employees’ contracts but you can’t unpick PFI contracts.

Chair: We have stimulated, I think, virtually every member of the Committee. Graham, are you done for the moment?

Grahame Morris: Yes.

Q243 Valerie Vaz: I was intrigued by your evidence from the RCN about "innovative ways of working", and I wonder if each of you could address yourself to the aspect of what is going right now, and could this have all been done without the new reorganisation?

Dr Carter: This is a heck of a challenge. The £15 billion to £20 billion on its own, which is absolutely massive, has never been done before, and that on its own would be a major challenge. The White Paper on its own would be a major challenge. Put the two things together and this is as big and as complex as you could get. I think it just needs a bit of unscrambling. We are not wholesale against the Secretary of State’s proposals. We have said how could you disagree with more clinical involvement, although we mean "clinical" in a more generic sense rather than just medical doctors? Who could disagree with more patient empowerment? Who could disagree with trying to get rid of process targets, which don’t serve any good purpose? So there’s lots of good stuff in it. It is the pace of the change. Again, one of the mistakes the previous regime made is that they didn’t pilot enough, they didn’t roadtest enough, they didn’t speak enough with people and they embarked on huge changes-take the creation of 400 primary care trusts, which most commentators thought was absurd. That was a fouryear experiment which, frankly, was a failure. It was all dismantled and we went back to 153. They went round in a huge loop and billions of pounds were expended. So we are not philosophically opposed to what is currently going on but we want to see a more measured approach to this at a time of such financial austerity.

One of the weaknesses of the NHS-we are great fans of the NHS and there is more to be proud of than concerned about-is that it still doesn’t learn and share from good practice. Tele-health, by way of example, we are huge fans of, and it is just so patchy in its implementation. You can go from one PCT where they are using it incredibly effectively to next door where it is as though they have never heard of it. Just two weeks ago I was up at the new Newcastle Children’s Hospital, which is very, very impressive. They have a small dedicated team there-it’s called a CANI team-which every morning is focusing on getting children out of hospital who are still ill but have conditions that can be adequately cared for at home by a small group of specialist nurses. It is not only good for the children who don’t want to be in hospital, and obviously good for the parents because they have the children at home, but it is also financially good. When I spoke to the chief executive of the trust about how long had this been running, he said, "Several years." I said, "Is this being rolled out elsewhere in the Health Service?" He said that there’s only one other example and that is Alder Hey Hospital. That is a very real, properlyevidencebased service, and two paediatricians couldn’t have spoken more highly about it, and yet we don’t seemingly have the ability to share that and say, "Look, this is a solution to part of a problem." I could go on and give copious other examples.

Dr Meldrum: I wouldn’t like the impression to get about that changes haven’t been happening. I started off in hospital medicine but I’ve been a GP now for over 30 years. The change I have seen in my practice, the shift from hospital to the community, has been huge, whether it is in diabetic care or cardiovascular care or asthma care-a whole lot of areas. So a lot of change has taken place. But I think to try to achieve the sort of savings that we have been talking about, both the pace and the size of the change is going to be completely out of kilter with anything that we have seen so far. That is why I have concerns that it can actually be achieved. I am not sure there are all the right levers in the system to help achieve it.

One of the issues that we have is the ongoing marketbased approach, the purchaser/provider split, which, to be frank, all three parties in England have been signed up to. Whether that encourages seamless care, good close working between primary and secondary care, whether it reduces transaction costs, whether things like payment by results incentivise the correct sort of behaviour, I think is extremely questionable. There is little evidence that the concept of the competing market to drive up quality and drive down costs has actually delivered.

Q244 Rosie Cooper: I suppose this is to Dr Carter. I have sat and listened to the idea of taking your practice and sharing it throughout the NHS under both Tory and Labour Governments, and everybody has their own bit of good practice that somebody else doesn’t have. I think we need a lot more innovation. If these pockets of innovation are real, why they haven’t been shared, and why are people not concentrating on the fact that it doesn’t just cost money delivering a service which is perhaps not the best, it also affects patients’ health? But that is not really the question; it was more a comment. Earlier on you talked about pay freezes through the health service. I wonder whether you think that was going to be applied universally or, for example, will GPs and those managing consortia not be demanding more money to reflect their new responsibilities? Is the inherent bit of this new "big bang" going to be that the new structures will demand more money for people in roles whilst others are still being caught by a pay freeze?

Dr Meldrum: I would hope not. We have already published principles that we believe should underpin GPled commissioning, and one of them is that GPs should not profit from the way that commissioning operates. We don’t think they should be paid bonuses. Obviously, if they are being employed by the commissioner to take on leadership they should be paid for that, but that is quite separate. We don’t believe there should be any link between how well you perform as a commissioner and the money you get in your pocket.

Q245 Rosie Cooper: I am not talking about profit. If, for example, you are part of a commissioning board, you would still have GP responsibilities, but you would be paid for that period of time you are on the commissioning board. Do you see that being an increase overall in pay that a GP receives?

Dr Meldrum: The only payment we believe that there should really be is to provide backfill in your own practice, so that the clinical work that you are not otherwise doing is backfilled, but that shouldn’t lead to an overall increase in the amount of money that GPs are getting, because any money you get for that will be offset by having to replace that workload within your practice. These people are already doing clinical work. If you take them away from that somebody else has to do it.

Q246 Rosie Cooper: So they should be paid no more?

Dr Meldrum: Yes.

Q247 Rosie Cooper: Okay. I will revisit that in a few years’ time.

Dr Meldrum: Absolutely. I would point out that for GPs and consultants it will be a threeyear payfreeze, because they got nothing last year and they’ll get nothing for the next two years.

Q248 Rosie Cooper: Absolutely. Forgive me, I understand that, but I think perhaps you might want to comment on how much money is going to be going out the door in redundancy pay, the structural costs which will be associated with what I call the "big bang". Frankly, if anybody is looking for a comment from me about what I think is going on, I have only got one phrase, "We’re making it up as we go along." That is what I see from asking questions. We can’t really get to the detail of this vision, because each stage is being made up as it arrives at the door. I think that is frightening for the Health Service.

Dr Meldrum: I think the Government’s own estimates of the costs of reconfiguration are around £1.5 billion. Other estimates have been higher than that. It is quite difficult to know in terms of redundancy, because you don’t know what sort of people will be made redundant and who might be reemployed. Certainly, I come back to both UNISON’s and the RCN’s comment that it is all very well supposedly getting rid of people who do backroom jobs as long as you get rid of the work that they are doing as well. If all you are going to do is transfer that work on to clinicians, then you have not only achieved nothing but you have actually made matters worse.

Q249 Dr Wollaston: I am quite interested in what we have heard from very many witnesses on this Committee that it is service redesign, designing better pathways of care and multiprofessional working which is going to deliver the biggest savings for the NHS, and particularly across health and social care. Do you have concerns that the potential loss of coterminosity that we will get with commissioning groups as opposed to PCTs will hinder the process and make it less efficient?

Dr Meldrum: It is certainly a potential problem. We don’t yet know what the setup of commissioning groups is going to be, and there are lots of different models being proposed. On one hand you want them to be very large to get the economies of scale and get rid of the potential for inyear fluctuations and risk in the budget. On the other hand, if you want to make people feel involved then you would prefer them to be quite small, which is why we think there may be a federated model where commissioning groups will get together and share the wider infrastructure in terms of overall management and some of the other processes they might involve.

I think you are absolutely right that the links with local authorities are going to be vital, not only in areas like public health, with what responsibilities are taken on by whom, etcetera, but in making sure that some of the other issues we were talking about-having a joined-up approach and realising that there’s this huge close link between what happens in healthcare and what happens in social care-are maintained, and also as part of the overall scrutiny and governance of the whole process. Although it may sound strange, I am the last person to advocate that GP-led groups should be just allowed to get on with it without a lot of group oversight, because one of the things that I want to see as a GP is not being conflicted in terms of patients assuming I am doing things purely to save money for a commissioning group rather than in their best interests.

Dr Carter: I think you touch on something quite critical to this whole process, which others have also touched upon. It is about us understanding what is the framework, what are the groundrules. When you talk to people at the Department they talk about, "We’re going to backfill on the detail." We would actually like to see the detail now. How is this going to work? How is it going to hold together? Who is going to take responsibility? In terms of service redesign-forgive me, Chairman, I am sure you will bring me back in if I go off too much on a tangent-one of the areas where we feel PCTs really failed is that they never really got into what they were primarily set up to do, and that was commissioning. Particularly in many of our large cities, in metropolitan areas, there is a huge need to rationalise or reconfigure the acute hospital provision. That simply has not happened. If commissioners couldn’t do that, I fail to see how GPs are really going to cut into that. It has been hard enough for managers to do it, and I can’t see GPs wanting to take the lead on maybe saying for a particular hospital, or part of a hospital, that people have known and loved for years, "Really, things have moved on and it needs to close or change." I think people are really going to struggle with that side of the agenda.

