Health Committee - Minutes of EvidenceHC 1583-II

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Oral Evidence

Taken before the Health Committee

on Tuesday 17 January 2012

Members present:

Mr Stephen Dorrell (Chair)

Rosie Cooper

Andrew George

Barbara Keeley

Grahame M. Morris

Dr Daniel Poulter

Mr Virendra Sharma

Chris Skidmore

David Tredinnick

Valerie Vaz

Dr Sarah Wollaston


Examination of Witnesses

Witnesses: Paul Burstow MP, Minister of State for Care Services, and David Behan CBE, Director General of Social Care, Local Government and Care Partnerships, Department of Health, gave evidence.

Q529 Chair: Good morning. Welcome to the Committee. As you know, we have been taking evidence now for some weeks on future policy developments affecting social care-the structure of the way social care is delivered, the way that it relates to other aspects of care in the health service and, indeed, in social housing and, importantly, how it is funded now and in the future. We would like to ask a series of questions around all those issues on policy, structure and funding.

Will you begin, Minister, by setting out where the Government are, in terms of their own internal deliberations on the issues-both the policy questions and the funding questions-and say how the Government plan to take the process forward from today?

Paul Burstow: Yes. Thank you very much. We are very pleased that you are conducting this series of hearings and plan to publish your report ahead of the publication of the White Paper. We see that as a valuable contribution to the process of the policy formulation itself and to helping us land a set of reforms that are long overdue in the area of social care.

It is best to set a broad context in that, when we came into office as a coalition Government last year and worked on developing the more detailed coalition programme for the Government that was published after the coalition agreement was signed, there was an agreement across the Government that we needed to move swiftly to establish a Commission to look at the question of funding reform. We proceeded to get terms of reference agreed and the appointment of that Commission prior to the summer recess of 2010. Andrew Dilnot and his team have produced an excellent report, which I am sure provides a lot of areas for discussion later in this Committee today.

But, of course, Andrew Dilnot’s report was only ever one part of a complex jigsaw puzzle. Another important element of that jigsaw puzzle is the work that the Law Commission was commissioned to do in 2008. It reported in May 2011 and, again, has produced a very useful set of proposals-76 recommendations in all. I guess that the third element in our approach that we took in leading up to the spending review in 2010, is that we as a Department saw the investment in social care, the protection of social care and the protection of the vulnerable as a key public policy priority for the Government. We reflected that in the decision to ensure that, by the end of the spending review, there will be an additional £2 billion a year going in to support social care through the two routes, which I suspect we shall explore in more detail. That is broadly where we are. We are obviously in the middle of a White Paper drafting season and the necessary cross-Government discussions that take place as part of that process.

Q530 Chair: May I ask you a few process questions and get them on the table at the beginning? You said that the Government are in White Paper drafting mode. Are we anticipating a single White Paper that covers both the policy and the funding questions? Are we expecting two White Papers? What sort of time scale are we expecting them in?

Paul Burstow: No. When the Secretary of State made his statement to the House shortly after publication of the Dilnot Commission’s recommendations, we made it clear then that we would publish a White Paper covering law reform and reform associated with the outcomes from the "Caring for our Future" engagement that concluded in December, and that we would publish a progress report on reform. It is our intention that those two documents are published at the same time.

Q531 Chair: Published on the same day, and in what sort of time scale?

Paul Burstow: We are talking about publication in the spring. There is no firm date printed into a grid, as it were, at the moment, but the spring is the time when we wish to publish the package.

Q532 Chair: I think I am right in saying that today cross-party talks are beginning between the major parties about funding options. How do you envisage those talks playing into the process?

Paul Burstow: All I can really say about those talks is that they are happening. We had our first meeting today. It was a constructive meeting. What we and the official Opposition have agreed is that we are not prepared to offer a running commentary on those discussions, but they are looking at issues of funding reform.

Q533 Chair: Do you envisage their being concluded before the White Paper and documents are published?

Paul Burstow: I think everyone involved in those talks would hope that that is the outcome that we achieve.

Q534 Chair: I accept that it is not yet anybody’s decision, but if it were decided to implement Dilnot as he recommends, would that require primary legislation?

Paul Burstow: It would require some primary legislation to implement some aspects of the Dilnot recommendations. There are 13 recommendations in his report. A number of them play across into the Law Commission’s recommendations: eligibility, assessment and so on. Yes, there are areas that would require legislation.

Q535 Chair: So should we expect that there will be primary legislation proposed by the Government in the next Session of Parliament?

Paul Burstow: What you can expect is that, in the White Paper, we will give our response to the Law Commission. In a way, the Law Commission report is the seminal piece of work around law reform. Indeed, it enables us to progress a number of policy issues, which, again, I expect we will explore-not least, embedding in a system that was designed in the 1940s and rather grounded in principles that were established prior to the 1940s. On that legal framework, it is very hard to stick the whole set of reforms that successive Governments have tried to apply to it. Law reform is actually rather key to delivering a lot of the changes around personalisation and so on that we want to see.

Q536 Chair: Next Session?

Paul Burstow: That is a matter for the Public Bill Committee. It makes these decisions, not individual Ministers in Departments.

Q537 Chair: But sometimes the Government can announce their conclusions.

Paul Burstow: I am not in a position to announce a conclusion today, I am afraid.

Chair: Okay. Thank you. Any other process points anybody wants to raise?

Q538 Dr Poulter: You made the point that you will not have necessarily come to a firm conclusion on the funding when you publish the White Paper, but, if I was understanding what you said correctly, there will be an indication of what your future direction of travel on deciding funding is.

Paul Burstow: What I said is that there will be a progress report. What I have not said is that we have already predetermined what the conclusion of that progress report will be. We are engaged in a series of processes, both internal Government ones and discussions with the official Opposition.

Q539 Dr Poulter: So alongside the White Paper, there will be a progress report on funding as well, and the conclusion on funding will not be part of the White Paper itself.

Paul Burstow: That is correct.

Grahame M. Morris: Can I just-

Chair: This is a process.

Q540 Grahame M. Morris: It is, absolutely. It is a question rather than a comment. Given the crisis we are facing in social care, the Committee has received ample evidence in respect of the imperative nature of addressing the issue. Are the Government arguing for legislation within this Parliament? I am left with the impression that we do not know what is going to happen. Are you pressing the case to have time set aside for primary legislation to implement Dilnot in this Parliament?

Paul Burstow: The Government’s position is clear: we want to see legislation introduced into Parliament at the earliest opportunity. What I cannot announce today, because those decisions have not been made, is whether it will be a second Session Bill or not. The intent is very clear. We want to legislate on social care reform during the course of this Parliament.

Q541 Barbara Keeley: Minister, you mentioned a jigsaw puzzle when you talked about the Dilnot report and the Law Commission, but there is also the current funding gap and the growing level of unmet need. In fact, the King’s Fund estimates that nearly 900,000 people are being left without basic care. Most commentators do talk about our social care system being in crisis. Could you say what the Government will be doing immediately to address this current funding crisis to avert the obviously potentially catastrophic impact on people’s lives and the NHS?

Paul Burstow: We are doing and will continue to do a number of things to support the social care system that we currently have while we move to a reformed system. That started with the spending review decisions that we took in 2010 and the decision that, over the life of this Parliament, we will be investing an extra £7.2 billion in support of social care. That will come in two ways: first, through the local government funding formula settlement and, secondly, through an unprecedented transfer of resources from the NHS to support social care. I am sure that the Committee has been looking quite closely at issues of integration. We are seeing that integration is very successful at brokering new relationships between the NHS and local authorities, so that we can better use the resources across the system.

We are also looking very critically at how we can improve productivity in the system. That is why we are, for example, working with the Local Government Association on a programme that it has constructed to support local authorities in addressing productivity challenges. Indeed, the previous Administration published a report looking at the disparity of costs across the system. There are still disparities across the system in terms of the relative expenditure on residential care, for example, and opportunities to the system.

Finally, we know from the research that has been done that, for example, investment in re-ablement services can significantly improve the quality of life for individuals and release resources. They can save costs in the system. We have recently announced a significant roll-out of telehealth and telecare. We know that when those are well deployed as part of system change, they can release resources.

Q542 Barbara Keeley: That is interesting. You have mentioned £2 billion a number of times in Parliament. How do you respond to Andrew Dilnot, who said, "There is no doubt at all that the additional money you provided to local authorities has not found its way through to social care."? Clearly, there is a lot of monitoring and evidence on that. Perhaps you would like to update us. The Alzheimer’s Society told us that a number of PCTs-two-thirds, I think-don’t know where the dementia strategy funds were spent. The Princess Royal Trust for Carers said, "The £400 million earmarked for carers’ breaks has not gone to the right place." That is an issue that you campaigned on in Opposition. How can you improve social care when you are actually unable, particularly now that there is no ring-fencing, to channel money to the correct part of the system? How can that work? You don’t have the say over where that money goes-whether it’s in PCTs, clusters or local authorities. They have the say and you do not.

Paul Burstow: There is a lot in there, including carers, dementia and the overall budget. Let us be clear that the total spend on social care in England is about £14.6 billion. In terms of what the Government could or could not ring-fence, it would not be that whole pot. There is still an awful lot of discretionary spend that the local authorities in discharging their statutory duties would have decisions over anyway. We need to keep reminding ourselves that these are local authority services. We are talking about locally elected bodies that are responsible and accountable to their populations for the decisions that they make.

You asked a question about the allocations. What we do know, and I will be happy to supply notes to give details on this afterwards, is in respect of the transfers of moneys from PCTs. The most up-to-date information that we have with regard to the £648 million that is being transferred is that 18% is going to maintain eligibility criteria, 18% is going to support additional investment in re-ablement services, 10% is going to support intermediate care services, 8% is going to early supported hospital discharge schemes-this January, we announced an additional £150 million to support additional investment there-8% is going on its greater crisis response and 38% is going to other services such as telecare, community equipment adaptions, mental health and so on. I will come on to dementia and carers, but that is where we are with the NHS money generally.

Q543 Barbara Keeley: It would be helpful to the Committee and as you embark on your cross-party talks to understand what is the gross figure or the current gap in funding. How big is it? We know what the Dilnot recommendations are. There is talk of other figures-£5 billion, £6 billion, £7 billion-to meet unmet need and to meet the current crisis. What is that figure?

Paul Burstow: Let me try to respond to that. In the work that was done leading up to the spending review, the question that we were asked by the Treasury and that we answered in the spending settlement was how we close the funding gap during the life of this spending review. The judgment that was made on the basis of the information available to us was that that gap gets closed by the money and by a rigorous programme of efficiency. Indeed, the King’s Fund-

Q544 Barbara Keeley: Can you say what the figure is, please?

Paul Burstow: The point I am making is that there is no gap. There is no gap in the current spending review period on the basis of the moneys that we are putting in plus efficiency gains through local authorities redesigning services. The King’s Fund in its work identified even with the worst case scenario that it required 3.5% efficiency savings. We don’t accept the position that there is a gap. We have closed that gap in the spending review. On the issue of unmet need, I am yet to find any agreement among academics on a definition of unmet need. Even the personal social services research unit says that it is a very hard area to navigate and come to any firm conclusions on.

Q545 Barbara Keeley: You are embarking on trying to work on the future funding and there is this crisis. It seems to me that if you do not have a method of getting to unmet need or knowing what unmet need is and you don’t believe there is a gap when almost all external commentators say that our social care system is in crisis-

Paul Burstow: There are three things here. There is the current spending period and what the Government have done to address the pressures that we identified at the beginning of the spending-hopefully, I have just outlined those and we amplified them in the submission that we provided to the Committee. There is then what we need to do to address the next spending review period. We have not started the next spending review yet so in a sense that is the next piece of work. There is the question about how you reform the funding system. Andrew Dilnot was not asked to look at the quantum. He was not asked to look at the total amount of money going to the schemes. He was asked some very specific questions about how we address the balance of the relationship between the state and the individual in terms of what each contributes to support their care needs.

Q546 Barbara Keeley: Indeed. But you can’t build Andrew Dilnot’s recommendation on a system in crisis where there is a gap. Is it your contention to this Committee that there is no gap, that there is no problem and there is no issue with the current system? You seem to be saying that you don’t think there is a gap currently.

Paul Burstow: It is a mistake to generalise and say, "The system is in crisis".

Q547 Barbara Keeley: That is what people say.

Paul Burstow: Let me give you a couple of examples of what I mean. Indeed, Julie Jones, in the evidence she gave you, made the observation that it is quite surprising how, with relatively similar levels of need, relatively similar levels of problem and challenge in the social care system, different areas are responding to it differently and therefore mitigating potential problems. Indeed, the report that was published by Scope which looked at these issues also came to a similar conclusion that there was not a direct correlation in terms of the investment that was being put into the system and the outcomes that were being achieved. They outlined some of the reasons for that and it was a very interesting report for that reason.

Q548 Grahame M. Morris: On the same theme, I want to take issue with the Minister’s response there and point out that there is an inconsistency with evidence that the Committee has received from the Local Government Association and from the directors of adult social services. You mentioned their commitment to efficiency savings and the accepted 3%, and your Department concurred that that was achievable. You mentioned £150 million for re-ablement, which we recognise, but still the LGA estimate that they face a funding gap in the order of £6.5 billion in 2011-12. That reflects the difference between what local authorities in England need to spend to maintain front-line services in their current form and the income they can get from the council tax, fees, grants, business rates and so on. There seems to be a difference of opinion there as to what the current situation is as expressed by the people who are delivering it on the ground and the Minister’s response to the Committee today.

Paul Burstow: I take that as a statement-

Q549 Grahame M. Morris: I am asking you to challenge it.

Paul Burstow: You are entirely right that there is a difference of opinion. All I am saying is that the difference of opinion is not solely between the Government and the Local Government Association and other witnesses during your hearings. The difference of opinion is broader than that. I referred to other witnesses that you have had before your Committee-Julie Jones in her comments and the work that has been done by Scope. This is not a simple issue of how much resource the Government are putting in-we are putting in £7.2 billion over the life of this Parliament; it is a also a question of the individual choices that local authorities are making in terms of the priorities they are making for investment in social care. It is quite clear that one of the challenges over the life of this Parliament and into the next is how you manage the demand in the system. One of the issues that you have been looking at and which we are looking at in the context of our White Paper is around prevention and early intervention, which are key to managing demand pressures in the system.

Q550 Rosie Cooper: Grahame has substantially asked what I was going to ask. If I was a member of the public out there watching this this morning, I would be filled with despair. They know they cannot get the services. Local authorities are desperately trying to get the funding to ensure that they can deliver basic services. You are saying that there is no gap. You are saying that financially you have put extra money in, but you have also acknowledged that you cannot ensure that the money goes where it is intended. It is very clear that money put in that does not have some real direction does not reach the parts it should. With all due respect, Minister, if you were a member of the public who desperately needed this service and who had listened to the exchanges so far, wouldn’t you think we were just talking a good game and not getting anywhere?

Paul Burstow: I don’t know and obviously I would be interested to see how people do read this hearing today. My response to these questions is very clear: there need not be a gap in funding if local authorities take the sorts of efficiency steps that the LGA has accepted are possible-a 3% level of efficiency. There is no gap opening. The issue is about whether each local authority chooses to do that; individual local authority choices differ from one part of the country to another, as evidenced in the work by Scope and Demos and by comments from some of the witnesses. It is not as simple as, "There is or there is not enough money in the system." It is also about choices that local authorities are making.

Q551 Rosie Cooper: Absolutely. For example, Lancashire county council only treats and helps very critical need. It has increased charges to such an extent that most people fall off the table anyway. Do you as Minister think that is okay?

Paul Burstow: Well, we have a framework through the fair access to care initiative. The revised version of that was published in 2010 and provides a framework for framing charging policies. Some local authorities-not all-are looking again at their charging policies. They have to do that in the context of the current legislative framework, and in certain circumstances they are, and have been, challenged on process in the courts. Am I satisfied with that? I am concerned that local authorities take the opportunity to engage with service users and carers in an open dialogue about how they redesign services. Where they do that, they are getting better results.

Chair: One more, Rosie.

Rosie Cooper: I just wanted to quickly say, I hear it. It’s all words; it’s motherhood and apple pie. Of course we should be consulting and communicating, but we also have to deliver. Talking isn’t action.

Q552 Chair: Can I just be clear, Minister, about precisely what the Government are saying about unmet need? Are they saying that they do not believe there is unmet need, or do they acknowledge some unmet need, but that is the result of variable performances by local authorities?

Paul Burstow: The first thing to say about unmet need is that defining and measuring it is a hard thing to do. The second thing we acknowledge is that as part of some of the questions we are grappling with from the point of view of a White Paper and funding reform, those changes necessarily require this territory to be explored. Some of your conclusions will be very relevant to that. It is also clear, partly from what I have seen already from the witnesses and from talking to academics, that trying to get a definition of unmet need that works is very hard. Coming up with the figure of 900,000 from the King’s Fund that was cited earlier, which I think is some years old, is open to a lot of academic criticism and not necessarily as robust as we would like.

Q553 Chair: But not being able to measure it precisely is not the same thing as saying that it does not exist.

Paul Burstow: One of the reasons that we recognised the need for a transfer of resources from the NHS to social care was the recognition that putting in resources to fill the gap, alongside efficiency savings, was an essential element because unmet need in one part of the system can drive costs in another part. That recognition was very much part of the spending review judgment that we made.

Chair: A quick one, Barbara, and then Andrew wants to move on.

Q554 Barbara Keeley: Minister, you have talked about consultation. If you are struggling with the definition of unmet need, I suggest-and I think this is very important because I don’t see how you can plan future funding of social care unless you grapple with it-that you talk to organisations such as Age UK and to carers. The people who are meeting the gap are carers who are taking on the load of demographic change and cuts to local authorities. In particular, we should talk to Age UK and carers in those local authority areas where there have been cuts, as my colleague was saying. If you are living in a local authority area where they are dealing with or trying to meet only critical needs, the carers and organisations that support older and frail people will know the definition of unmet need. I think, and I am sure the Committee shares this feeling, that we cannot keep ducking the issue of unmet need. As numbers approach 1 million, it is a serious thing.

Paul Burstow: I do not accept that we have ducked the issue; I am merely saying that measuring it is a difficult thing to do. As part of the judgment that we made in the spending review, we looked at the impact of unmet need in social care on the NHS, and it is an important judgment in the overall funding settlement that we made in the spending review. Of course we talked to Age UK, but I think it, candidly, would acknowledge that it does not have an absolute handle on that unmet need. When you go round, I hope that you do not just go to the places that are saying, "It’s all terrible." I hope that you also talk to those places that are engaging in the way that I have described and, as a result, are redesigning services and getting better results. They are not just talking about it, but doing it as well.

Chair: We will come to some of that later, but Andrew first.

Q555 Andrew George: In a recent video on the departmental website, you described the fact that care is not free as a "nasty little secret." I agree that it is probably a shock and is rather nasty for people; I am not sure that it is a secret. Some other aspects are rather nasty and, perhaps, a surprise to people. I will cover three: consistency of assessments, portability and the role of care workers.

On the first point, under the existing guidance of fair access to care services, there is an assumption-I want to probe you on this-that there is a precise science of assessing care needs. To what extent do you believe that that is true? To what extent can you work towards national consistency across all local authorities and achieve consistency in assessing what is either critical or substantial need?

Paul Burstow: There are a number of aspects to that. First, in terms of the recommendations that we have had from Andrew Dilnot and the Law Commission, and that have come out of our "Caring for our future" engagement, there is a bigger question about the nature of the assessment process. The current process is generally described as a deficit model of assessing-it is, "What can’t you do? We will fill that gap," rather than, "What is it that you can do? What are the assets in your community? What support do you have from your family and wider network of support?" We can reinforce support so that mutual aid and self-care is underpinned. That is one of the challenges of moving from a system that looks back to the 1940s and the poor law principles to a system that is based on 21st century values and is particularly focused on how we get the right outcomes for people.

One of the interesting things from the Law Commission’s report is that it says that we need to have a clear set of principles for decision makers. It says that legislation must be founded on the idea of well-being and that it should not only be about providing bundles of services to people, but be about working through with the people, as part of their assessments, the outcomes that they are trying to achieve in their lives. In that sense, it is not a science, because it is about designing bespoke support and outcomes for an individual.

Q556 Andrew George: You are moving the debate in an entirely different direction-to those in need of care being treated either as individuals or in the context of the community, and the support that they currently have whether or not the local authority provides any additional support. I want to get back to whether you genuinely believe that there was ever any chance of local authorities achieving consistency in assessment-quite apart from consistency in services. Would we ever achieve that, or is it a pretence even to believe or imply that it can exist?

Paul Burstow: The Law Commission and the Dilnot Commission recommended going for a more consistent eligibility. The financial services sector, for example, says that that would be an aid to them in terms of coming in and providing more financial services. If we accepted those recommendations, the work of implementation, post-legislation, would be critical in designing the new eligibility framework, so that it could be robustly implemented across the country. In the end, because we are designing a system that is ultimately about trying to achieve the goal of personalisation-of shaping services round individual citizens and enabling them to have lives in their communities-inevitably, I suspect, there will continue to be that sort of tension. It is not a social security yes or no; it is a more complex picture.

Q557 Andrew George: Moving on to portability, we can perhaps assume from your answer that it will be impossible, and might even contradict the desire of a Government, to devolve responsibility and that some issues are matters for local determination in any case and should not be part of a Stalinist central control-based system, anyway. Given the portability of those with care needs as they move from one local authority to another, do you agree that it is reasonable that, where hard-won care packages have been agreed and assessments made for a vulnerable person, they should have some certainty, on arriving in a new local authority area, that that package of care within the law is portable and lasts for a reasonable period before they are reassessed later?

Paul Burstow: Yes.

Q558 Andrew George: How long should that reasonable period be?

Paul Burstow: In "A vision for adult social care", which we published in 2010, we set out that we were minded to accept recommendations on portability. There is work to be done on the design of that and, obviously, we want to see your recommendations as well, as we formulate the final version of the White Paper. But we are clear that portability is emblematic of the poor law principles that still infuse our 1940s-designed social care system; that is a classic marker of a system that effectively allowed a state institution to decide who could move and who could not. That has to be unacceptable in a modern 21st century social care system.

We want people to be able to move to where they want to be-to be able to work and be with family or whatever else-so portability is certainly an important part of what we want to see in the White Paper.

Q559 Andrew George: Finally, the biggest and perhaps most nasty secret of all in the care sector is that-would you not agree?-it is built on the backs of the lowest-paid. Care workers have had an appallingly unfair press. Of course, where care standards are unacceptably low they need to be dealt with. But we are talking about people on minimum wage working antisocial hours, taking on care levels of acuity that are significantly different to those 20 years ago. We have to bring migrants to this country because, often, insufficient people who are prepared to work in such conditions can be found in many local communities. Do you think that is sustainable? Is your Department concerned about this?

Paul Burstow: Can I start with the first point, which was an unfair press, by acknowledging that an awful lot of people-the vast majority-who work in our care work force do a fantastic job? They are dedicated and compassionate and should be applauded for that. We tend to focus on the shocking and appalling. Having said that, we must not allow abusers and those who are lacking in compassion and are not delivering good-quality care to be able to hide behind everyone else who is doing a good job. That is why we have been clear about the need to strengthen the safeguarding framework and about the role of the Care Quality Commission in shining a spotlight on the NHS and care providers and so on, to root out bad practice and get it dealt with. That is why we have also said, for the first time, that we need a much clearer set of nationally agreed training standards for care workers and health care assistants, because that is not there at the moment. That is why we have also said that there needs to be a code of conduct.

Yes, you are right; this is not a well-paid sector. I have made comments over the years, saying that that has an impact. But it is interesting, looking at the analysis done by, for example, the Centre for Workforce Intelligence, which looks at reasons for staff turnover in organisations, to note that often there are issues to do with the quality of the management, the nature of the leadership and whether they are getting personal development opportunities in terms of training, and so on. The pay is not the main driver for their choice of job, or indeed for their choice to stay in the job. Again, I am happy to supply the source for that. It is not just me making it up. Research has been done.

Q560 Andrew George: I would be very interested in looking at the methodology, and certainly many of the people I talk to who work in the care sector want to do a good job and are committed to what they do. They feel proud of the work that they do, but in many circumstances they are paid the minimum wage, and have to work shifts-night shifts, and weekend shifts when they would like a social life, but that is denied them. They are doing work which, frankly, I think no one in this room would do for the salary that they get. I question the basis on which those assumptions are made, although I am not saying that those issues are not important.

Paul Burstow: May I speak to that point? I don’t disagree with some of the issues that you listed as being reasons why not everyone chooses this as a profession to go into, and of course we need to do a lot more in terms of the work force to raise its status. That is part of the work that we have been engaging in with the sector over the last few months, and it will certainly feature in the White Paper. But in terms of the work that has been done, I was referring to the national minimum data sets that were published in September last year. When care workers were asked what they liked about their role, 31% said they enjoyed the work, 20% said they enjoyed working with elderly people and clients, 18% said they enjoyed improving people’s quality of life, 14% referred to job satisfaction, and only 4% quoted good pay. In terms of why they leave the job, apart from 0.5% who apparently leave because of death, according to the statistics, transfer to another employer is the biggest single main reason. Pay comes in at 4%. I will happily provide those figures, and you can look at the methodology, but that is where I’m getting my evidence.