There is a whole raft of other things, and we put this in our submission to the White Paper, which the White Paper is simply silent on. By way of example, there is workforce planning. Workforce planning at the best of times in the NHS is an inexact science. It is very, very difficult. There are lots of times that they have got it right, but plenty of examples where they haven’t got it right. Who is going to do that in this brave new world? It is not readily apparent to us, and there is a whole raft of other examples we could give where we feel there is a danger here that things are going to fall between the cracks, and then we are going to be playing catchup. The trouble is that in the interim period it’s not going to be any good for the service, which we feel potentially would be significantly destabilised.

Q250 Dr Wollaston: The point that Sir David Nicholson made was that the dual challenges of efficiency savings and service reorganisation needed not to be in parallel but to be mutually reinforcing. Do you think the reorganisation is going to be more likely to frustrate all that process rather than being mutually reinforcing?

Dr Carter: Potentially it could, because service redesign and service change is difficult at the best of times. It was difficult in the previous Government in a very healthy financial climate. I think there is going to be a huge amount of tension in the system, and one of the things that staff and commentators think-the current worry-is that the service redesign at the moment is done on the back of needing to save money rather than the back of a good, properly thoughtthrough strategic plan which is taking a local health service forward. And therein lies the tension.

Q251 Chair: Can I just probe you a bit further on that? You said in answer to Dr Wollaston’s question that potentially it could frustrate the process. Do you have any evidence of changes that you think need to be introduced along the service reconfiguration line that have been put on hold or slowed down as a result of the publication of the White Paper?

Dr Carter: In the health service, in times of economic crisis-this is not the first time we have been there; the difference here is the scale of it-all the things that most of us subscribe to, and I’m sure people around this table would, to do with primary care, preventative stuff, are what gets squeezed first, because the acute hospital end is so difficult. Again, to give an example, we have been talking for a long time about issues to do with the sexual health of our children. This country now has the highest levels of teenage pregnancy in Europe. We have a scandalous level of abortions, which is extremely worrying. We believe there is a huge underinvestment in sexual health nurses and others that could help prevent young people getting into this in the first place. We feel that what will emerge is that those are the very services that will be cut, whereas actually they are the services that should be reinforced.

Q252 Chair: What I am probing, from any of the witnesses, is this. I can see that that is a threat and I wondered whether it is a present reality, where evidence can be produced of service change that is necessary to deliver the efficiency gain that isn’t being carried out, because people are being distracted by another agenda?

Dr Meldrum: It is probably a little bit early to say, because there is still a lot of uncertainty about exactly what the process is going to be. Certainly, the evidence from previous times of reconfiguration is fairly clear-that it has caused people to take their eye off the ball. They are more worried about reapplying for their jobs, or whatever, rather than actually indulging. Certainly you can imagine that the enthusiasm for being really engaged with this process is going to be diminished if you realise that in 18 months you are likely to be made redundant.

Guy Collis: Just one example. It is not an actual thing that is happening but it is a specific threat. It might be worth the Committee looking at something like the Productive Ward series which is designed to save billions. There are concerns that, with the White Paper and the review of arm’s-length bodies, this is exactly the sort of positive thing that could be lost, with the Institute for Innovation that runs the series being transferred to the national commissioning board, which will have a huge range of other things to be covering. So that might be something extra to look at.

Q253 David Tredinnick: I want to ask about savings and potential job losses, but before I do, can I ask Dr Carter something? With this workforce planning issue that you have mentioned, is it not inevitable, if you take out the strategic health authorities and primary care trusts, that the decision making doesn’t go down, it actually goes up? So the Department itself is going to find itself making many of these decisions which have been made by strategic health authorities and primary care trusts. Certainly when you come to workforce planning it is not something you can do through commissioning practices, is it?

Dr Carter: I agree with you, and at the same time as losing the strategic health authorities and the PCTs, the Department of Health is going to be shrunk significantly.

Q254 David Tredinnick: My point to you is that it is going to go up and not down. You were suggesting that it was going to be tough for commissioners. I am saying it is impossible for commissioners. If you have lots of commissioning practices, this is a strategic issue and the only place for it to go is the Department of Health.

Dr Carter: Yes, absolutely.

Q255 David Tredinnick: Thank you. On savings, we had the chief executive of NHS Buckinghamshire before us, who suggested that there is a very small amount of money that can be saved "from administrative savings, management savings and the financial back office," and that really if you are going to make the kinds of savings that we are being asked to make, or the Government has asked to be made, it has to come out of clinical care. Do you think that is correct-that trying to get it out of the back room and by improved admin is just not going to work? You can’t do it on this scale.

Dr Meldrum: I think if you are basically going to run the system as it is run and try and get it out of admin, I would agree. I go back to my views about the sort of increase in bureaucracy and management costs that we have seen over the last 10 years, roughly from 6% to 14% of the budget by most of the commentators’ common consent. But that would mean moving away from the marketbased system and the various transactional costs that that creates, to a different system. That is going to take considerable time. But even that, I would concede, is probably not going to make the savings. The main place you will make savings is trying to save on emergency care. That is the bulk of where you are likely or where you can make significant savings.

Q256 David Tredinnick: On emergency care, if I heard you correctly?

Dr Meldrum: Well, urgent care.

Q257 David Tredinnick: Urgent care?

Dr Meldrum: Urgent care in terms of preventing unnecessary admissions, getting earlier discharge, all these sorts of things. But, again, unless the facilities are there elsewhere, that is going to be extremely difficult to do.

Q258 David Tredinnick: So do you think it is vital to fundamentally reconfigure the way we deliver our services?

Dr Meldrum: Well, it is always necessary to do it, because medicine changes. To get back to the point I was making earlier, the idea that we have not been reconfiguring over the last 30 years is completely wrong. But to make the scale of savings and then reinvestment that you are talking about would mean fairly massivescale reconfiguration, which would probably be quite costly in the shortterm, because you are talking about, if not closing hospitals, closing units but setting up alternative facilities in the community. All the evidence shows that that is not particularly cheap, even though in the long term it may be a good thing to do.

Q259 David Tredinnick: I think there is a budget, though, isn’t there for that reconfiguration? I think the Government have made it clear there is a budget for reconfiguration, except that there’s going to be an additional startup cost, or you could call it a reconfiguration cost?

Dr Meldrum: I don’t think, as far as I am aware, that there is a significant budget to cover the sort of startup costs you are talking about. This is really using the savings that you have identified and, as I say, there is a timing problem as to how you achieve that.

Chair: There is an anticipated spend, which is not quite the same thing as a budget.

Dr Meldrum: Yes.

Q260 David Tredinnick: The last thing I want to touch on is job losses, and I would like to ask each of you what are the consequences for the workers you represent of these financial constraints on health and social care, particularly on job losses but also pay?

Dr Carter: I will come to that, but I want to give what you I like to think is going to be a very blunt answer about your first point. Whilst the NHS has got some inefficiencies, it is still overall a very efficient service. If you think you can take £15 billion to £20 billion out without affecting frontline services, I would say the people who say that are disingenuous. If that sum has to be saved-and I question whether it has to be-and if they are going to take that out, the consequences are that you will have to close clinical services, which I think is extremely regrettable.

Q261 David Tredinnick: Could you actually get it out of the reserves, as you were suggesting earlier?

Dr Carter: This is one of the things I want to discuss at my next meeting with the Secretary of State. We believe that there is a significant amount of money in the system that is not readily apparent. I stress again no one is suggesting sharp practice, but whether it be foundation trusts or other trusts, there is a whole set of conventions which people use where you accrue money, and I believe that there should be a much more transparent understanding about exactly how much money is currently in the system, and that should be the first port of call.

I have already mentioned some other areas. Hamish has mentioned the exponential rise in the number of NHS managers, and we think there is a lot of very good management in the NHS, but it has been massive over the years. Running in parallel with that, you have also had an exponential rise in the use of management consultants. You don’t need both. That’s the kind of thing that you should be looking at before you start cutting-sorry, I will let you come in.

David Tredinnick: No. That is very helpful. You have made those points and I am very grateful to you.

Dr Meldrum: The job loss question, as we have hinted at earlier, is quite difficult until we know how, if we do achieve them, the £15 billion to £20 billion savings or freeing up of resources are going to be redeployed. We are certainly aware that, from the doctors’ point of view, it may mean that they will have to be employed in different ways in different environments and there may be even elements of retraining that will need to take place. Whether you will have overall job losses is difficult until we know more about it or get back to the narrative.