Q561 Andrew George: If that is the basis of your evidence, it sounds to me as if your Department may become complacent about the fact that you believe that you can rely on the current work force and that they will always be there and be content to be paid the rate they are, and to receive the sort of public press that it seems your Department is almost colluding in in terms of the comments that are being made about the quality of their work.

Paul Burstow: That is a bit of a mischaracterisation of the Department’s position.

Q562 Andrew George: I exaggerate to make my point.

Paul Burstow: It is a huge mischaracterisation. I outlined a number of things the Department is doing. Let me mention another one. When the Prime Minister made his announcement, which was reported as being primarily about nursing, he also announced the establishment of a nursing care quality forum, made up of not the great and the good but front-line staff, to advise on how we spread best practice, and to make sure there is a very clear focus not just on NHS quality of care, but on the social care sector as well. One of the streams of work that we were working on with the sector during the autumn last year was around quality and work force. We see those as being absolutely interconnected, and we have had some very good feedback from that. The information is on the Department of Health’s website, and indeed led to some of the coverage in the Telegraph yesterday and the Express today. It seems that the easiest way to hide something is often to publish it on the DH website.

Chair: In addition to talking about those issues, the Prime Minister has also been talking about integration, which I would like to move on to if I may.

Q563 Rosie Cooper: Minister, the Prime Minister is reported to have said that health and social care must be merged. I wonder whether you agree, and if you do, whether you have any thoughts on how, the time scale, and what we are to understand you mean by the words "integration" and "merger", and exactly who you see being involved.

Paul Burstow: I certainly agree with the Prime Minister that we need greater integration between health and social care, and indeed that needs to reach beyond health and social care into housing and other aspects of public services. What the Prime Minister has definitely not said, if you read The Guardian article that has that headline attached to it, is that there is to be a sort of new grand design of a structural merger of health and social care.

Indeed, the reform programme that we are going through at the moment with regard to the NHS puts in place a number of pieces of architecture that are very much designed to incentivise and drive integration across the system: the establishment of health and wellbeing boards with their specific duties around integration and their responsibilities for looking at the use of the NHS flexibilities around pooled budgets and so on; the duties that are to be placed upon the NHS commissioning groups to integrate services both within the NHS, which is not itself as integrated as we need it to be, and with other providers as well; and the role that the National Institute for Health and Clinical Excellence will have in setting quality standards across health and social care. All these things and others around tariff design and so on are all about one common purpose, which is how we incentivise a system to behave differently and act in a way that ensures services are wrapped or designed around individuals and their needs.

Q564 Rosie Cooper: So you are not really talking about integration; you are talking about voluntary collaboration. Integration is a misnomer in your description.

Paul Burstow: We are obviously on a spectrum of what we mean by integration.

Q565 Rosie Cooper: I have been trying to establish what you mean by integration.

Paul Burstow: What I have just described is a series of steps that are about integrating services. What we know from the research evidence that exists so far, from the advice we have just received from the NHS Future Forum and from the work that the King’s Fund and the Nuffield Trust have done is that this is as much about cultural behaviour as it is about structures. What we are trying to design is a set of structures that reinforce the cultures that we need to get organisations to work differently and to work together. If that means it is voluntary collaboration-I don’t think it is. It is more than just voluntary collaboration. It is definitely sending a very clear signal into the system.

I will end, if I may, with one final point. One of the other things that the NHS reform legislation provides for is, for the first time, a clear statement of the Government’s mandate for the NHS, which has itself to be consulted on, and that is itself an opportunity to make very clear this Government priority, which is integration of health and social care.

Q566 Rosie Cooper: I am still, frankly, bemused by your definition of integration. I still do not actually understand. Again, I go back to being a member of the public-would my dad understand what you have just said? Would I get very clearly what difference it would make to me? The answer is "No, not really." I will come to actual budgets in a second. I cannot see the model that you are trying to describe. Are you saying that local government and health will be in it? Does that include GPs? How do you get those bodies all working together in what I would call a real integrated system?

Paul Burstow: Let me try again, because obviously I would want to make sure that your dad and others understand what we are trying to achieve here. The key point here is the principle that you orientate the services around the individual and that the services work together to meet a set of identified needs. So that is partly about what we have already been talking about, which is the role of assessment and how you make sure that assessments are joined up themselves, that they do not repeatedly ask the same questions and that different agencies come together.

Let me give you a practical example. Two weeks ago I was in Cornwall, and then I spent some time in other parts of the south-west and I visited Taunton in Somerset. In that situation I was visiting a service that has been established. It is called the integrated support service. Why was it integrated? It was integrated in their terms because it brought together pharmacists, occupational therapists, nurses and social workers. That team had as its remit both prevention of admissions by early intervention and support, and the promotion of safe and effective discharges from hospital in a timely fashion. It provided a combination of emotional support and practical support in terms of speeding up access to aids and adaptations and looking at medication reviews once they came out of hospital. It is a combination of things, which, if done well, can enable somebody to get back on their feet and back into the community at the earliest opportunity.

Q567 Grahame M. Morris: May I follow on from Rosie’s question while we are on this subject? The Health Committee did not go to Stockholm or Singapore, but we did go to Carlisle and Preston and saw some excellent examples of innovative, integrated models of co-operation between health and social care. One of the questions I wanted to ask is about an unintended consequence of the Health and Social Care Bill. I am making this suggestion to you, because it has been suggested to us that a consequence of the changes the Government are bringing forward is that we are disintegrating innovative models of integrated care, and I am sure that was never the intention. How do you respond to that?

Paul Burstow: Thank you. No, that most certainly is not the intention. Where people on the ground are saying that to us, we are working very closely with them to ensure that integrated services, where they have been commissioned, are protected. Indeed, in the NHS operating framework for 2012-13, we have made it very clear that we want to make sure that as we transition from the current system to the new, we are safeguarding and securing existing integrated arrangements. So you are absolutely right. We both understand the concern that there could be an unintended consequence and we are guarding against it.

Q568 Grahame M. Morris: What, in practical terms, can you do to safeguard these new and innovative integrated care models that have been developed? For example, we have had letters from Sir Bill Taylor and the Cumbria and Lancashire chairs pointing out that the Government are imposing governance models in this transitional period as the PCTs are clustering. That is causing their model to disintegrate. I hear your rhetoric, but it does not seem to square with what we have seen on the ground and the evidence that we are getting.

Paul Burstow: My rhetoric, as you put it, is also based on the opportunities I have as a Minister to go out and talk with people as well. So all I am saying is that, as we go out, we both need to be open to the possibility that there are good things going on on the ground, and that there are people collaborating in the ways I have just described.

Q569 Grahame M. Morris: But what, in practical terms, are you doing to support examples of good practice?

Paul Burstow: Let me give you the very clear practical thing we are doing: that is, through the very clear instructions we have given in the NHS operating framework for 2012-13 and the performance management that sits around that as we manage the transition. That is a very practical, real thing that galvanises how the NHS behaves. Of course, one of the other things that is emerging from the move to clinical commissioning groups is that in terms of relationships at a local level, which are a key element in sustaining integrated services commissioning for populations, the fact that you have GPs who are very much part of their population-they get place, they get their geography, as well as their patients-they are often a much more fixed point, just as local authorities are, than the teams of managers within PCTs that move around the country. If anything, we will have a more stable system, which is more able to design and sustain these sorts of changes in the future.

Q570 Dr Wollaston: May I just say that it is as much about putting in place more specific mechanisms, which will drive integration, as protecting the system from threats? As you already mentioned, you have visited the south-west. Yesterday, the Health Committee went to Torbay and saw some fantastic examples of how they have genuinely integrated health and social care, but there are some real threats. I am concerned to hear you say that you do not think there is a funding gap, because it strikes me, from having visited Torbay, that actually there is a real danger that really well integrated systems will retreat back into a silo mentality because of the threats to the funding of social care.

I wondered if you would reflect not only on that, but the threat, perhaps, from Monitor’s role, if Monitor starts to interpret its role differently and moves away from promoting integration and more into looking at competition roles. Will that undermine integrated care pathways? What specific steps will you take to ensure that that does not happen? Once they have set out independently, there will be very little that we can do to influence their decision making.

Paul Burstow: What I am saying about the gap that you are in pursuit of is that, as part of the spending review, we took the steps that we judge are necessary to close that gap. The challenge for local authorities is to make 3% efficiency savings every year as well. By the combination of the funding settlement that we have given to local government and that, there is no gap. That does not mean that there are not continuing demographic pressures in the system, and that we will not have to confront them as we come towards the next spending review. What we are saying very clearly is what I have just said.

In terms of the issues around integration and competition, one thing that has been said very clearly to us by the NHS Futures Forum is that these two things should not be seen as poles-with competition at one end and integration at the other-that can’t co-exist in the way the system works.

The issues are around good contracting, ensuring that those contracts reinforce the notion of pathways, reinforce the notion of commissioning for populations, and that organisations must have interoperability-which is one of the points we heard from Torbay-when it comes to the way that information passes around the system. Indeed, the NHS Futures Forum report on information makes that very point-that actually information is as big a driver of integration and cultural change across the system as just saying that we want to see more integration. I do not accept the proposition that competition of itself needs to lead to less integration-quite the contrary.

Q571 Dr Wollaston: Right, okay. Coming on to another point, looking at the drivers for this, do you anticipate there is a role for outcomes frameworks in driving this? Is there a case for having a single outcomes framework covering older people, which looks not just at health, well-being and social care, but at housing, and sees it as a whole-system approach?

Paul Burstow: I certainly agree that we need a whole-system approach and we have accepted the recommendations the NHS Futures Forum made to us about aligning the outcomes frameworks for social care, public health and the NHS. When you come to grapple with how you boil those down into one document without making it more confusing, we concluded that having three that do overlap, for example in terms of mental health and frailty is the best way to incentivise different parts of the system to work collaboratively, where working together is an essential part of achieving their own outcomes and assisting others to achieve theirs.

Q572 Dr Wollaston: Right; so you are not going to have a single one.

Paul Burstow: We won’t have a single one because we think there are still discrete elements of social care, and the model that is there as part of social care, that are different from the health service. Having them separate but overlapping is the best way to do that.

Q573 Dr Wollaston: Have you seen the response from Chris Ham of the King’s Fund to your response to the Futures Forum’s report? He has made the point that you need to commit to more specific actions to drive integration.

Paul Burstow: In terms of those iterations, I don’t think I have seen the response to the response of the response. We have written back to Chris and his team in response to their report, and we have agreed that we need to do more work with the King’s Fund and the Nuffield Trust on how we take forward their recommendations and those of the NHS Futures Forum. They are absolutely right: there is a lot of work going on, for example, with regard to health and well-being boards. There is a whole early-implemented programme that is not particularly visible, unless you are involved in it. That is bringing together directors of public health, GPs and local authorities. They are working through a whole series of learning sets, and again we can send you some details on that. That is proving quite galvanising across the system in terms of getting people to talk differently about how they integrate these services.

Yes, we are going to continue working through the recommendations and ensuring that they are reflected in the White Paper we will publish this spring, in terms of what next steps we need to take. The last thing I would say, picking up on your earlier question, which I forgot to mention, is that Monitor will also have duties around integration. The duty on Monitor is to promote the interests of patients, and it can use as its tool for doing that, integration, just as much as it can choose competition. The key thing is that it needs to do it in the interests of the patient.

Q574 Dr Wollaston: If it starts implementing it in a way that is not driving integration, will you have powers to step in and direct it to behave differently?

Paul Burstow: Not in the sense that you mean. In listening to colleagues in the Lords, we are looking closely at the way in which the NHS mandate’s writ would run across the system. That is an issue which I think will be explored further on Report.

Q575 Valerie Vaz: I want to take you back to a couple of points. Obviously, colleagues have covered various things, but I just want to clarify a few things. You mentioned Torbay. Have you actually visited Torbay?

Paul Burstow: Yes.

Q576 Valerie Vaz: When did you do that?

Paul Burstow: I think it was last summer.

Q577 Valerie Vaz: Do you see a future for the care trusts?

Paul Burstow: I think that they proved to be an interesting experiment, but as an experiment they did not really get out of the lab. One of the problems with the care trust model is that it did not lead to any significant transformation across the service. I think they can teach us lessons about how you can orientate organisations around people. The interesting thing about visiting Torbay was their model of saying, "How do we get this organisation to change the way it works? We have to think about Mrs Smith." That is their sort of way of mobilising that. It was not just the structure; it was about the culture and behaviours within the organisation. Those are the lessons I take away from my visit to Torbay.