On the other hand, we know that demand on healthcare over the years has been increasing faster than certainly the normal rate of inflation, and that there has been some increase in workforce over the years to cope with that. That increase in workforce is unlikely to take place, so at best we are going to see stagnation, if not losses, yet that workforce is going to have to cope with significantly increased demand. I haven’t really seen how this is expected to be delivered. Yes, you can say people have to work harder, work more efficiently, whatever that means, but I still think that, as others have said, the impact on patient service, and particularly on planned elective care, which is often the area that gets impacted first, and other areas like mental health, too, which don’t hit the headlines always, are going to be areas where I think the public and patients are going to notice significant diminution in level of service.

Q262 David Tredinnick: Okay. I would just like to hear you all on this, and I’m sure the Committee would too, through you, Chairman. Guy Collis?

Guy Collis: We would agree that you can’t take out £15 billion to £20 billion without having a massive impact on both staff and the services they deliver. It may also be worth just quickly looking at things like rationing, which seems to be rearing its head already. There are PCTs, trusts, in, I think, Warwickshire and Essex, that have been reported recently, where things like IVF treatment is already under threat. Other things like injections for chronic back pain, and even things like hip operations, hip replacements, are being potentially cancelled for a period. So some of these things are already beginning to come through and actually that ties back to some of the things McKinsey suggested in their report last year, socalled lowpriority areas, that they think could be dropped. In terms of the impact on staff, I think to try and quantify the numbers at this stage is very hard, but obviously there is massive uncertainty and concern.

One area we have not talked about is the potential for privatisation. There are already pathology services in London, for instance, being broken away and moved off to private companies. The Shared Business Services organisation, a joint venture between Steria and the Department of Health, is being used to take on some of these backoffice functions that you referred to. There is also the prospect, probably further down the road, but with all hospitals moving to foundation trust status, of what happens to those that don’t make it. We are already seeing the first district general hospital at Hinchingbrooke being handed over to a private provider, either Circle or Serco, and I think Mark Britnell, the former Department of Health employee, has suggested that it could be as many as 30 hospitals which are eventually subject to private takeover.

Allison Roche: In terms of social care, obviously the workforce is predicted to increase by 2025 from 1.7 million-there are four models of growth if you have read the Skills for Care Report back in May, and it is either estimated that it will be 2.1 million or 3.1 million. Regardless of whether you agree with any of those models of growth, the most key areas predicted will be in terms of the voluntary community sector and the unregulated care sector at the moment, which is the growth of the personal assistant. So if we know that the workforce is going to grow and we know that we have got impact or efficiency savings cuts, and if you have read the report that we submitted, you will know that the large amount of social care costs is actually in labour costs. What UNISON thinks will happen, which obviously we want to campaign against, will be the decrease in pay and wages. Two years ago the average pay for a social carer was £6.40. It is now £6. So one thing we think will happen-

Q263 David Tredinnick: So it has gone down?

Allison Roche: Yes, it has gone down. There will be more privatisation, more increase of the unregulated care system. One of the things we would like to come out of the spending review is looking at how the transformation of personalised care is going to be supported, monitored and funded, largely.

Q264 David Tredinnick: Thank you for that. I have one last question to do with increments. What is your reaction to the possible freeze on the pay increments built into the Agenda for Change programme? You have the twoyear freeze on pay negotiations, but I think there was an assumption that the increments would go ahead. What is your view on that?

Chair: It is relevant for all the witnesses.

Dr Meldrum: Yes. They are a contractual right. They are the time that people take to get up to the rate for the job.

I think when one looks at what, certainly, doctors have done already, as I say, effectively, senior doctors have a threeyear pay freeze. They got nothing last year; they will get nothing over the next two years. Before that, despite the fact that Daily Mail readers might have a different impression, since the new contracts in the early part of this decade, they have had belowinflation pay rises. There are already wider murmurings about what is going to happen to their pensions, having just gone through a major review in 2008 to try and address the issues there. I mentioned too, for consultants, the attack on their SPAs and the fact that the budget for their clinical excellence awards has been halved, and there’s a review of that.

I think if you are wanting to get cooperation and motivation from a workforce at a very difficult time, then there is only so far you can go in how much you can impact on their personal reward. I think you have probably gone about as far as you can expect to go in terms of what they see happening in the rest of society. We are not divorced from what is happening there. We realise that there is a balance between pay and job security, but even job security, for the reasons we have mentioned, is still a bit doubtful over the next four or five years in the NHS.

Dr Carter: I think the NHS will have a significant problem if it begins to talk about increments. Hamish and Guy have already covered the fact that most health workers have been prepared to live with the twoyear pay freeze. They are also seeing the squeeze on jobs, training, and so on and so forth. We have been getting a small but steady stream of emails over the past six or seven weeks, because we have just come through that time of the year where trusts have published their annual reports. This is something that the Prime Minister commented upon. What we now know is that in the financial year that has just finished the average pay rise for a trust chief executive was 7%. We would say that that showed very poor judgment and very poor leadership in a time of such economic austerity.

Just to be clear on this, because we have done a lot of work on this, there are a huge amount of NHS trusts that last year, the financial year that has just finished, didn’t have a pay rise at all. They saw what was coming; they knew what was going to be expected of their staff, so many of them had no pay rise. Another cohort had the same level of uplift that staff did last year, which was 2.75%. So, for the average award to be 7%, it meant that a significant number of FT trust chief executives had doubledigit pay rises in what was already a tough economic climate. Our members are talking to us about this and we are doing some more work on this.

So if within that same kind of era, that same financial climate, you then come along and say, "Look, we’re sorry about the fact that you have got to have a twoyear pay freeze. We’re sorry for the fact that a lot of you are going to be downbanded," and so on and so forth, "and, by the way, we’re going to freeze recruitment," I think that is a recipe for serious discontent. I think that has shown, as I say, very poor leadership. That detracts from the many FTs and trusts that we think behaved really responsibly in the way that I have suggested. I think it is indefensible for FTs to have awarded themselves doubledigit pay rises in such a tough economic climate.

Q265 Chair: Thank you. Mr Collis, I guess, wants to comment on this. Then I would like to go to Valerie and to Nadine, but, hopefully, within the next 10 minutes at least to draw this section of the session to a close and move on to social care.

Guy Collis: Just briefly I want to reemphasise that rises in increments are a contractual right under Agenda for Change. So any movement away from that would require renegotiating contracts, whether on a collective basis or individually. The worry here would be that you could end up with a two or moretier system of pay. As to undermining Agenda for Change, we need to remember that it is an equalityproofed system, and no one wants the NHS to be mired in litigation or legal issues, particularly around issues such as equal pay.

Q266 Valerie Vaz: I just want to comment on the backroom staff and the admin staff. I have had personal knowledge where the consultant is running around because she doesn’t have an admin person. She is running around and putting the notes in the file and then the buildup is waiting while she is going to find the reports, and we’ve all seen the letter that’s dictated in March and you actually receive it in June. So I share your concerns about that. But what I was more concerned about-and it is something we touched on earlier-is this pay freeze, this recruitment freeze, and what happens to the people who are currently being trained-doctors, social workers, nurses. Where are they going to go and how is that going to affect the service, say, two years down the road?

Dr Meldrum: Certainly, in terms of doctors, as you know, one of the things the last Government did was very significantly increase the number of medical school places, quite rightly, with the idea that Britain should not be relying on overseas doctors to provide its staff. We are still relatively underdoctored compared to many other countries in western Europe in terms of numbers of doctors per head of population. Although we would normally have argued that we still need more doctors, the question, whether we need them or not, is whether we can afford them. We have real concerns that for the foreseeable future it may be difficult to provide employment for all the doctors that we are training.

I mentioned earlier that we do a cohort study. We take a group of doctors over 10 years from the day they qualify and follow them, interview them and look at their career decisions and how they change. A lot of them are already talking about working abroad, spending significant time and maybe even staying abroad. My other worry, as I mentioned earlier, is that because of the impact of changes more senior doctors will decide to retire. In one sense, you may say, "Well, that will go some way to solving the excess of people," but it is not the right way of doing it. It is not an efficient way of doing it, particularly if you lose some of your brightest young doctors at one end and your most experienced doctors at the other end at a time when you are trying to make difficult and innovative decisions to try and reconfigure services and work more efficiently.

Q267 Valerie Vaz: Will they all get jobs when they come through?

Dr Meldrum: They may or may not. For the first time we have seen the possibility that even medical students coming out of medical school may not get into foundation programmes, which they need to finally get fully qualified, fully registered as doctors, because of a variety of reasons. What I didn’t mention to you is the impact of doctors from Europe who have, in a way, freedom of movement, and particularly from some of the new accession states where obviously they do see pay and conditions as still reasonably attractive in the UK; and because many more doctors from abroad speak English than British doctors speak foreign languages, it tends to be a oneway traffic. So there is that impact as well, which is nigh impossible to control. So it gets back to looking at the overall workforce implications. Whereas I would agree that it has never been an exact science, and I would also agree that leaving it purely locally isn’t the right answer, it doesn’t seem to me that the correct structures are necessarily going to be in place at a national level to make sure we have the right workforce, both in terms of numbers and in terms of skill mix.

Dr Carter: Just in the last two weeks I was up in Leeds and a newlyqualified nurse said, "You can’t get a job." I was over in Belfast and was told exactly the same. I have already mentioned what happened in 2006. This is what I predict will happen: over the next few years it will be increasingly difficult for newlyqualified people to get jobs, and they will go abroad. On average, about 3,000 nurses a month retire. We know that, because they are our members and we lose them. So it only takes a few months for the deficit to be quickly impacting on the ability to provide services. I predict that what the NHS will do is what it has done for 30 or 40 years. In times of crisis, which will just be a couple of years away from now, it will go back to developing countries and it will raid their impoverished nursing workforce and bring them into the UK. I have no problem with the individuals who might want to get out of a poor country, but that is no way to run a national health service and I absolutely predict that that will happen.

Q268 Valerie Vaz: Do you see more reliance on agency staff generally here and abroad?

Dr Carter: You shouldn’t have to, because there are many trusts that are really well run and many of them have simply eradicated the use of agency nurses. Again, it is something which we touched on a few moments ago-that you have got this huge differential in performance. Trust A looks after its own staff, recruits, has no agency nurses at all, and then you literally go into a different part of the city and find there is a massive overreliance on agency nurses. You really shouldn’t have to do that in this day and age.

Allison Roche: I want to talk about the social workers, because our members are telling us that in the adult social care workforce social workers are actually being downgraded, despite all the recommendations of the Social Work Taskforce and all the social work health checks that directors of social services are supposed to be implementing. What is happening is that most of the public sector, which is now delivering 20% of care services, are largely functioning as re-ablement teams, preventative teams and doing the duty of care through social work. So one of the issues that UNISON is raising is that if that group of social workers is being diminished or not replaced, which is what we are finding, where is the duty of care falling and who is taking the responsibility for risks? What we have found is that it is care managers-a new layer. What we have found interesting is that this is almost being mirrored in the private and voluntary care sectors. I mentioned that pay had gone down from £6.40 to £6 an hour, but what has not gone down and what has been maintained is this middle layer of management, i.e. those senior care workers who are on NVQ2. So there is a clear need that has been identified in all sectors that training and skilled care staff are quite important. Our concern is that if that group is to be maintained there needs to be some career progression from the bottom, which is being squeezed in terms of pay and conditions.

I just want to give you some examples. If we were looking at not just freezing increments and looking at efficiency savings and how a private company may respond, they will say, "Because we’ve not got any higher care fees given by the local authority, what we might do is tell our workforce to provide their own uniform. We are no longer paying for it. Actually, we’re not going to give you a mobile phone for when you have to call people while you’re travelling, and we’re not going to pay for those calls either." Or they might say, "You’ve got to provide basic medical equipment." So somewhere the cost is found, usually through the private workforce. I think it is those issues that we really need to be concentrating on. In the public sector, what we are finding is that local conditions are being eroded. So where you might have got double pay for working weekends or shift work, you no longer will. Where you might have got enhancement pay, you won’t, for lone working, for example, which is often a health and safety issue for a lot of care workers.

What recently we have found very interesting is a new trend where care workers are expected to stay at home, be on call and not get paid for it. So they could be at home for up to 70 hours in a week but only be paid for 35 hours because they literally only get paid for actually going to that visit. This is an increasing trend which we also would like addressed because we think it may perhaps not fit in with the Working Time Directive, which needs to be explored. But we don’t think it is right that workers should be expected to stay at home on call without getting some remuneration, basically.

Chair: My selfimposed objective I am missing by a mile now. Nadine, Mr Sharma and Rosie Cooper want to come in as well.

Q269 Nadine Dorries: Dr Carter, you said earlier in response to one of my colleagues that your members would agree to, or that they understand there needs to be, a twoyear pay freeze. You have 400,000 members, do you? Can I ask you when did you ask them that?

Dr Carter: Via surveys.

Q270 Nadine Dorries: So you have done that recently?

Dr Carter: Oh, yes.

Q271 Nadine Dorries: To how many members?

Dr Carter: We have extensive consultation processes via our regional branch networks and we visit all over the country. At every meeting I personally am having, we always raise this issue and we ask them, "So how do you feel about this?" Time after time people come back and say, "I can swallow it for a couple of years because I understand where we are going."

Q272 Nadine Dorries: Can I ask you a more specific question? Can you tell me when you actually surveyed your members with regard to the CSR and how many you surveyed?

Dr Carter: No, we haven’t done that, because the CSR has only just happened. What we have done is we have gone out extensively to our members to test the water on what they feel about the twoyear pay freeze. By way of example, two months ago I was up in Leeds and we had a conference with 300 of our activists. We asked them and we talked to them about this, and I can confidently say I think 100% of people accepted the reality of it.

Q273 Nadine Dorries: How do you think Agenda for Change and the incremental freeze on pay increase will all work out?

Dr Carter: We don’t accept at this moment in time that there should be a freeze on increments. I have already said that what we want to see is the financial impact of the twoyear pay freeze factored in to the supposed efficiency savings that the NHS has got to make, because there has been no change on that. We can see no justification at the moment for freezing increments.

Q274 Nadine Dorries: It has always been difficult to retain skilled and good nurses within the NHS. You said that you have anecdotal examples of people you have been speaking to in various hospitals. Do you have examples of people who are leaving the NHS now in greater numbers than they would have done, in anticipation of what might be happening in terms of going forward?

Dr Carter: No, I would say the opposite is the case. At the moment people are staying put and trying to hold on to their existing jobs and we are not seeing a lot of jobhopping at the moment. There is huge insecurity in the system. Can I just throw in, for ease of reference, that we have got over 400,000 members, but 25% of them, 100,000, do not work in the health service? There is a huge private, third sector component out there which a quarter of our members work in. At this moment in time, interestingly enough-and I can send you the detail on this-surprisingly, in this difficult climate, 85% of our members working in the NHS are still expressing high degrees of job satisfaction, but most of them are expressing high degrees of insecurity about their longterm future. So most nurses are actually still feeling good about the job they are doing. They are just worrying about their own future. That we can give you the details on.

Q275 Nadine Dorries: In terms of nurse specialisation-and I understand the comments that you have made, so I won’t go over them during your comments today-there is the other end of the spectrum as well. Some people would say that there has almost been an overspecialism in the nursing role and an overextension which has left many patients without basic nursing care on wards, such as toileting, personal care, cleansing and feeding. Do you not see this as an opportunity for a slight readjustment in order that the patient will actually benefit from nurses who may not be as specialised in their own career progression, that we may get back to seeing people who want to be good, fundamental nurses at ward level-which I admit will cost less and will be a saving for the NHS-and that there is actually a glaring need within the NHS for that level of care?

Dr Carter: I couldn’t agree with you more. Apart from the issue about the over-specialisation, specialist nurses, we believe, have proven their worth, both in clinical and economic terms. What I have said, and I have been in this job threeandahalf years, is that there is a gap in some hospitals-it is not uniformly the case-and in some institutions that train nurses. I have consistently said that you have to start with the fundamentals of good patient care. I think in some of our universities there was far too great an emphasis on the academic component-and you need a strong academic component-at the expense of what I would call handson flying time with patients. We have seen over the past few years huge scandals in the NHS. One of the problems that we believe has happened is that there has been an alignment, or realignment, of skill mix with a heavier reliance on healthcare assistants. That has been compounded by many of those healthcare assistants not even having as much as an hour’s induction, which we think is quite scandalous. What I am about to say is not RCN policy, but I personally regret the demise of what I am sure you will recall was the State Enrolled Nurse. I think there was a role for a nurse with a very heavy emphasis on practical handson, fundamental patient care. What I would like to see-

Q276 Nadine Dorries: I would even go further than that. There was the demise of the auxiliary nurse first. So I would even go further down than that and say actually that may not have been the role of the SEN but that it was the role of the auxiliary nurse, who was often the feeder, who sat and fed. In terms of your statistics-I think we have seen a statistic recently-you say it is not every hospital. I would argue with that, because I see the figure which shows that 500,000 patients are undernourished on wards because of lack of feeders.