Q578 Valerie Vaz: So you saw a model that actually worked, did you?

Paul Burstow: I saw a philosophy that had been translated into a set of operational responses, but the philosophy-

Q579 Valerie Vaz: That worked?

Paul Burstow: Yes, it did-not the structure, but the philosophy.

Q580 Valerie Vaz: We visited yesterday, and what we heard were public servants who thought outside the box and thought about their patients, their clients and their customers. I hate using that word "customers", because I do not think they are customers in such circumstances. They went beyond what they were asked to do, as public servants, and developed a system. You have accepted that that works. There is an element of good practice. Could that not be looked at and rolled out throughout the country?

Paul Burstow: There has also been a research programme around integrated models of care, which published in the autumn of last year. I think it pointed us to not simply seeing structural changes as the key component in delivering different behaviours among staff and the organisations that commission those staff. That is why the health and well-being board programme is now as much about changing cultures and behaviours and supporting different behaviours. It is also why, as I say, when I visited Knowsley-because I have visited Knowsley-and when I visited Torbay, the interesting thing was the organisation’s philosophy, which they then translated into the way they ran themselves: it was fundamentally about centring themselves around people, what needs those people had and how best to meet them. I think that is a very good philosophy.

Q581 Valerie Vaz: My point is that it works in an area. I am just thinking of saving the public money. Taxpayers’ money is very important and a lot of costs have been incurred with the reforms. I am just saying that a model works. Why can you not use that to translate it into other areas? I will come on to the health and well-being boards, but is that not a model that you could perhaps continue to pilot?

Paul Burstow: Clearly, that is an issue in terms of policy formulation that, if the Committee wants to make recommendations on it, we would need to consider in the context of a response to the White Paper and of a response to your recommendations.

What I am saying is that, for one reason or another, before this Administration took office the care trust experiment never escaped the lab. The last Government never actually got round to doing whatever would be necessary in their terms to direct it to happen. We are now taking a different approach-health and well-being boards are a key part of that-to drive integration not just in a few places, which is all that was ever really delivered with that programme, but across the whole of England.

Q582 Valerie Vaz: One of the things that we picked up from that was the flexibility they had, when people are coming out of hospital, to look at extra care and homes that people can go to-they can buy a few beds-so you can have that halfway house and you are not clogging up beds in a hospital. One of the things that strikes me about this general debate is that we see the elderly as a kind of problem. We need to kick them out of their homes. We need to get them to pay for the care that they have actually paid for already through their taxes, if they have worked.

That brings me on to the housing issue. That is something that came across in evidence. Do you not see a role for housing associations or people involved in housing, in relation to the elderly, on health and well-being boards?

Paul Burstow: You are absolutely right that housing is a key component in all of this. That is why in the guidance we will be publishing about joint strategic needs assessments there will be very clear guidance around the need to build into that housing needs assessments. There are very clear duties already on local authorities. My colleagues in the Department for Communities and Local Government recently published a strategy. There have been more announcements today about housing. I agree with you that we should not be having some sense of consternation about the fact that we have been successful as a nation in enabling people to live for longer. We should be focused on how we compress morbidity, how we actually ensure that people live well, for longer and less disabled as well?

Q583 Valerie Vaz: Generally, in terms of all this joined-up thinking, do you have any systems in place for a national strategy to look at housing, welfare, health and social care? Are there any systems in place this year?

Paul Burstow: It is called the White Paper, and we will be publishing it this spring.

Q584 Valerie Vaz: That is now? Do you have any systems in place?

Paul Burstow: In terms of cross-Government-

Q585 Valerie Vaz: You do not have to be sarcastic with me. I am aware of a Government White Paper.

Paul Burstow: I apologise. But it is. That is the place where-

Q586 Valerie Vaz: But do you have any strategies in place?

Paul Burstow: If I came across like that, I apologise.

Q587 Valerie Vaz: Yes, you did.

Paul Burstow: The White Paper is very much that document. That is the place that pools together a lot of work that has been going on in the Department since the Government came into office. Yes, it will look across the Government as well, so we are obviously with colleagues in other Government Departments as part of the formulation and finalisation of the White Paper. Of course, there are those inter-ministerial discussions about housing and other matters.

Q588 Valerie Vaz: Is the Department currently developing other models in terms of flexible housing? We have a situation where we have deferred payments already, and an elderly person’s house stands empty while they are in residential homes. What is the Department’s thinking on flexible housing?

Paul Burstow: Some of this has actually come out specifically today. Grant Shapps from CLG has made some further announcements.

Q589 Valerie Vaz: Well, Grant Shapps is not here, and you are.

Paul Burstow: I am trying to demonstrate the fact that the Government are joined up and what we are doing on housing, which is not directly within the Department of Health’s responsibility. But in our work on social care reform, we recognise-

Q590 Valerie Vaz: That it is coming out, yes.

Paul Burstow: In that context, one of the things that Grant Shapps has announced today is building on a programme for the London borough of Redbridge where they have been looking at how they can support people to downsize-not force them to downsize, but support them to make that choice. We know from the International Longevity Centre, for example, that people underestimate the scale of what they will need to do to future proof their homes. All of those are things we are factoring into the work that we doing, leading up to the White Paper and its implementation.

Q591 Valerie Vaz: But you definitely do not see a role for housing specialists on the health and well-being board, or are you open?

Paul Burstow: Not as a mandatory thing. We have a small number of core members.

Q592 Valerie Vaz: Could they sit at the table?

Paul Burstow: But the interesting thing, of course, is that many directors of adult social services-obviously not in two-tier areas-are, in fact, double hatted. They have housing as another of their responsibilities, so the housing conversation is very much part of the role of the health and well-being boards.

Q593 Valerie Vaz: In terms of following the money, could the money go through the health and well-being boards or do you see it going to the CCGs?

Paul Burstow: The money for social care from the NHS?

Q594 Valerie Vaz: Yes.

Paul Burstow: The money for that very clearly goes to the local authority to support their social care activities. Health and well-being boards are legally part of local authorities, and it is the most logical place for those conversations to take place.

Q595 Chris Skidmore: You said that it was more ethos than structural form that had driven change, but where we went to visit yesterday it was very evident that pooled budgets were necessary in order to drive the change needed in Torbay and so reduce hospital beds. The long-term savings that were made in the NHS were the result of almost the NHS pump-priming social care. I am interested whether you would rule out any future decisions about whether we should have pooled budgets across authorities or clinical commissioning groups? Or is that something that you do not believe is effective?

Paul Burstow: The danger of mandating such things is that you wind up getting perverse behaviours because people have been told to do it rather than actually seeing the logical case for doing it. That is why the ethos issue is very important. I am not today ruling it out. I would be very interested to see what your Committee’s recommendations are on this. We will be saying more in the White Paper about integration and further incentives.

Q596 Chris Skidmore: If you look at integration as a permeation between those budgets, you would possibly be thinking about allowing local authorities and local NHS organisations the freedom of decision to pool budgets.

Paul Burstow: One of the other ways in which we think this can be driven and an area where we are determined to move at pace is the whole area around personalisation and, within personalisation, the use of personal budgets. We have made a very clear commitment about rolling out personal health budgets, particularly in regard to continuing health care, and we are progressing at a good pace now in terms of personal budgets within social care. We want to be able to see people, when they choose to have those personal budgets, in a position to bring those budgets together to achieve the outcomes they need.

Q597 Chris Skidmore: Are personal budgets the only mechanism that you would be happy with? Obviously, the whole roll-out of personal budgets is gathering pace. It will deliver results, but would you then, once that has happened in the course of this Parliament, look again at maybe-

Paul Burstow: We of course will keep looking at these things. I do not see personalisation and personal budgets as the only way. I think they are a very powerful way of allowing people to take control of things and shape the services they need, both health and social care and, through Supporting People, housing. That is about meeting their needs. But I also think that the work that health and well-being boards will do in terms of assessing the population needs together across health and social care, building in the housing input I was talking about and then framing the commissioning strategy for their population is a game changer in terms of the way in which organisations are going to work at local level and the way in which the personalities within those organisations collaborate.

Q598 David Tredinnick: I am hoping to ask you a few questions about personal budgets later in the proceedings, but for the moment can we just go back to health and well-being boards and the fact that the Government rejected a recommendation of the first Future Forum report? I just wondered why. This was the recommendation that "Health and wellbeing boards should agree commissioning consortia commissioning plans which should be developed in line with the joint health and wellbeing strategy." Can you explain why the Government rejected that, please?

Paul Burstow: Yes. Basically, we see health and well-being boards as being a pooling of sovereignties between two agencies that have very different accountability frameworks-between local authorities and the NHS. The NHS has clear accountabilities ultimately to Parliament. Local authorities clearly have accountabilities directly to their electorates; they are elected bodies. Effectively to hand to local authorities an absolute veto over commissioning decisions by the NHS would have blurred those accountabilities. It would have been a de facto transfer of responsibility and accountability to local government. That was not what the Government wanted to do, and that is why we have taken the view that we do need to see joint strategic needs assessments and health and well-being strategies as a part of the continuous process of commissioning. They are not separate; they are part of the cycle of planning services. That places local authorities in a very different relationship, but not one of being above the NHS or subordinate to it.

Q599 David Tredinnick: I am not sure I see where this absolute veto comes in. The recommendation was that "Health and wellbeing boards should agree commissioning consortia commissioning plans"-that there should be some link with these fledgling commissioning consortia. It seems a bit strident to say that we do not want to get involved in absolute vetoes. Surely what we are talking about here is sensible communication to achieve joint aims, which is quite different.

Paul Burstow: Absolutely, and that is exactly where the position of the policy is now, in that what we are saying-

Q600 David Tredinnick: If that is the case, surely you have rejected just what you have agreed to.

Paul Burstow: No, no. What we rejected was the notion that there would be a sign-off by a health and well-being board. What we have accepted is that you have an iterative process, an ongoing process, of reviewing and examining the commissioning plan that has been produced by the CCG. The CCG doesn’t just take the health and well-being strategy, go away into a dark room, produce its commissioning plan and then hand it back and say, "Do you like it or not?" That is a sort of sign-off process. It is actually one that it is collaborating with throughout the process of producing the commissioning plan. It is absolutely the case that what you have described is what we intend to be the way in which these relationships and processes work.

Q601 Rosie Cooper: So it is a talking shop.

Paul Burstow: No, it is not, because the idea of agreeing and determining population need, translating that into the priorities for commissioning-they are most certainly not, because they have themselves legal force, which commissioners will have to take into account and demonstrate that they have taken into account. That is both social care commissioners and health commissioners.

Q602 Chair: Can I just conclude this part of the discussion by taking you right back to the beginning, Minister? You said that The Guardian had got it wrong when it reported that the Prime Minister had told the Health Secretary, Andrew Lansley, to formally merge the two areas-health and social care-"to save money" and improve patient care. That was a wrong report was it?

Paul Burstow: I have to be very careful because I said some things a couple of years ago that really upset The Guardian. I apologised to it at that time, and I do not want to have to apologise again. What I said was that if you look at the headline and then read the first paragraph and the rest of the article, the article does not really bear the headline that the sub-editor put to the story. The story is principally about the report of the King’s Fund and the Nuffield Trust. There is not actually any direct attribution to the Prime Minister at all.

Q603 Chair: But if it is wrong that the Prime Minister has told the Health Secretary to merge the two departments-and I can understand that that might be wrong-what the Committee is hunting for is the sense that there is a game changer here. Forgive me for saying so, but I have given evidence to Select Committees in the past when I have held briefs similar to those that you hold and I have described the importance of co-operation between health and social care. Indeed, my predecessors in ministerial roles have done so even further back into history. We are hunting for why things should be different in the future? What is the game changer? Or do you think that this needs to be a continuous development and there is nothing more urgent about this now than there was in the past?

Paul Burstow: The point that was made very strongly to us after the Future Forum’s work is that there is not a silver bullet. There is not one thing that will change the system and make all of this happen, which is what you are hoping we can offer. But what it does say is that a whole series of things can incentivise and drive organisations to work differently. You are right: it is a process and an endeavour.

What we have put in place, once the legislation that is currently before the House of Lords secures Royal Assent, is a whole series of new nudges, pressures and obligations in the system that force the system to behave differently. If you are looking for the nearest thing to a game changer, it is the issue of personal budgets and the personalisation agenda-the ability to hold a personal budget that sits across your health needs, your care needs, your housing needs and, through the trailblazers the DWP are leading, perhaps some elements of benefits as well. That allows you to start personally integrating services to meet the needs that you have in a way that best fits your circumstances.

Q604 Chair: But if you are going to deliver the objective of much faster rated integration-I accept that it is a process not an event-personal budgets are part of that. If you want to create structures that allow commissioners to look across institutional boundaries, you need to give them incentives to do so. I do not understand how you deliver integration unless those incentives on commissioners exist.

Paul Burstow: I would say that the health and well-being boards are the place where those boundaries disappear. The processes I have described already are part of that.

Q605 Chair: But do those boundaries disappear if the health and well-being board is still responsible for different budgets and, as you stressed, different accountability systems?

Paul Burstow: One of the very specific things that health and well-being boards are obliged to do is to ask themselves the question: should we be using the NHS flexibilities to allow us to commission services differently?

Q606 Chair: When you say NHS flexibilities, you mean section 75.

Paul Burstow: Yes, precisely. It is not an after-thought; it is a fore-thought. It is part of the process right from the outset. In other words, why would we not want to use these where we commission differently and better for our population?

Q607 Rosie Cooper: But the health and well-being board does not commission. The problem here is that there is no connect. It has no power. You keep on saying that the health and well-being board will commission. It can make suggestions and can agree, but it does not actually do.

Paul Burstow: And of course it is possible, under the flexibilities, for CCGs to delegate some of their commissioning function, so that it can be exercised through health and well-being boards. What you say is not strictly true.

Q608 Dr Wollaston: Every part of the country obviously is different and a model that applies in an inner-city would not apply in a rural area. Do you take a view on there being parts of the country where there are really outstanding examples of integrated health and social care delivering real results for patients? If so, why are you not rolling those out and saying, "These are the models that people should be adopting"?

Paul Burstow: There are lots of places that are, as you say, delivering truly excellent services and are genuinely integrated. I mentioned the example in Taunton; that is just one. I also visited a service in Bristol, which is integrating around intermediate care.

Our dilemma in looking at the experience of rolling things out is how successful that end practice has proved in the past. Although we are directing some programmes from the centre, we do not think that you can achieve the best outcomes for individuals through dictating a fixed model of integration and saying, "That’s what everyone should do." We think that health and well-being boards are the places where these issues are worked through, where the relationships that are essential to good commissioning across service boundaries are debated and decided and where the priorities are set.

Q609 Dr Wollaston: So you see the health and well-being boards as the guiding mind that will, in each area, dictate the model that is right for it.

Paul Burstow: I would describe them as the local system leader. They are not just a talking shop; they are the key place in driving reform across the system.

Q610 Chair: Including the whole national health service budget: the acute sector as well as the more obvious local authority sector.

Paul Burstow: Absolutely, because in the end the building blocks are there: the joint strategic needs assessments and the health strategy are set within the context of the board.

Q611 Dr Poulter: I am sure that we will turn to Dilnot in a moment, but funding is not necessarily the main issue. We should be talking about the real issue, which is the way that the system is configured in terms of social care and whether there is co-operation, or lack of it, between different players in the field-the NHS and social care. Is not the system broken? The issue of funding is secondary to that.

Paul Burstow: I accept that the system of social care that we are currently operating-the model of care is fundamentally a crisis-management model-is broken. We need a system that is promoting well-being, focused on early intervention and providing advice, guidance and navigation through the system. Those are key elements in any reform that we need to put in place.

One thing that has come across time and again during the engagements that we have had is that, if we are looking for game change, it is a not a single thing. But taking the recommendations of the Law Commission and enacting them would provide a fundamental shift in the way that the system operates, moving from services to outcomes, from crisis to well-being, and so on. So it is an important change.

Q612 Dr Poulter: Sure, but in respect of an issue and concern that has been raised so far, yes, you are right: it is a crisis-management model. The problem is the financial drivers of the model-for example, with regard to payment by results in hospital care, where a hospital is only rewarded for acute care in that hospital and is not rewarded for preventing admissions and working collaboratively with community care or for working to look after the patient when they are discharged from hospital after they have broken their hip, because there is fragmentation of the payments system. Unless we get the payments system and tariff system right-look at chronic disease tariffs and that sort of thing-we are never going to get the drivers of care right.

Paul Burstow: I would certainly agree with that. Obviously, we have inherited a process of tariff design that has been very focused on episodic care and acute care. What we announced in the White Paper for reform of the NHS 18 months ago was the beginnings of design of new year-of-care tariffs in mental health, for children’s mental health and for long-term conditions.

I confirmed just before Christmas that we are now working to put in place the first tariffs around long-term conditions, for the very reason that you described. We want the patient pathway to be properly funded. That does mean investment outside of the acute sector. It is certainly a key part of how we incentivise those sorts of changes.

Q613 Dr Poulter: Sure. There is an acceptance that we need to look at some chronic disease tariffs, so thank you-that is very useful. The NHS will be better at managing people with long-term conditions through chronic disease tariffs, but actually the question of how we tie in and bring in social care to that mix is a bit more complex. We have some good examples, which have been outlined by you and members of the Committee, where social care is very well integrated with NHS care, but actually that is hugely variable and relies on the good will of the staff and of different organisations working together. As we have seen, and as you have conceded, mentioned and agreed with on the NHS model, it is putting in place those financial drivers to drive integration that matters. Is there not a case for the Government to push in a meaningful way for pooled budgets between social care and NHS care to make sure that we break down these cultural silos that have existed for many years?

Paul Burstow: That goes back to Mr Skidmore’s question earlier on. What I have said is that we are not ruling it out for ever. We have a series of things that we are doing that we want to embed around the role of health and well-being boards. Something that came across very strongly during the engagement and that undermines attempts to get the systems to align and to work around the needs of individuals is the leadership in the system. We tend to teach people to be leaders in silos rather than to be leaders across systems. One of things that we are looking to say more about in the White Paper is how we drive change in the way that we are teaching and training and continuously professionally developing leaders across health and social care so that they are able to work across the system to break down those boundaries. That is a very important means of overcoming some of the concerns that you describe.

Q614 Dr Poulter: Sure. That is true, but, to some extent, that happens already. For example, you have it in a hospital. You have multi-disciplinary team meetings. You have occupational therapists working together with physiotherapists, social workers, doctors and nurses. That has been happening for a number of years, yet we still have the problems that we have described-discharge planning and the fact that care in the community does not happen effectively for very many patients when they go home. We see a lot of issues about the frail elderly being readmitted to hospital due to inappropriate admissions, so we know there is a big problem here. The key issue is that unless we get the budgets aligned-we have good will among teams and workers already, working together-is working across the system ever going to happen?

Paul Burstow: There are two things that we are doing that speak to that. Specifically, one is the introduction of a post-discharge 30-day tariff that will effectively provide the bridge from hospital back into the community and a funding stream to support development and investment in services. The second is to pump prime that. During this spending review, we agreed to put in £150 million this year, £300 million from April into re-ablement and a further £300 million the year after. We are trying to address that but in a systems way. There is no point just fixing the bit about discharge. You have to have both ends of the pathway right as well.

Q615 Dr Poulter: That is hugely welcome, but do you think that a 30-day tariff is enough to bring in and tie in social care? I am talking about the long-term social care needs of an older person in particular. The rehabilitation will happen, I am sure, and hopefully be effective for some conditions in 30 days, but effectively tying in social care is about not just a 30-day tariff, but something that is longer term than that. That is where the drive and the emphasis from members of the Committee has come on pooling budgets.

Paul Burstow: Because a lot of the conversation in this Committee today has been about how we manage demand, the gap or whatever, and the pressures on the system, one of the things that is worth saying about all that is that the investment through that new tariff in re-ablement and the investment we are putting into re-ablement itself unlocks resources in social care. There is a huge incentive for social care to come to the table and to be part of designing those services. Indeed, in the operating framework, we made it clear that they must be at the table designing those services. We know that studies have shown that in the 10 months after a re-ablement package has been delivered, social care costs are 60% lower than they otherwise would be, so there is a huge economic compulsion there, let alone anything else.

Q616 Dr Poulter: I absolutely agree that there is a huge compulsion, but the driver is still lacking. I have one final question. Currently-the Dilnot report flags this up very well-the NHS has done pretty well in terms of funding increases under the previous Government, but social care, old people’s funding and social care funding lag somewhat behind. For the future, how would you envisage the distribution of funding between welfare and housing for older people and the NHS? Do you think that is something that needs to be looked at, leaving aside the issues of pooled budgets?

Paul Burstow: Forgive me, but those are very much the sort of questions that get looked at by Governments in spending reviews. We made a judgment about the relative allocation between those areas in the last spending review. If the Committee has thoughts on informing our policy process to write a White Paper, then we would be very keen to see what those are. But we don’t have, if you like, a new view that the balance is wrong and that we need to change it now. We have a view that we have a spending review period that we are in. We are sticking to it and we have a spending review to look forward to.

Q617 Chair: Do we not have to stop tiptoeing up to this fence and then constantly refusing it? We have heard this morning that section 75 flexibilities allow us to ignore this difference. We have heard that health and well-being boards are going to look across the boundaries. Now we have heard this new excuse-forgive me for saying so-that there is a spending round and we have a set of decisions about how much is on local authorities and how much is on the health service and no, we can’t review that either. Do we not have to decide whether we are serious about integrating these services and bite the bullet of, to use your own phrase, pooled sovereignty, so there is a collective decision between all those who are interested in delivering services to elderly people and a willingness to accept a collective outcome? If we don’t do that, I don’t see how we get the efficiency savings and the quality improvements we all want to see.

Paul Burstow: My argument-the Government’s argument-is that the things we have already done, the things that are in train as a result of the legislative reforms we are making at the moment are no small thing. But they are, taken together, a significant set of changes that drive the system in the direction we both want it to go, which is towards a more integrated system. If the Committee has things that it thinks we ought to consider further, we have said-I have said today-that the White Paper will consider further issues about how we take forward the recommendations from the NHS Futures Forum on integration and also from the King’s Fund. We will obviously want to respond to the Select Committee. What I am not doing today is adding yet another set of things. We are doing a lot. I would be happy to provide a note setting out the totality of the work that we are doing across the systems to drive integration. I don’t think probably that I have done it justice in all the answers that I have been able to give today.

Q618 Chair: If I may say so it would be very helpful to have a crisp set of why it will be different. It is the strong view of the Committee that it needs to be different. We have yet to be persuaded that it is going to be.

Paul Burstow: I will happily make sure that happens.

Q619 David Tredinnick: This ties into personalisation, which I think we are moving towards. Why are service users prevented from using part of or all their direct payment to purchase care services from a local authority? Doesn’t this build on the Chairman’s point that we are dancing around the issue? My understanding is that service users are prevented from using part of or all their direct payment to purchase care service from a local authority. Isn’t that an artificial hurdle in the current climate of integration?

Paul Burstow: The first thing to say about that is that is a continuity point-it is not something that this Government have just imposed as a new requirement-but it is the case that direct payments are one of the routes by which people can take more control over their care and how they want to see their care organised. Personal budgets are also alongside that. So for those who do not want necessarily to take all the responsibilities of managing the budget and so on, personal budgets provide an alternative. These things sit within an agenda about personalisation that is much richer than just giving people money.

Q620 David Tredinnick: In fairness to you, you said that you want to orientate the services around the individual and talked about allowing citizens to have lives in their communities. Indeed, the Committee-sadly, I was not with them-was in Taunton yesterday, which we have already discussed. One of the points I understand from our earlier discussions that came up was that people there are electing to use acupuncture, for example, which is now available through NICE guidelines for lower back pain, as we all know. I would suggest that has considerable cost-saving elements because it is very cost-effective-it is the cost only of the needles rather than drugs. People clearly want those options, so there is a whole range of services in the complementary world that you might want to address, Minister, when it comes to the White Paper you are preparing. There will be a demand for a whole range of other services: homeopaths are out there, the Royal London Hospital for Integrated Medicine, and there is also one in Bristol. Public demand is likely to shift. I respectfully suggest that you might want to include that in your White Paper.

Going back to the point I just made, which has been put to the Committee before, local people want to be able to spend some of that budget on local authority services, and I think that is something that needs to be looked at. We have also heard examples of people being offered personal budgets that will not meet their needs, and are not equivalent to services offered by their local authority. What can you do to reassure people that personal budgets are not being used to ration care?

Paul Burstow: On your point about alternative ways of meeting needs and your example of acupuncture, I could give another example, which I saw when I met the user of a personal health budget who had COPD. They could have been sent in the traditional service model down a physiotherapy route, but they chose instead to use some of that resource to join a choir. The follow-up on their health status showed they were healthier; they had broken down social isolation; they were out in their community. So they got both well-being benefits in terms of their mental health as well as physical benefits of actually using their respiratory system through the choir. That ticked the boxes in terms of health. Being creative with personal health budgets is one of the real opportunities out there, and I agree with your point in that sense.