Dr Carter: Yes, absolutely. We don’t disagree with the fact that in some of our hospitals there are problems with nutrition, hydration and wound care. We think that one of the fundamental causes of that is that you have got healthcare assistants that have not been properly trained that are now carrying out tasks that, historically, nurses, State Enrolled Nurses and others, were trained to do. I would like to see-and I have been talking to Anne Milton, the Health Minister, about this-a system whereby our healthcare assistants are properly trained and properly regulated, because the reality is that many of them are now providing that frontline care. You can’t blame the healthcare assistants, but what we are seeing in some of our hospitals is healthcare and nursing care being provided on the cheap.

Chair: One of the joys of an inquiry on public expenditure is that nothing is out of order, but I think if we are going to try and resolve the future structure of the nursing profession this morning we are certainly not going to get any lunch.

Q277 Mr Sharma: I think, generally, everything has been covered and there were a couple of mentions of this figure of £15 billion to £20 billion. Everybody is looking at the workforce planning, service organising, and it is all financeled rather than needsled. Nobody is talking about what the local needs are. Don’t you think that under that, where we are talking about skill mix, it is going to be a services mix as well, where certain hospitals will be forced to take extra when the smaller hospitals may be closing down or forced to reduce their services and redirect certain services to different hospitals? Nobody is talking about what pressure it will bring on the patients, on their travelling and going a great distance. Do you think that there is a threat of closure of any hospitals, or many hospitals, under this whole review?

Dr Carter: I think there is, and I think it has been done for the wrong reasons. If you switch and get a greater investment in primary care, with good community infrastructure-not just nurses, but right across, physios and so on and so forth-you can keep people and care for people more effectively, or effectively, at home and lessen your reliance on acute hospitals. Our fear is that what we are going to see is a squeeze on the acute hospitals without the reinvestment in the community infrastructure, which is going to make a difficult situation even worse.

Dr Meldrum: I would add to that. I share the concerns. There seem to be three reasons why you might want to reconfigure or certainly two reasons. One is good clinical practice and bringing more services closer to home, which is perfectly justified, and there is an evidence base for that. The second is economic, and if it is purely done for economic reasons that is not necessarily good. The third thing is the political aspect. I imagine it is very difficult as a Member of Parliament to say that the hospital in your constituency should be closed. I understand that problem, and it is why I have always said that this will not work, certainly unless clinicians work together, but unless there is real engagement of the public so that they are actually part of the decisionmaking process, not just sort of, "We have come to close your hospital and we are here to consult you," which is the method that you tend to get-unless they are really signed up and can actually see the clinical reasons.

I have a local hospital in my own area in East Yorkshire, which provides very good service in many ways, but there are some of the things that it has traditionally provided which you would say medical evidence shows would be better provided elsewhere in terms of safety and effectiveness and everything else, whether it be maternity services or cardiac services or whatever. But it is very difficult, both as a local GP, and certainly as a local politician, to say, "Yes, by all means run down the services at that hospital." An awful lot of people are going to have to make some difficult decisions if we are going to achieve effective clinical reconfiguration.

Guy Collis: To take your first point about the financiallyled £15 billion to £20 billion savings, I would certainly agree that, given the new focus on outcomes in the White Paper, it is ironic that this part of it is driven by the financiallyled approach.

In terms of the closures of hospitals, the White Paper certainly makes the prospect of merger and takeover much easier, but it has also removed the previous Government’s safety net in which failing hospitals could be brought back into the NHS. So there is definitely more uncertainty about that. And there is the expanded role of Monitor, the foundation trusts regulator. They would now be responsible for ensuring continuity of service, but they would also have to define what counted as essential services. So there is still a lot of concern and detail missing, I think.

Rosie Cooper: I am going to hopefully be helpful by taking us back a little bit but then moving straight into your social care agenda.

Chair: Thank you. Good.

Q278 Rosie Cooper: Everybody wants to protect the Health Service, and I do passionately, and will do with all my might. I want it to be efficient, I want it to be cost-effective and, most of all, I want it to be clinically brilliant so that we are providing the best there is. If you listen to the discussions that we have had today, we have a few circles to square. Dr Carter talked about McKinsey’s report, and the idea that 40% of patients may or may not need to be in hospital, and the Chairman referred to admissions which would be appropriate but unnecessary. If you take that to be true, that of the order of 40% of patients shouldn’t be in hospital, a reduction in provision is going to be required to make those savings. We have discussed how difficult that is going to be. Patients are not going to be at the core here. They are not going to be on the consortium. They are going to be on well-being boards, which are adjacent to and, therefore, for me, other than being a consulting body like the Overview and Scrutiny group-and you’ve heard what I think about that: a complete waste of time. Unless you are at the table with a vote, you are going to find those decisions difficult, if not impossible, to drive through.

When I asked the Secretary of State about that, there was one question I did get an answer to. His response was that it would go to the reconfiguration panel, which gets us into exactly all the arguments we have ever had before, but now you the doctors, the GPs, the consortium, will be in the front line. So that is a circle that is going to be really impossible, well, really difficult, to square in order to get the cash released out of it. You have talked about foundation hospitals, large increases in the CEOs’ pay, their fundamental freedoms, and also the fact that there is £2 billion to £2.5 billion locked up in reserves throughout the system there. Are you suggesting that they should be reabsorbed by the Department and that freedoms of foundation hospitals should be eroded in these financial times?

The question that brings us to the new agenda is, when we look at it-and we have looked at these numbers-the social care funding gap over the next few years could be between £3 billion and £5 billion. Do you think that money that is sitting there in foundation hospitals’ reserves could be taken in by the Department of Health and used to plug that gap, which would mean that our elderly population would not have to pay so much for services whose costs, without doubt, will be increased? Do you think that we should treat it as a whole systems review where foundation hospitals are in or out?

Chair: Gosh. Who would like to start? It was Dr Carter who raised the question of the reserves. Shall we start there?

Dr Carter: In times of such economic austerity, I fail to see how parts of the public sector can be allowed to keep huge sums of money, and remember it is a minimum of £2.5 billion to £3 billion, and I actually think it is a lot more. Now would be the time to say, "Look, you cannot keep that." I know it is going to be frustrating for people, but where is the justification if there are other parts of the Service that simply can’t cope? At the end of the day, this is public money for public services. These are not independent organisations. I have said it several times this morning. I think there is a huge amount of money in the system and that there is no justification for sitting on it in this current economic climate.

Q279 Rosie Cooper: What about the difficulties of releasing cash, because some of the things that you suggested would release cash would take many years before you would actually get there?

Dr Carter: That, Mr Chairman, is where I think the NHS has got itself into a pickle. You have now got a federated system where some are people saying, "We are fine, thanks. We have a nice big healthy reserve," and sometimes in the same city or town there are people that are really struggling. It is completely lost on the general public as to why that is the case.

Q280 Chair: Presumably one of the uses for these reserves could be to invest in the necessary reconfiguration to achieve the kind of restructured service delivery you have been talking about?

Dr Carter: Yes, and that restructuring, by the way, if I can come back to Ms Cooper’s earlier point, I predict will cost far more than what is currently being predicted.

Q281 Chair: There are two figures we have to be careful not to confuse there. One is the cost of the White Paper, and the other is the cost of the reconfiguration of healthcare delivery. It is the second of those you are saying will cost more than people anticipate?

Dr Carter: Indeed, yes.

Dr Meldrum: I have grown up in nothing other than the NHS, and in a system of social solidarity I have always found it odd that we have competing hospitals and this split between purchaser and provider. I recognise on one hand, what incentive is there going to be for foundation trusts to make profits if all you’re going to do is immediately take them away? On the other hand, I think a far better system is one whereby they are much more part of the whole process of the discussions about how we deliver effective, seamless healthcare.

We have had examples in the past where consultants have not been allowed by their foundation trust managers to go and talk to GPs because they worry that all they are going to do is flog off parts of their business and say, "We don’t need to see these people in outpatients. We don’t need to admit them," and that represents a loss of income. That, to me, is scandalous in a system where we are all meant to be working together and the only way we will make these difficult decisions and make them stick is if we do work together.

So for me it is not a question of ideology or anything else that says, "I don’t like the purchaser/provider split in the market." It is actually what I have seen in terms of the evidence base as to how effective it is and, particularly at times when money is tight, how effective it is going to be.

Chair: Some the biggest challenges around joint working are with social care. I would like to move us on to that, and Chris Skidmore is going to start.

Q282 Chris Skidmore: Thank you, Chair. I have several specific questions regarding public expenditure for adult social services and the facts and figures regarding the Comprehensive Spending Review. Before I get on to those, I just want to get your opinion about the scale of the challenge facing the social sector even before the CSR was announced.

UNISON, you talked in your evidence about a "demographic time bomb". I wonder if you could possibly specify about the nature of what this challenge will be over the next four or five years.