Q621 David Tredinnick: On the point you have just made, one thing about singing, of course, is that it has a dramatic impact on the body, just going through a range of notes. There are many studies out there. I absolutely agree that if you are going to think out of the box, there are a lot of other ways: music, playing trumpets, as I know from someone I know well.

Valerie Vaz: I am just worried about the headlines: "Scroungers playing the trumpet."

David Tredinnick: For children with asthma, playing a trumpet or cornet is a very effective way of expanding their lungs and getting rid of the problem. There are many studies that show that. We had better not dwell on that. I am sure the Chairman wants me to stay within the bounds.

Paul Burstow: What I was going on to say was that the opportunity that personal health budgets and personal budgets give is not so much for the state to think outside the box, but to allow individuals to think outside the box. It is that fundamental shift that this is about.

On your point about reassurance on personal budgets and the levels, there have been some figures published recently. My challenge to colleagues in local government is that they should be looking across the piece at the levels that are being set and should use that to challenge. In terms of the longer-term assurance, the change in the legislation that would come from recommendations from the Law Commission will, I think, give the greatest assurance, because it is about saying, "What are the outcomes a person wants to have in terms of meeting their needs? What are the services they need?", and about providing clarity about what the decision makers in the system have to do. Those things are absent at the moment because of the very complicated, complex, confusing legal framework that we have.

Q622 David Tredinnick: My last question relates to what you have just said. How do you integrate health and social care funding for individuals who do not qualify for integrated personal budgets?

Paul Burstow: This is someone who may well be entitled to a personal health budget because they qualify by need, but is affected by the means-tested nature of social care, which comes back to Andrew George’s earlier point. The issue of people not knowing that they potentially face catastrophic costs in social care and that it is a means-tested system is one of the nasty secrets of social care. We still see headlines in our newspapers that convey the impression that those who write those headlines do not know themselves that social care is not free and never has been. That is a real problem. Therefore, making sure that we have designed the system in a way that makes it far more transparent is critical to encouraging people to plan and prepare for their future care needs in a way that most people do not. Therefore, making sure that we have designed the system in a way that makes it far more transparent is critical to encouraging people to plan and prepare for their future care needs in a way that most people do not. People make a distress purchase at the moment.

To come back to your point about not being able to integrate the budgets, we increasingly need to allow people who are self-funding their social care needs to bring together their commissioning of services and the support they need with their personal health budget. There is no reason why they should not be able to use their own resources, as self-funders, to reinforce and support their overall package of care and support.

Q623 David Tredinnick: In my constituency, people are turning to sport and are electing to get involved in physical activity to reduce stress. Choirs are another way of doing that. I am pleased to hear that you are thinking in a wide-ranging way about many different options, which, I am sure, will offer much encouragement to the many people who are watching this live on television.

Paul Burstow: And we will publish the evaluation of personal health budgets this October, so we will have more to share then.

Q624 Barbara Keeley: Can I bring us back to funding? Minister, you have just said that care is not free and never has been. Care would have been free for the 400,000 people in greatest need if the Personal Care at Home Act 2010 had not been stopped and reversed by this Government, so you should not say that. That was an opportunity to give free personal care to some people.

Paul Burstow: That was a future event that did not happen because the election did not produce that outcome.

Q625 Barbara Keeley: It was a piece of legislation that had gone through.

On Dilnot and funding, would it be fair if people with the same social care needs reached the Dilnot cap on care costs at different times? To balance that, if you think it would be unfair, should we be looking at a national pricing structure and resource allocation system to make sure that whatever decisions are made about the Dilnot cap, and whatever level it is set at, people reach it at the same time and that there is not a new postcode lottery?

Paul Burstow: Are we talking about people living in the same locality or the difference between one part of the country and another?

Barbara Keeley: One part of the country and another.

Paul Burstow: Right. Designing a single price structure fails to recognise the differences in costs from one locality to another. Before the election, the Department of Health published a detailed analysis of the wide cost variation of different aspects of social care support, with a view partly to challenging the system to consider how it could benchmark itself to reduce costs.

I do not think that it would be fair for two people living in the same locality with the same assessed needs to find themselves hitting the cap at different levels. I do think that it is perfectly fair to design a system that says that people living in different parts of the country should have care packages designed with their local authority, which might have very different cost bases. I would not want to lump additional costs from one locality on to another in the system.

Q626 Barbara Keeley: I see. Can I come back to the issue that I asked you about earlier? I and the Committee need to be absolutely clear about your estimate of the gap between levels of local authority social care funding and levels of need. Perhaps you can tell us again if you do not think that there is a gap. What do you think that figure will be across the next 10 years?

Paul Burstow: If I may, Mr Dorrell, I would like to provide a letter that recaps on things that I have said in public before. Back in 2010, after the announcement of the spending review, I set out to the Association of Directors of Adult Social Services conference exactly how we got to the numbers and how a robust programme of efficiency and improved productivity in social care would mean that there need not be a gap. The current level of service can be maintained, and choices by local authorities are key to whether there is a gap or not.

Q627 Barbara Keeley: But do you believe that there is a gap? You are now saying that there need not be one-is there?

Paul Burstow: I believe-this is turning into a theological thing, and I don’t mean it in that sense-that prior to the spending review settlement, a gap was identified. The spending review settlement, through a combination of additional resources of £7.2 billion in this Parliament and a rigorous efficiency programme, requiring up to 3% efficiency savings a year by local authorities, will be sufficient to allow local authorities to choose to maintain the current level of provision. Some local authorities have chosen to invest more in their services in the past year and a half; others are choosing not to. The overall change on the CLG figures shows a 1.5% reduction in spend on social care. We know from the ADASS survey that local authorities say that 70p in every pound that they have taken out of spending on social care has been done through transformational change and service redesign.

Q628 Barbara Keeley: The ADASS figure is that £1 billion less is being spent on social care.

Paul Burstow: Of which £700 million comes through service redesign transformation, and the balance from tightening eligibility criteria, changes in charging policies and so on.

Q629 Barbara Keeley: So are you saying there is not a gap? You have said there does not need to be a gap; are you saying there is not a gap?

Paul Burstow: I am saying that, after all that Government can do, there should not be a gap, but then there is a decision that each local authority has to make about how it uses the resources.

Q630 Barbara Keeley: You are not answering my question; is there a gap? Not, "Does there have to be?"

Paul Burstow: I think I am answering the question. I am just not answering the question in the way you would like me to answer it.

Q631 Barbara Keeley: I am asking you a question. You are the Minister responsible for social care services. People say that social care is in crisis. Is there currently a gap between local authority funding and need?

Paul Burstow: I am saying that when we came into office, ahead of the spending review, there was a gap. We took decisions about the amount that central Government could provide to support social care during this Parliament-£7.2 billion. And we identified the need for there to be a rigorous programme of efficiency savings-3% per annum by local authorities. The Association of Directors of Social Services agreed that that was necessary and is taking steps, along with its colleagues in the Local Government Association, to deliver that. It is therefore down to judgments by individual local authorities about their own priorities as to whether they spend the money to secure that outcome or not.

Q632 Barbara Keeley: So you do not see a gap? I think it is a straightforward question.

Paul Burstow: And I think I have given straightforward answers several times.

Chair: We are getting into a Paxman situation.

Q633 Barbara Keeley: My final question was going to be about what proposals the Government had to address the current funding gap. Presumably, as you think there is not a current funding gap, you are not putting forward any proposals.

Paul Burstow: What I said earlier is that we obviously take a view, as we come towards the next spending review, as to what the demographic pressures and cost pressures are in the system, about what the baseline is and what we have to do if there is a gap that needs to be closed. But we did that in the 2010 spending review. We put in place sufficient resources to enable local authorities, if they so choose, to protect social care at its current level.

Q634 Chair: Can I develop the question in a slightly different way? If it is true, following Barbara’s question-I am not seeking to re-ask it-that there is not a gap, why are we considering the Dilnot proposals to raise more money for social care? Is it part of the policy purpose of the consideration of the Dilnot options to unlock new resources for social care?

Paul Burstow: The way in which I see that, and I think the way in which Andrew Dilnot, when he spoke to this Committee, also sees it, is that it is about enabling more private wealth to be levered into the system, so that people can spend more, and earlier, on interventions that actually probably would lead to a reduction in their lifetime care costs, if they do it in a planned way, rather than in a crisis. Dilnot, of itself, was not about levering in more state resources. That was not the question in the terms of the reference that we set him. His question was, "How do we get a fair balance between what the state and what the individual provide?" How do we enable people to insure that risk-not in the literal sense, but in terms of what means, through financial services, might be available? His view, which has been confirmed through our engagement with the financial services sector, is that it does create a space, depending on the level of cap you set, to grow a financial service market that allows the whole character of social care to change from a distress purchase to one where you are planning in advance to mitigate-to future proof-your care needs.

Q635 Chair: Is it the Government’s view that it is necessary, in order to maintain a properly funded health and social care system, to unlock those new resources going forward?

Paul Burstow: They are an essential component going forward, because they also speak to another issue that is very important, and which we spent a lot of time in the autumn discussing with the sector, which is about quality, and how we make sure that people can, through greater choice and awareness of what the options are to meet their care needs, also help, through those choices, to drive improvements in quality. That quality will be a very big part of what we will set out in the White Paper.

Q636 Chair: It follows, does it not, that if in the Government’s view it is necessary to address both volume and quality of demand, if the policy conclusions that come out of the Dilnot process raise less money than Dilnot proposed, the funding gap will remain?

Paul Burstow: The fundamental point, which was very strongly put to us during the engagement and we think is absolutely right, was that we should not accept the inevitability of current demand pressures in the system. We should be looking at how our current models of care can be changed to models of care that bend the demand curve, bend the cost curve, and drive the quality curve up. That is at the heart of what we want to bring forward.

Q637 Chair: But that is a constant isn’t it, whether or not we do Dilnot?

Paul Burstow: Absolutely.

Q638 Chair: The point about the Dilnot process is that it unlocks the opportunity of new resources.

Paul Burstow: It unlocks potential new resources. He would argue-and he did in his report-that it unlocks an important set of nudges and behavioural changes as well.

Q639 Chris Skidmore: I want to go on to the point about financial products, given that it was raised a moment ago by the Minister. We had the ABI here several months ago, voicing general scepticism that if the cap is set at a certain level-say £35,000, as per Dilnot-you wouldn’t really have an appetite within the financial sector to provide those products. Obviously, the industry group has been set up to look at that, and I was wondering whether you are able to describe the process or say what information you have on the latest industry news about how this would work. We have seen in the news, and yesterday in The Daily Telegraph, the idea that the cap might be £60,000, which might be viable for the industry to enter. Andrew Dilnot said to the Committee that he would be reasonably happy if the cap was around £50,000. I understand that you may not want to talk in detail since current cross-party talks are ongoing, but if you are able to provide an update, or any idea of the financial products, I am sure that would be welcome.

Paul Burstow: The report in The Daily Telegraph, and subsequently in the Daily Express today, is an accurate reflection of material on the Department of Health website. One document was put on the website on 13 December, and another was added the same day. One of those documents covers the outputs from all six work streams that we have been pursuing-personalisation, integration, financial services, quality, prevention and so on. It says to the Government that a cap on care costs at between £50,000 and £60,000 would, in their view, stimulate a market for financial services. Who are they? Most of the big players in the sector. Why are they at the table? Because we realised that part of any reform of funding that is serious about having a role for the financial services market needs to engage meaningfully with it. That is what we have been doing over the past few months, and I will be happy to ensure that these documents get to the Committee.

Q640 Chris Skidmore: In terms of the modelling you are doing, obviously a key aspect of whether Dilnot is going to succeed will concern momentum and to what extent you are able to get new entrants into the market fast enough for there to be an uptake, and whether the funding model will work fast enough. At the moment, the number of products available can be counted on two hands, and the number of people taking them up is below 10,000, or something. Has any modelling been done to show what you would need once a policy was implemented, and how fast you would need people to sign up to it, in order to make it viable?

Paul Burstow: The various factors that you would need to take into account to construct such a model are quite complicated, so there has not been detailed modelling. There has, however, been a lot of detailed discussion with the industry about how it would respond in the event of different levels of cap. As I said, we have heard back from the sector that in its view, even a cap as high as £60,000 would create sufficient space for more entrants with more products.

Those products are not about insurance per se; they are often about the use of pension savings through annuities linked to disability needs, or through a new generation of equity release products. A variety of those sorts of things would allow people to access the various sources of wealth that currently are not perhaps as well deployed in supporting care needs as they might be if the financial services industry felt it was an environment in which it could operate.

Q641 Chris Skidmore: At the same time, local authorities were encouraged to roll out their own sort of separate asset-release schemes.

Paul Burstow: That is a deferred payment.

Q642 Chris Skidmore: In terms of the insurance modelling, if local authorities are offering asset deferred payments, does it look as though packages will tend to centre more around pension-based packages rather than equity? Because if you have the local authority system in place, you will not have any need to take up an equity-based insurance package.

Paul Burstow: That comes back to the earlier conversation we were having about eligibility and where eligibility falls. Depending on where you set that, there will still be a space between the point at which a person might want to start planning, preparing and future-proofing their home and so on and the point at which they would be eligible for any consideration either by state support or by being in the meter to get to a cap. There is a space there for those sorts of products to allow people to plan, who are prepared to use resources differently.

Q643 Chris Skidmore: Very briefly, we have talked about this subject’s being highly controversial and we have mentioned various papers that have already picked up on what is ongoing. A concern of mine is that the traditional view of the press has been of people having to sell their house to pay for their long-term care, and therefore Dilnot was seen as a panacea, whereby your house would somehow be preserved. That is not necessarily the case. We looked at domiciliary care. I wondered whether you wanted to clarify what you felt on Dilnot, which does not necessarily protect the home. There may be a gulf between the discussions that are ongoing and any policy, and the expectation that Dilnot will completely protect the family home.

Paul Burstow: The thing to say about the Dilnot Commission report is that it did not offer us a blueprint; it offered us a design guide. There is a whole series of parameters that you can move up and down, and that has an impact on the extent to which you do or do not protect assets and who you incentivise to behave in certain ways. The key things here, if we are to change the demand curve, are about how we get people to plan and prepare earlier and how we help people through better advice, information and care navigation to use the resources they have, and the resources in their communities and private and other services, to meet those needs. That is the sort of set of things that we are wrestling with as a result of the inputs we have had from the engagement over the autumn, the work from the Law Commission and Andrew Dilnot’s work, which will come together in the White Paper in a few months’ time.

Q644 Chris Skidmore: Dilnot himself spoke about the crucial need to have some information and advice, and to make sure that is readily available. I guess that will be in the White Paper as part of the strategy.

Paul Burstow: Yes, we will amplify it. We have said a bit about how we see that being very much a universal offer. It is a key intervention at a very early stage-the provision of good-quality, reliable information and good-quality navigation of what the possibilities are. That itself could have quite a profound effect in terms of how people then choose to use their resources going forward. As I was saying, the research evidence shows that people dramatically underestimate how much they need to adapt their properties to be able to live in them well, safely and healthily for many years to come.

Q645 Chris Skidmore: Just one more point-moving on from Dilnot. Dilnot did not cover residential care and did not cover living costs of up to £7,000 to £8,000. That will still be the framework within which we operate for the White Paper, I imagine.

Paul Burstow: Dilnot covers both domiciliary and residential. It covers the whole spectrum. What we will set out in the progress report is what conclusions the Government have reached at the time we publish the White Paper.

Chair: Carefully chosen words.

Q646 Valerie Vaz: Minister, you mentioned the Law Commission earlier. You said that there were 76 recommendations. Is it possible for you to tell the Committee roughly what you are likely to accept and not accept?

Paul Burstow: Seventy-six recommendations-there are many in there.

Q647 Valerie Vaz: I am just asking for a broad answer from you. I do not expect you to know each individual one, but if you do, that would be great.

Chair: If you do, please write to us.

Paul Burstow: Thank you very much. That will be a feat of memory, let alone anything else. There are a number on which we have already given indications about our view. For example, we have made it very clear that we intend to legislate in the safeguarding area to place safeguarding boards on a statutory basis, and to establish clearly the duty of co-operation between different agencies. We have indicated that we are very sympathetic to the recommendations for moving the status of carers on to the same basis as service users in terms of entitlement to assessments and the follow-through of services. That is quite an important shift in terms of meeting some of the concerns that Barbara Keeley raised earlier. We have also indicated issues about having a universal offer about information, and the duties that would sit around that.

Those are the three that we have already particularly said. We are working through a whole host of others. Clearly, if we were to implement a funding reform, we would need to look clearly at the recommendations that have been made about eligibility-the commission talks about a standardised approach-and at issues around assessment. We would need to look at assessment anyway if we were to implement the carers recommendation.

What we have said publicly as a Government is that we see the current legal framework as being well past its best-before date. It really does provide an obstacle to implementing many of the changes we need to see. In fact, one of the reasons we believe that some of the policy changes that have been attempted over the last decade or more around personalisation have not stuck in the system is that the system defaults back to a legal framework that does not accept them, so it rejects them when the going gets tough. We need to reset the legal framework to make it fit.

Q648 Valerie Vaz: Speaking about a legal framework, did you ask them to look at the legal framework around integrating health and social care?

Paul Burstow: The Law Commission as part of its work looked at the draft legislation that we were producing when we produced the Health and Social Care Bill, and certainly we would welcome the Law Commission’s views as and when we complete the drafting process.

Q649 Valerie Vaz: Did you ask them to look at that?

Paul Burstow: They looked at it, yes.

Q650 Valerie Vaz: They said that you didn’t.

Paul Burstow: They looked at the Health and Social Care Bill, and commented on integration.

Q651 Valerie Vaz: Are you accepting that? Is that an area that you are going to accept?

Paul Burstow: In 2008, when they were set the task of looking at the law review, they were not asked, as I understand it, to look specifically at integration. When it came to finalisation of their report leading up to May 2011, they did look at the draft Bill that the Government had published, to see the issues around-

Q652 Valerie Vaz: Specifically around integration?

Paul Burstow: Yes, around integration.

Q653 Valerie Vaz: And which you are accepting. They told us something different, but I just wanted to clarify that from you.

Paul Burstow: I will need to have a look at what they said to see why it is different.

David Behan: In their recommendations, they clarified the overlaps with other services, including the NHS, and also including housing, to pick up on the theme of the Committee. They also commented on consistency between the legal frameworks, coming back to the point about incentives that I think you covered, and they wanted to ensure that they were supporting partnerships with requirements around co-operation. My recollection is that of the 73 recommendations, there is a recommendation around co-operation between health and local authorities in the way that they further their duties. I think the key issue was about the principles on which the future legislation should be based, and where they broke ground in many respects was saying that we need to set out the principles on which these systems should operate.

Q654 Valerie Vaz: And you will definitely take that on board. Okay.

The other area, when they gave evidence to us, was that they said you asked them not to look at the definition of "ordinarily resident". Why was that?

Paul Burstow: I was not privy to the decision, because it was made in 2008.

David Behan: Ordinary residence is an issue of administration rather than the law, and they were looking at matters of law rather than policy.

Q655 Valerie Vaz: I beg to differ, because you can define it, and it is defined in law. You can define "ordinarily resident". In fact, it could make for much more clarity if you did that. There are other pieces of legislation that do define it.

David Behan: That is an interesting point, but currently "ordinary residence" is not defined in the law, so what the Law Commission looks at is what was defined in the law.

Q656 Valerie Vaz: Right, but they specifically said before us that you asked them not to look at that. I just want to clarify that.

David Behan: We asked them to look at the law, not policy. We drew a distinction between the law and policy.

Q657 Valerie Vaz: We did, but you specifically asked them not to look at the definition.

Paul Burstow: That request was made in 2008.

Q658 Andrew George: Minister, you have a reputation for taking up the role of highlighting the importance of carers. They are often overlooked, and you are well aware, of course, that estimates-I think informed estimates-suggest that up to £119 billion is saved, in effect, by the provision of care from informal carers. Apart from the carers strategy published last year, do the Government-your Department-intend to ensure that the role of carers will be at least acknowledged and dealt with in the White Paper?

Paul Burstow: Yes. It is also being embedded in the changes that we are making to the NHS through the Health and Social Care Bill. Carers feature in many aspects of the patient-involvement requirements much more explicitly than ever before. We have been talking about the extent to which the central direction and rolling out of things works. In opposition and in government I have been critical of the fact that although the previous Administration rightly focused on the need to people getting access to carers’ breaks and so on, demonstrably it did not happen as much as it should have. We are seeing similar difficulties in terms of securing that policy goal. That is why the operating framework that we published for this coming year, compared with the one that we drafted in our first year, is much more explicit than ever before about we expect the NHS to deliver against our commitments on carers.

Q659 Andrew George: That is helpful, of course, but as your own record shows, although the Government estimate that there are about 5 million carers, another estimate is 6.4 million, which is about 15% of all households. This is a substantial issue, yet only 4% of carers receive any kind of assessment and the latest information suggests that that figure is falling rather than rising. To what extent are you satisfied that carers are getting the support that they deserve, are informed about their rights and the support that might be available to them and are becoming more rather than less isolated in the community?

Paul Burstow: I am certainly not satisfied and expect both the NHS and social services to do more. That is why, in the operating framework for 2012-13, we have said to them that the NHS has to collaborate with carers’ organisations and with its local authorities to agree a carers’ plan for its locality, drawing on the strategy you just mentioned. It has to be explicit about that and has to sign it off with its local authority; it has to spell out the financial contribution it is making to support carers; it has to identify how many carers’ breaks there will be; and it has to indicate the numbers. All of that has to be published to aid transparency.

On your point about the numbers of assessments and packages, we have one year’s figures showing a slight dip after a significant rise over a number of years. So yes, we need to watch that carefully. That is why one key priority in the strategy is for us to focus on identification of hidden carers and why we are working with the Royal College of General Practitioners on a series of pieces of work to really elevate the profile of carers within the GP community, as a key way to identify them. That is why we are working with organisations such as Sainsbury, which is introducing a new scheme shortly to identify people who do a double shop. Doing a double shop is a good indicator that someone is buying for someone else who they are caring for. That has been successfully trialled in Torbay. I visited the shop in Torbay while visiting the care trust, which was doing some interesting work, too.

Q660 Andrew George: You said in your earlier answer to me that your route to carers is through carers’ organisations, but few carers have the time or the ability to join such organisations. Surely, one route to them would be through the cared for, who are, after all, registered in some way and known about by the state, and through local authorities or the health service.

Is it not appropriate, given an earlier answer that you gave me, that when assessing the needs of those who require care, you consider them in the context of the support that might be available to them from family, friends and the wider community? In those circumstances, don’t you think that that is the route by which you should be identifying where the carers are and what support they need?

Paul Burstow: Yes, and we are. In the strategy, we identified the need to have a whole-family approach to assessment as a key part of that, so that you are not just assessing the person who needs care and support but looking at the whole family’s circumstances in terms of what support they can give. Also, you should not be making assumptions about who will provide care. Again, that is the reason we are collaborating with the Royal College of General Practitioners on work that they are doing to elevate the priority and visibility of carers. When a carer comes to the GP’s surgery with someone they are caring for, they should not be invisible. They should be a part of the conversation and they should be identified as a carer as well.

Q661 Andrew George: But a 4% assessment is still, you have to accept, woeful. I would hope that the White Paper and the future strategy would look at ways to assess that. You say that it has increased significantly, but to increase significantly to only 4% is rather woeful, I am sure you will agree.

Paul Burstow: I certainly agree that there is an awful lot more that we need to do, and we will set that out in the White Paper. There are a number of things we are doing, and the strategy that we have set out provides that. I agree with you that we need to find various ways of engaging with carers. It is one of the reasons why we have maintained the Standing Commission on Carers, which is made up of carers, so that we have a direct voice into Government from carers themselves.

Q662 Andrew George: Finally, if I may, on the issue of flexible working, which was highlighted in the coalition agreement in relation to the carers strategy, are you content that progress is being made? You mentioned carers’ breaks, respite care and support for carers, which is clearly essential. If you are going to enable carers to live outside the home in which they are often tied providing care, is it not essential that that you have discussions with the Department for Work and Pensions?

Paul Burstow: In terms of flexible working, the conversations are with BIS and my colleague Edward Davey, who has been leading on the consultations around extending the rights to request flexible working, meaning that there is an opportunity to widen the numbers of carers who currently have access to flexible working in the future. Good progress is being made there. I know that he is seized of the importance of supporting carers in that way.

Q663 Barbara Keeley: I am slightly bemused by the notion of identifying carers through double shops at Sainsbury’s. I would not say that that was not worth doing at all, but surely the place to identify-

Chair: A sure-fire way to find a teenager in the house as well.