Allison Roche: Yes. We have over the last year submitted to the Green Paper from the previous Government and we are at the moment wanting to participate in any engagement with the new commission that has been set up to revisit what most stakeholders have been discussing in the last year or two. Fundamentally, we see there are two main issues really that need to be addressed through the work that the Commission will be doing, which I presume will be linked to some of the discussions and recommendations that come out of this Committee as well. Principally, we think there has been, obviously, bad underfunding which has had already a big impact regardless of how councils now will budget next year. We have seen across the country-and I will just quickly list them-residential homes, the choice councils are making on whether to privatise them or just to sell them off completely, or they want to close them down. If we are looking at-

Q283 Chris Skidmore: To stay specific, what would the demographic challenges be that you mentioned-this time bomb? Could you specify what you meant by that? That’s really what the question was.

Allison Roche: I don’t know if we have mentioned a demographic time bomb in terms of the fact-I just want to quote the context-

Q284 Chris Skidmore: It is 2.1: "The pressures on the social care system are set to increase in coming years as the demographic timebomb combines with growing public dissatisfaction".

Allison Roche: Yes. I don’t really feel there is a need to focus on the actual demographic time bomb in the sense that we know it is an increase in the rate of the elderly in terms of population growth.

Q285 Chair: This is about the rate of increase of demand for social care that was identified by Wanless, which is the underlying basic fact that has to be addressed by social care authorities, is it not?

Allison Roche: Yes. What I am saying is that I would rather focus on how social care can meet the demand of that increase rather than talking about the increase itself.

Q286 Chair: I think Mr Skidmore wants to start with what the scale of the challenge we are facing is, in terms of the continuing rise in demand?

Allison Roche: We are talking about the recognition that care services have been underfunded. The provision at the moment has led to rationing, which is the list I was about to explain.

Q287 Chris Skidmore: We will come on to the funding elements in a moment. I just wanted to get the panel’s view on the demographic challenge to start with, because that will impact on the nature of public expenditure, as you will see from my further questions. Have you any comments to make about it?

Dr Carter: Mr Skidmore, if I follow your question correctly, what we know-and I am sure everyone here knows-is that not only are people living longer but they are living longer with more complex conditions. Many of those people with those complex conditions, providing there is the infrastructure, can be cared for at home. If there is a squeeze on this budget, that will be compromised, and on the one hand more of those people will be coming into hospital, we believe, unnecessarily. Equally, with the problems that the NHS is facing, which we have been discussing this morning, we predict that you will see more delayed discharges. Because of the impact on social care, we won’t be able to take people out of hospital as fast as hitherto. So there are these pincer movements coming together, which frankly doesn’t augur well for the future.

Dr Meldrum: I have probably not a lot to add, because I don’t have absolute figures, but in terms of the predictions, in terms of ageing, in terms of the increase in chronic diseases and co-morbidities-and we have to factor in things like obesity and alcohol to that, too, and the exponential rise in things like diabetes-then we certainly have the problem that the other two speakers have talked about in terms of providing adequate social care.

But there is also the wider socialdeterminantsofhealth issue and the impact that has. That is because, effectively, what we are still talking about in the health service is an illness service. Yes, we do some preventative work, and very effectively, but in terms of some of the wider determinants of health and the impact on the healthcare system, we are still a long way off achieving anything near to the Wanless fullyengagedtype scenario which effectively was his argument for saying that you will need growth in healthcare of about 4% per year in real terms. If it is the sort of Wanless nonengaged, I think it was nearer 8% to try and cope with that.

Q288 Chris Skidmore: The Local Government Association provided us with figures across the Comprehensive Spending Review period, on the cost of adult social care, and they estimated it would grow roughly 4%, with net expenditure in 2011-12 growing from £16.7 billion, to £20.4 billion in 2014-15. That is an increase of £3.7 billion in the cost of adult social care. Now, it has been announced that we are going to have an extra £1 billion for the personal social services grant, an extra £1 billion coming from the NHS, so therefore, to take that away, that is £1.7 billion that is-

Dr Meldrum: I would add that that money is not absolutely ring-fenced, so we can’t guarantee it will go there. There is a caveat.

Q289 Chris Skidmore: So the caveat is that for the personal social services grant and the NHS the £2 billion is not entirely ring-fenced?

Dr Meldrum: Yes.

Q290 Chris Skidmore: Okay. Let’s just say for now we will model the £1.7 billion that is left over, taking away that £2 billion. The LGA have also said that that £1.7 billion could be found by 3% cashreleasing efficiency savings across the CSR period, but that would mean "squeezing every last pound", which was their words in their evidence. How comfortable are you all about local government meeting this demographic demand? This is just standing still without reducing the level of care. That is saving £1.7 billion, if we do have the £2 billion delivered with the 3% cash efficiency savings. What are your views on that?

Allison Roche: I will say what I was going to say to your first question, which probably sits better in this response. We already know what is happening in terms of how councils are responding. One of the omissions in the narrative here is around personalisation of care. The target was supposed to be 30% by 2013 under the previous Government, and with the new Government, I believe, there is talk of wanting 100% of personal budgets, which is quite a significant transformation of social care. If that is going to be the direction of travel, I think we need to look at how councils are going to provide those services. What we are finding around the country is there is a lot of misinformation and misunderstanding about how personal budgets can be delivered in terms of services. I will just give you an example. I said there is a whole list of things that are happening. There is the closing down of daycare centres and residential homes, the removal of community transport as part of your budget costs, and meals on wheels are going. I think Nottingham has just announced that it is not even going to bother investing in any tele-care, which would benefit all the preventative reenablement work. So what councils are telling people is, "We are having to close down the daycare centre because people now have personal budgets and that means choice. That means we shouldn’t really be providing oldfashioned services."

In fact personalisation is not about that. It is about increasing choice and diversity of services. One of the roles of personalisation is to develop local markets. What is missing out of this conversation around the funding of care is how those local markets are going to be developed if we are cutting back on services. So we think there needs to be a lot more guidance. For example, this Committee could recommend much clearer guidance to local authorities around how personalisation should be implemented, particularly under efficiency cuts.

Q291 Chair: Could you just give an example of what that guidance might say, because in the example you have quoted, with personal budgets, clearly the intention is that they be spent on something, but you are concerned that there wouldn’t be any daycare centres for them to spend their budgets on. That is effectively the concern, is it?

Allison Roche: For example, it is not clear legally or in terms of professional judgment with local authorities whether people, if they choose not to have a personal budget, which is just really a virtual budget, where they take the service rather than the cash, can use that cash or direct payment to buy back a local authorityrun service, such as a daycare centre place.

Q292 Chair: Is there a reason to think that they might not be able to, if they have cash and want to spend it on a localauthorityprovided service? Why would they not be-

Allison Roche: Because it would then be deemed as a personal budget as opposed to a direct payment. Originally, there was an idea that you could mix and have part personal budget, or virtual budget, and part cash, say, if you wanted to employ your own personal assistant but still wanted to retain some services. That is how personalisation started, but that mixture of budget has, over time, got lost or confused. There needs to be very clear understanding around what personalisation of budgets means in terms of delivering and funding, even if we are looking at the voluntary, community and third sectors being developed to provide some of the services.

Q293 Chris Skidmore: Dr Meldrum, do you have any specific points about the 3% cash efficiency?

Dr Meldrum: No. The only thing I should mention is that we’ve probably got about 6 million unpaid carers in society, and the impact on them will increase. These are people who perhaps have jobs and other things, so there is an impact on the overall economy. If there is poorly or inadequately funded social care, it can be much greater in terms of the strain on the huge number of unpaid carers.

Q294 Chris Skidmore: I do want in an inquiry on public expenditure to pin down the nature of these savings. In point 9 of your evidence, Dr Meldrum, you use the Institute for Fiscal Studies to mention that "unprotected departmental expenditure limits would need to be reduced by 33% over this period. This could be reduced to 25%," taking £13 billion regarding, you say, welfare payments. The LGA have said that that 25% reduction over four years would really be around a saving of £3.6 billion. Would you recognise that as a figure for the 25% you are talking about? You also mentioned, "The impact of cuts of this magnitude on social care would be enormous and the effect on the NHS of the consequences could be considerable." That is the 25%. Evidence we heard from the Association of Directors of Adult Social Services and the LGA themselves, combining the demographic pressures with the 25% cut, you are talking more like savings of 40%, which is about £5.6 billion. Would you recognise that £5.6 billion figure if you are looking at 40%?

UNISON, in your evidence, you have mentioned that Rochdale Council is now planning a cut of more than 50%. I think it is quite important for this inquiry to establish what is the level of savings or cuts, whatever you would like to call them, that we are looking at in social care.

Dr Meldrum: I think I would need to get back to you on the exact figures. I am very willing to do that. I don’t have them completely in my head but we will certainly get back to you on that. It doesn’t seem to me, at first sight, to be an unreasonable assessment that you have made, but we will get back to you on the specifics.

Allison Roche: We have a National Social Care Forum, which is largely focused on children and adult social work, and then we have a Home Care Forum, which is largely personal assistants, voluntary sector, public sector. So we have two national forums which are regionally represented. My understanding just from talking to them is that councils are not going to ring-fence a lot of the care services. What they are going to do is increase, obviously, the tariff of the carepackage part, if you like, through the resource allocation system, which will mean that everybody who is receiving care at the moment will get less care but a higher cost of care. That is one way that they are dealing with it, or they are going to increase the criteria, which I am sure you have already heard about from other organisations. Regardless of how these efficiency savings or cuts are going to be implemented, there are going to be no winners, and the situation following the CRS is going to be frustrating for professionals, frustrating for service users, frustrating for care workers, regardless of what level of care they are providing.

There are also specialist services like dementia. There is a commitment to improve that care. I am not sure where the funds are coming for from that. We have issues around mental health nurses as well, some of whom are social workers and some of them aren’t. In terms of the workforce, what we would like to see out of all of this is, rather than the efficiency reviews of bringing health and social care together, it needs to be underpinned by much clearer workforce planning, for example, embedded in a less chaotic career and training structure, to be honest, because that is quite absent. If we want efficiencies to work and for there to be winners, we need a much clearer framework of workforce planning and training skills.

Q295 Chair: Could I just ask the RCN if you are supporting this in the work you have done on the planned effect and service changes? You referred to the fact that you were publishing some stuff on Friday from the NHS. Have you done a similar review of nurses employed in local authorities?

Dr Carter: Not so much in a review in the way that I can give you a set of figures, but we have certainly been talking with our members and with our local authority partners about the issues. The thing that is quite apparent to all is, predating all of what we are talking about now, social care was under huge pressure. There are examples of lack of congruence of strategy. I think that is a big weakness in the system where you have two parallel public services-the NHS and the local authority-and the common denominator is the public, the patient, the service user. In some areas we think there is simply costshunting, pushing it from one to the other as a means of surviving the next week or whatever. That simply isn’t good enough.

Q296 Chris Skidmore: Do you think that will only get worse?

Dr Carter: It’s inevitable that it will get worse, and £1 billion certainly won’t be enough to cushion it from that. All the indicators are that the squeeze will result in social care becoming more destabilised, which is why as part of these reforms I think there should be compulsion about the local health service and local authorities working together-I know it’s a cliché-in a seamless way, to try to get the service more efficient and more effective, which currently in some parts of the country it isn’t, and in other parts it is.

Q297 Chris Skidmore: In terms of ring-fencing a social care budget, we have heard mixed views on that from other evidence sessions. I just wondered what your view on ring-fencing was in particular.

Dr Carter: The problem with not ring-fencing-and there is a whole range of budgets that are not-is that it is often the budgets for people who are most vulnerable and most impoverished and are least able to fight for themselves that are raided, whilst others, it is politically, with a small "p", very difficult to do. So I think there should be more ring-fencing and more protection for those people.

Dr Meldrum: I would certainly agree that, if the money that is effectively being topsliced from the NHS is meant to be used in social care to try and help protect the impact on the NHS, then it must be targeted at those areas where it will have that impact and not get lost in the overall budgets. Otherwise there seems to be little sense in actually making that transfer of money.

Allison Roche: Yes. UNISON has made it quite clear in its submission that we do support ring-fencing, primarily for the following reason. I know personalisation is about moving people out of beds and out of residential homes and putting care back in people’s actual homes, but there are still support services that are very much needed, and what we might call softer. For example, if you are paraplegic and you can’t move and you are dependent on a personal assistant, just one person, one to one, all the time, there is not much stimulus. The idea of being able to go to a daycare centre to interact with other people is also a mental health issue and it is part of preventative care in the sense that this person is not going to deteriorate further through depression, for example. The support services need to have some considered ring-fencing around them, and that is our major concern.

However, it isn’t ring-fencing in isolation. We don’t know what the Commission in Social Care itself is going to be reviewing, and at the moment we have had very little communication with that commission. We know that care is going to move to a new funding package and there will be a mixture and discussion around how that is funded. I think and I hope that that discussion will look at how, for example, personal budgets will keep up with inflation but will have some overhead costs built in, because it is not just about the overhead costs supporting those extra services I have just mentioned. If I am a voluntary community organisation and I want to develop a social enterprise providing care, I also will have overhead costs, so the personal budget has to provide some means of giving me the overhead costs for my provision. It is that kind of area where again there is no narrative or detail about how we are going to achieve that. If we want personalisation, we have to look at how we are going to afford the infrastructure to support that, because it is certainly going to be needed by our care users.

Q298 Dr Wollaston: Can you summarise what you think are the implications for the NHS of the social services cut-backs?

Dr Carter: I think I have already said it. I think the most immediate impact will be more delayed discharges on the one hand and then, as I said a few moments ago, you will find people becoming ill and having to be admitted, but had there been the infrastructure out there that could have been avoided.

Q299 Dr Wollaston: Right. Would you like to see pooled health and social care budgets?

Dr Carter: Yes. I think it has been a huge wasted opportunity over many decades now. I spoke earlier about a lack of congruence between various parts of the public sector, not working together. Whether you need to formally pool budgets or not, for me that is not the issue, but it is about having more joint plans and having more, if you like, bespoke plans that are put together as a result of the needs of a particular community.

Dr Meldrum: I would add, I think, that in places like Torbay, which have experimented with care trusts, it seems to have been quite successful. There is always going to be a difficulty of course whereby the healthcare budget is free at point of use based on need, whereas the social care is based on your ability to pay. Marrying up these, we have all heard in the past, "Is this a medical bath or a social bath?" If it is a medical bath you get it free and if it is a social bath it is based on your ability to pay for it. So you get into these rather arcane arguments. I don’t underestimate the difficulties and that is one of the reasons why it has not been terribly satisfactorily addressed up until now.

One can look north of the border and see what has happened in Scotland where they have had supposedly free social care, but of course the problems of providing that are a huge strain and I doubt, although it might be a road we would ideally like to go down, whether that is achievable given the present spending constraints. So whether or not it is actually pooled budgets, I would certainly argue for much closer working together than we have often seen in the past, much closer decision making, the left hand knowing what the right hand is doing. My hope-and it is maybe a vain hope-is that with the closer working with GPled consortia and local authorities, we might start to see some of that. We will have to if we are actually going to try and get out of this mess.

Q300 Dr Wollaston: So you feel quite hopeful overall?

Dr Meldrum: No, I said that was my hope. I didn’t say I felt hopeful.

Dr Wollaston: Okay.

Q301 Chair: Specifically on that point, the LGA and ADASS, when they came, said that they thought that links were "steadily improving" Do you agree?

Dr Meldrum: Yes, from a low base.

Allison Roche: We did try to merge budgets when individual budgets were piloted a couple of years ago. What was quite interesting coming out of the research there was that not everybody wanted the individual budget and it was very hard because the structures in terms of organisation nationally weren’t merged. There is a whole set of structural issues that had to be addressed. There is a whole set of legal issues that involve a lot of different legislation, primary legislation. There is a lot more work that needs to be done in terms of merging health and social care budgets together.

Also, in terms of the workforce, healthcare assistants are much more highly qualified, for example, than care workers and they have a different set of competencies, a different set of health skills compared to social care. Social work and healthcare have very different, distinct professional outcomes, means of monitoring, etcetera. So again I will refer back to the fact that you can’t merge a budget without looking at the workforce issues or the structural issues as well.

Dr Carter: Can I briefly add something? There has been a success story in the NHS that emanated from the early to mid90s in relation to mental health, when there were mental health services in the NHS and in social services that didn’t speak to each other and were in different offices, and there were some appalling scandals of homicides, and so on and so forth. That has been put together, and whilst of course, sadly, occasionally there are still problems, nothing like there was before, and that is just a very good example of two public sector agencies working together.

Q302 Rosie Cooper: Can you describe "put together"?

Dr Carter: Yes. Community mental health services are now managed predominantly by the trusts, whereas before community health services were managed by social services-

Q303 Rosie Cooper: Forgive me, when the local authority people were here they told us that an investment of a pound that they put in would be realised in savings in the health service, so it was a difficult path to tread. I suggested that they might, in that event, then wish to give over their responsibilities to the health service to make it work, and they resisted that very strongly. I hear what you have just said, but the bottom line is that this is about the people out there who need these services, and all this future nonsense is going to come up about "my responsibility," "your responsibility," the gap. Older people, people with chronic conditions out there, will expect that help which, especially because it is not ring-fenced, is going to be getting further and further away from them, and what they receive will get narrower and narrower. What can you do to make that model work now?