Barbara Keeley: The Minister knows I have proposed a Bill for a number of years on the identification of carers and directing them to sources of support. It is a shame that that issue keeps being ducked-by the previous Administration as well as this one. It is quite easy to identify carers. GPs control their lists. They find people with particular long-term conditions or who have just had a stroke or who have cancer. The hospital discharge does the same. That is the point at which to say, "Who is going to be the carer for this person?" The other place where identifying hidden carers needs to be done is in schools, where an alert teacher can notice a young carer. I drafted a Bill with some help from outside in 2006. Why do we keep ducking this issue? This session has been all about ducking the issues. This is ducking it-identifying carers through a double shop at Sainsbury’s when GPs could be required to do so through their contracts, as they are expected to give injections or do certain follow-ups. Are we taking this issue of our commitment to carers seriously at all? It is not that there is not a way to do it. I have provided a way to do it. I will send you again, Minister, a copy of my Bill. Let us not get into shopping as a way of identifying carers.

Paul Burstow: What I would say, Barbara, is this. What we are not doing is saying that there is one magic bullet that allows you to identify all the carers in this country. Your Bill is certainly not a magic bullet, either.

Q664 Barbara Keeley: It would go a long way.

Paul Burstow: That is why I said in my remarks that one of the things that we are doing as a Government, which has not been done before and which we think will make a significant difference, is that we are actually concentrating on raising awareness of the issue among the GP population. It has not been done before.

Q665 Barbara Keeley: You could require them to do it.

Paul Burstow: That is one of the things that we are doing. As for our comments on the initiative by Sainsbury’s, rather than me attempting to defend that proposal-which I think is very good- it would be better if I sent you some of the figures that came out of the collaboration between Torbay Care Trust and Sainsbury’s in terms of the numbers of people identified as carers. I would have thought that we should share in common a desire to identify more carers and make sure they get our support.

Q666 Barbara Keeley: GPs and hospitals.

Paul Burstow: And try as many different routes to doing just that.

Q667 Rosie Cooper: Sainsbury’s knows about carers better than GPs.

Paul Burstow: -rather than having a one-size-fits-all approach, which I do not think will work.

Q668 Chair: Do you want to pursue this?

Q669 Rosie Cooper: I do. As for this Sainsbury’s nonsense headline-grabbing idea, can you tell me how Sainsbury’s identifies those doing a double shop? Using a store card? How does it identify them? When it has identified them, what does it do? Who does it tell? Which data protection nonsense does it breach? Does it ask me if I am a carer? Yes, I am. Have I been a young carer? Yes, I was. How does this all work? Once you are spotted as a potential carer in Sainsbury’s, look out. What happens?

Paul Burstow: Let me go through some of that. I spent a bit of time when I was in Torbay looking at their piloting of this and the way in which they have unpicked those various questions. What they do is very simple. They do some basic training of their staff on checkouts-to be alert to double shoppers. They provide them with some additional information in their shopping bags and they follow that through in terms of the numbers of people who then present themselves to the local authorities as possibly being carers. It then triggers the carers’ assessment processes and so on.

What I am not suggesting-and please do not run away with the idea that I am-is that this is the solution to the identification of carers. It is a contribution to the identification of carers. It is wrong to denigrate a supermarket which chooses to act in a socially conscious way and engage in this particular programme.

Q670 Rosie Cooper: I think you will find that I am rather more amused by a Health Minister who appears before this Committee and has made the level of contribution and increased our understanding of where the Department is today because frankly I am just astounded at what I have heard. It has not increased my knowledge one jot. We have had a lot of good talk. As for the people out there, none of this actually seems to be at the point of making a difference.

If a GP does not know that there is a carer involved or people need care, it is time to pack up and go home. While this may very well be a great add on and add value, the truth is that Sainsbury’s is selling products. We are grateful for anything it can do, but it is at the margins. We need to be dealing with the real problem, and that is helping families, carers and the cared-for. This is mad.

Q671 Chair: Before we pack up and go home, could we have a brief series of questions on personalisation?

Q672 Dr Wollaston: Also on the subject of carers, should there be greater flexibility for allowing the personalised budget to go towards employing carers if that is the choice of the individual?

Paul Burstow: Sorry, I didn’t quite catch the question. Can you repeat it?

Q673 Dr Wollaston: Going on to personalised budgets, do you think that there should be greater flexibility to allow carers to be family members employed through personal budgets?

Paul Burstow: There already is some flexibility-I know this from my own constituency work as much as anything else-to allow people in certain circumstances to be able to employ a family member in those situations, so that flexibility is there now. If we need to clarify it further as a result of your inquiries, we would certainly want to do that.

Q674 Dr Wollaston: There are certainly some people who are being prevented from spending their personal budget in that way.

Paul Burstow: If there is a need for additional guidance to make it absolutely clear and put it beyond doubt, that is something we would want to do.

Q675 Andrew George: Can we have a written note on that?

Paul Burstow: Yes, of course.

Q676 Dr Wollaston: Returning to carers, do you think that assessments should be carer blind? Should we start running the meter towards a care cost, taking into account the contribution for carers to make it fairer to individuals or are we de facto saying that the system would collapse because there would not be the funds within it without using those costs?

Paul Burstow: I certainly think that what we said in the carer strategy is that we need to take a whole family approach to assessment, and to look at the whole family circumstance in terms of designing the meter. One of the problems I have coming to the Committee at this stage is that there are lots of issues of policy development that are not concluded. I cannot present to you the White Paper setting out all those policies. I understand that that is frustrating for members of the Committee, who would like me to air all of the conclusions that we have reached or will reach over the next few months. I hope, Mr Dorrell, that your Committee, as it clearly has been doing during its hearings on this, will provide us with some further stimulating recommendations that we can take into account in that White Paper.

Chair: That is for others to judge, but we will do our best.

Q677 Grahame M. Morris: I want to put something to you that was put to the Committee when we visited Lancashire, following meetings with groups of carers and with officials and politicians from the local authority. You mentioned personalised budgets being a game changer earlier, and one of the anomalies that they pointed out was the pressure on local authority day care services as a consequence of the personalised budget holders not being allowed to purchase care from the local authority. Is that something that the Government are aware of and that they intend to address?

Paul Burstow: That is a point that Mr Tredinnick raised earlier, and the point that I made was that personal budgets allow people to still purchase services from their local authorities, so it allows them to have greater independence and ability to shape the service they want, and we think that allows us to address that concern.

Q678 Grahame M. Morris: That was not the information that was given to us, unless I have misunderstood.

Paul Burstow: Would it be possible for the Committee to let us have whatever it is that you have and then we can give a proper response?

Grahame M. Morris: I would be grateful for that.

Q679 Chair: I am sure that we can do that. May I ask a question about personalisation? I think that everybody is familiar with the arguments in favour of personalisation as a means towards greater engagement by the individual in the design of services and greater empowerment of individuals-all of that is clear. That is one set of issues. Another set of issues is portability around the country, which Andrew George has covered. Is there not a set of concerns on the other side of the spectrum that we need to be aware of, namely that the more you define the individual’s need in terms of money and in terms of the formula in order to allow personalised budgets, the more difficult you make it for the system to reflect the precise circumstances of a family or a particular set of individuals and the more you move away from designing service towards, in effect, reinventing social security? The Department for Work and Pensions looks at the circumstances of the individual and defines them in monetary terms, but that is absolutely not what the NHS, at the other end of the spectrum, does. I wonder whether there is a conflict of cultures here that has not been fully reconciled.

Paul Burstow: It is an important part of how we reform the system to understand that we are not introducing a scientific process where there is an absolutely right answer for an assessment of human beings’ needs in terms of them being able to maintain their independence, their dignity and their ability to integrate and be part of their community. There is not just a thing you can do by tick-box rote to do that. I think that that comes out strongly from everything we are doing.

In terms of the Law Commission stuff-I think this is very important-and the idea that you have a set of clear principles that are about the individual and about outcomes, and not just about provision of services, the National Assistance Act 1948 is all about providing a service to meet an assessed need. The new social care legal framework, as recommended by the Law Commission-we have given a number of indications of the areas where we definitely want to pursue it-is very much about saying that it is not just about the services. It is about what you need in terms of your life-the ability to have education, the ability to be in your community enjoying social activity and so on. They are listed as the things that should go into the drafting of a Bill, and we see that as being an important and fundamental shift. Although, on the one hand, that has the appearance of being more social security because you are monetising, it firmly pulls it the other way because of the statutory framework. Landing that well and implementing it effectively over the next few years is very much the task that we are focused on and determined to deliver.

Q680 Chair: But are you cognisant of the fact that, if this is interpreted as a set of defined circumstances on national criteria, you are moving in the direction of a rights-based system where the rights are ultimately converted into money, rather than into a set of services that are flexible to the individual’s needs?

Paul Burstow: That is going to be the very key thing in the design of the assessment processes-assessments that are about assessing to deliver outcomes and commissioning that is about commissioning to deliver outcomes, and not just procuring a lump of service. One of the criticisms that we have heard about the way that a lot of social care is currently commissioned in this country, and I certainly think that it is a fair criticism, is that we commission far too much not on quality but on quantity and price. We need to move to a situation where we are commissioning for outcomes, and that has to be right through the system down to the individual with the use of their budgets, in terms of the plan that they have to meet those outcomes.

Q681 Chair: But even just talking in terms of outcomes creates another potential conflict, doesn’t it? You may have a view about what the outcome is, which represents best practice, good quality and so forth, and individuals may choose a different outcome, which more closely reflects their views. That is part of the conflict that potentially arises.

The reason for this line of questioning is to test the extent to which the Department has thought through the implications of what sounds, at first principles, like common sense, but once you apply it into the guts of a very big spending programme you may create some conflicts that have not been fully reconciled.

Paul Burstow: Also, this goes back to some of the questions about facts. In the end, we are living within a resource envelope and we need systems that make it as transparent and as clear as possible how resources are being allocated. So you are absolutely right that, in designing not only the policy but the detailed implementation, getting that right so that it is transparent and people can see how finite resources are being used to deliver the maximum public good is absolutely one of the tests, both for the White Paper and its subsequent implementation.

David Behan: If I may, Chair-

Paul Burstow: What I meant to say.

David Behan: No, no, perish the thought. The interesting thing is the proportion of people who are taking a direct payment as opposed to a personal budget and by far the higher proportion are taking it as a personal budget. In effect, there is a mixture, between what people will procure themselves-that might relate to your point about whether this measure is similar to a benefit-and what they arrange and take from the state, which is already pre-arranged for them. The balance is far more towards a personal budget than it is towards direct payments.

If you look at the figures and trends over the past decade or so, you will see that there is a great attraction around personal budgets rather than around the direct payments. That means that the presentation of this issue as an either/or is that, because it is providing people with choice, people want to exercise some choice. There was talk earlier about what people might do differently in terms of singing lessons for COPD. But my guess is that that will be supported by some slightly more formal and perhaps traditional services, which will also be appropriate to meeting those needs.

I think that the emergent evidence is that people are having a mixture of the traditional and perhaps the not-so-traditional, so it is not really an either/or. I think your question is really about what the mixture is between these things and how that is taken forward. I think that we are trying to apply some thought to what that will mean going forward and also applying that thought in relation to personal health budgets for people with long-term conditions, which I think was part of an earlier question from the Members.

Chair: Thank you. We are running out of time, but we have a question from Dan.

Q682 Dr Poulter: I just have one question, building on what the Chairman just said and some of the concerns that were raised. Isn’t there also a risk with personal budgets that you may have some local authorities-we have already seen this-that, when they look to make cost savings, might see personal budgets as a way of closing down some services and focusing emphasis on personal choice? More expensive local services may be closed down because the drive to run a more comprehensive local social care network and health network may be compromised by the drive for personalisation. Is there not a risk that local authorities may take that approach?

Paul Burstow: Of course there is that risk. It would be crazy to pretend otherwise. Therefore, in terms of the implementation of these policies going forward, it is going to be a case of asking what steps you take to mitigate that. Part of it is about making sure that the criteria you use around eligibility and the resource allocation decisions that are being made are as transparent as possible, and that those discussions are held in a way that allows the views of service users, carers and so on to have an impact. That is the best safeguard we can put into ensuring that you are getting the right outcomes from the money going in.

Q683 Dr Poulter: Yes, because there is a tension there. We might say that we support personal choice, which we recognise is to some extent a very good thing, but, at the same time, by supporting the funding of that, we lose some of those comprehensive services on a local level that service users and carers very much value.

Paul Burstow: The work and research that has been done by IBSEN , the group, and POET, and, indeed, last year’s National Audit Office report on markets have all looked at issues around personalisation. The general conclusion was very clear: that people valued the extra control that they gained back over their lives as a result of having access to either a personal budget or a direct payment.

Q684 Dr Poulter: But you accept that tension?

Paul Burstow: Yes. Of course there is a tension.

Chair: We have covered a lot of ground. Thank you very much for your patience and good humour.

Prepared 7th February 2012