Dr Carter: That is the point I am making. We saw copious reports on homicides and serious incidents of people with mental health problems and systems not talking to each other, different language, different computer systems, different offices. Now that they have been put together that is something that really has worked, and it has significantly ameliorated many of the problems that we saw. Surely that model can be rolled out for this sector.

Q304 Rosie Cooper: That is really important because the idea of that pooled budget-pool this, pool whatever you like-won’t work unless there is an absolute one point of responsibility.

Allison Roche: I would just like to say that I agree with you to a certain extent, but that is largely because, for some historical reason, the United Kingdom divided or excluded social care from the welfare system, but no other European country did. If we look around the world, for example, social care is normally put very much on the same footing as healthcare. So we have a very unusual historical delivery of social care. For example, occupational therapists and social workers have very distinct jobs and train for three to four years and belong to professional organisations which support their ongoing development. In some authorities they have been asked to almost take on each of their different roles and there is resistance to that because they don’t see why they have trained to work in one profession and now have to suddenly switch. I keep on emphasising that the workforce needs support, and if you want to be merging it-

Q305 Rosie Cooper: If we take that analogy on, what you are saying is this, and I’ve experienced this with a close friend’s relatives, a father who was terminally ill who has now died but a mum who had Alzheimer’s. They must have had, I don’t know, eight or nine people in through that door assessing for this, assessing for that, assessing for the other and, quite frankly, what a waste of money. There really has to be some measure of what you are saying they are resisting, because frankly that is not the 21st century, and do you want to be seen and assessed by seven different people when one or two, depending on the medical model and the social care model, will do? Why do you have to do it? You can’t carry on wasting money doing that.

Q306 Mr Sharma: As a former daycentre manager for Adult Services, I can see the difficulties faced by many families and individuals, but I think that is where, as Rosie said, there are efficiencies to bring there so that services can come to one place, assessment can be done once rather than with seven or five different people going there and then contradicting each other. If there is one care manager assessing the whole service and then putting the paperwork together, I think that would be the best way, giving the service to the service user and their family, don’t you think?

Chair: The point Ms Roche was making that the distinction between health and social care is-I don’t think it is quite true to say uniquely but certainly, distinctively-a British phenomenon is one of the huge policy challenges in achieving efficient use of resources across what should be a single system.

Q307 Nadine Dorries: I would just like to piggyback on both of those comments and say, anecdotally, I am someone who has just been through five assessments with somebody. In the end I said, "What happens to this assessment now?" and was told, "Nothing. It is going to be filed. We have just made the assessment." That is five people, five salaries. So I completely endorse what you have both just said.

As part of the reorganisation, GP consortia are embracing new territory and will possibly extend the roles of practice nurses and GPs and take away a lot of the services provided by the secondary sector and save costs. Do you see, therefore, a role for the social care sector to do the same thing, to be innovative in the way social care is provided? If so, how, and do you see that actually saving the NHS hospital, secondary sector, costs which can be transferred over? Do you see a cost saving and a way of embracing what is happening as a way of developing how social care is delivered in a way that would save costs?

Chair: Dr Meldrum?

Nadine Dorries: Yes, sorry, I was asking all of you.

Dr Meldrum: As we have said repeatedly, we have to look at many issues such as skills mix where service is delivered, and at one level it sounds a perfectly logical, perfectly reasonable argument to use. When you talk about how you then free up resources, particularly from hospitals where even with the tariffs you often get marginal costs rather than the overall costs and manage to make that appropriate reinvestment, it is challenging. So I don’t in any way disagree with the philosophy behind your question. All I am questioning is the practicality of actually achieving it. It has proved remarkably difficult in the past. First of all we have to get these various people talking to each other at the very least, which in some places seems to be quite difficult to achieve. I am not one of these people who thinks it is all about largescale structural change. It is the process, it is the way people work, that will actually make it happen. I absolutely agree these are the discussions to have, the decisions that will have to be made, but past experience has shown that trying to take money out of hospitals is very difficult. But if we don’t achieve it we are going to fail and the public are going to suffer.

Allison Roche: The majority of social care is actually general care, as I think all the demographic models will show. When we looked at all the different types of funding models last year with the previous Government, most of the evidence showed that perhaps the majority of care-and I think it was averaged up to about 70% to 80%-is general personal care. There is very little room for savings there at the moment, as we have already explored this morning, because, largely, wages are very low-they are just over the minimum wage-so there are going to be no savings on cost and, as I have said, those wages have gone down in two years. If we then are looking at plugging the gap of more specialist care, the costs of providing that care means we will have to expand, with more qualified care workers.

We have two sets of care workers. We have senior care workers in social care, and we have what we would call healthcare assistants. Again, I come back to the fact that they are in two sets of different negotiated bargaining bodies. One is Agenda for Change, and one comes under the national local government bargaining, and are employees of the LGA. They have different terms and conditions and they have a different set of experiences. They have different qualifications. One is supported, and has a much clearer career progression, where they can go from being a healthcare assistant and aspire to being a nurse-for example, a more qualified senior nurse, I think. I am sure Peter will expand on that. But they have a very much more motivated wellpaid structure. A care worker in local government has no motivation because last year they were getting 40p more for even going from no qualifications, which they normally pay for themselves, to getting NVQ2. There is no incentive to go higher than that, because there is no pay increase. So you have two systems which are rewarding staff differently.

We have 60,000 healthcare assistants in UNISON. They in no way want to come down to being on the level of our local government care workers. What we want to do is lift our local government workers up to the same level as those healthcare assistants. So if we are looking at merging and seamless provision, we have to look at the workforce and how that is going to affect them. In the last White Paper there were only two paragraphs on the workforce. I think the TUC made a very strong submission to the last Government saying that they had misunderstood the importance of the workforce in delivering new personal social care and drawing up much more closely integrated health and social care.

Dr Carter: I want to chunk this right down and give a very practical example of some services that we see again in different parts of the country. An example I will give is on pressure ulcer care. There are some PCTs that have invested in small teams of nurses that are highly skilled in the treatment of pressure ulcers that, via our social services colleagues, go in either to people’s own homes, residential or care homes, and treat and intervene on pressure ulcers very, very quickly, thus obviating the need, ultimately, to come into hospital, as that is one of the reasons why many people do come into hospitals. That is a good example of a relatively small investment paying for itself several times over in the course of a year. It is another frustration, and you would think, "Why isn’t that rolled out uniformly?" Of course I could give other examples, but that is a very real, tangible example of something that makes an instant impact, saves money but is obviously very good for patient care.

Q308 David Tredinnick: With all the pressures on county councils now and their spending budgets, we have to be prepared for some care homes to go into the private sector, and that is not intrinsically a bad thing, is it?

Dr Meldrum: I don’t have an ideological objection to it. On the other hand, one has to say, where is, necessarily, the gain, unless you assume that the private sector is going to provide the care more efficiently?

David Tredinnick: Well, I think the thing is-

Dr Meldrum: Some people will argue that it may do that, but it may do that by driving down wage costs, employing less qualified and less trained staff, and suchlike.

Q309 David Tredinnick: But in this environment, where there are these pressures-it is certainly affecting my constituency-if an outside provider can see an opportunity in a care home, which the county sees as a very considerable cost in this current environment, should we not be prepared to look at these options in a positive way rather than a slightly disparaging way? It represents change, and it is something going out of the local government budget.

Dr Meldrum: I am not looking at it in a disparaging way. I practise on the east coast of Yorkshire and we have a significant number of private residential homes, of mixed quality. One of the messages I get from all the owners of these homes is that the downward pressure on their budgets, affecting the amount of public money they have to look after their residents, is considerable, and some of them have actually gone out of business. One way or another, if it is public money that is paying for the service, the argument about whether it is paying for it from the public sector or from private providers must boil down to, "What are the advantages you get one from the other?". The main argument that one hears from those who support the private sector is that they can do it more efficiently than the public. That may or may not be the case. I think the evidence is pretty debatable as to whether that is indeed the case, or whether in fact they do it by cutting costs and cutting corners elsewhere. I think one really needs to look closely at the evidence, and to me it is not a saving just to make the inference that because we are getting the private sector to do it we are not using public money. You are still using public money.

Dr Carter: We have absolutely no ideological objection to the private sector. The key for us is, are people providing good quality care? If a private home owner is demonstrating that, that is fine with us. We would actually like to see more of our members getting into social enterprise. So ideologically, we have no problem with that.

Q310 Valerie Vaz: Just a quick one-word answer. If social care fails, are the costs absorbed by the NHS?

Dr Carter: Ultimately, it will be, because that is where people will go.

Dr Meldrum: Yes.

Allison Roche: Yes.

Chair: That is exemplary. Thank you very much indeed. Thank you for your evidence this morning. You have given us plenty of food for thought. Thank you.