Health Committee - Minutes of EvidenceHC 317

Oral Evidence

Taken before the Health Committee

on Tuesday 19 June 2012

Members present:

Mr Stephen Dorrell (Chair)

Rosie Cooper

Andrew George

Barbara Keeley

Dr Daniel Poulter

Mr Virendra Sharma

Chris Skidmore

David Tredinnick

Dr Sarah Wollaston


Examination of Witnesses

Witnesses: Richard Humphries, Senior Fellow (Social Care), The King’s Fund, Dr José-Luis Fernández, Principal Research Fellow, Personal Social Services Research Unit, London School of Economics and Political Science, Dr Ros Altmann, Director General, Saga Group, and Anita Charlesworth, Chief Economist, Nuffield Trust, gave evidence.

Q1 Chair: Good morning. Welcome to the Committee, and in the case of some witnesses welcome back to the Committee. We are, as you know, conducting what we hope will be a relatively brief followup inquiry to our Social Care Report, which we published in February, because of our concern to ensure that this agenda moves forward. This is a brisk mini report, we envisage, updating our thinking following the report that we issued in February.

Could I ask our witnesses, briefly, to introduce themselves, please?

Dr Fernández: I am JoséLuis Fernández. I am a Principal Research Fellow at the London School of Economics. I belong to a research centre called PSSRU that has been working in the area for a long time, and I have been involved in a series of reviews on longterm care funding arrangements.

Richard Humphries: I am Richard Humphries, Senior Fellow at The King’s Fund. We have a longstanding interest in the reform of social care funding and what that means for the NHS, in particular.

Dr Altmann: I am Ros Altmann, Director General of Saga, the largest provider of home care in the UK now, and also involved in delivering, as much as we can, integrated care and piloting integrated care.

Anita Charlesworth: I am Anita Charlesworth. I am Chief Economist at the Nuffield Trust. The Nuffield Trust works principally on healthcare, but we do a lot of work on the interface between health and social care. I am also a nonexecutive director at Whittington Health, which is attempting to deliver integrated care.

Q2 Chair: Thank you very much. We would like to start, if we may, with a brief overview of how events have moved on since we issued our report in February. I would like to ask each witness in turn to give us their response, very briefly, to our core recommendations in February, how you feel events have moved on since then, and general reflections so that we get the cards on the table at the beginning of the session.

Dr Fernández: One of the recommendations that the Committee came up with was in support of the Dilnot conclusions. At the time, there was very broad support for the Dilnot recommendations. It is a relatively short space of time since then, but there have been some changes in that respect. This is partly because, although everyone recognises that the Dilnot Commission was addressing some very worthy objectives-to reduce the risk that people will significantly deplete their assets because of social care needs-some of the stakeholders are now realising the implementation difficulties of some of the recommendations. For example, some local authorities at the time still believed that there would be some sort of centrallyfunded entitlement to care, which is looking very unlikely now. Therefore, there is more of a risk perceived by local authorities in terms of implementing the proposals.

But there are other things as well. In particular, there is more acute awareness of the resource constraints that local authorities are facing, and I think there is a view now that we should consider very carefully what the opportunity costs of funding those proposals would be. If local authorities are having to cut eligibility criteria to reduce the number of packages that they are providing to a smaller number of individuals, then the question is whether we fund something which is aiming at reducing the risk of asset depletion or perhaps prop up that meanstested system in order to allow local authorities to provide more packages of care.

Richard Humphries: We very much welcomed the Committee’s report. We felt that it was absolutely in the right direction in its support for a more integrated approach to using resources across social care and health locally, and we welcome the opportunities presented by Health and Wellbeing Boards to take that further.

We also welcomed the Committee’s acknowledgement of the funding pressures on social care. The latest ADASS budget survey I think confirms that, for the second year in succession, getting on for £1 billion is coming out of local authority adult social care budgets. That reinforces the need for change across a number of fronts.

The third aspect of your report which we welcomed was the endorsement of the capped cost model of Dilnot. In our view, the necessity for reform has never been greater. While we accept that the economic circumstances have never been worse, we remain of the view that this is a challenge which will not go away. There is not a nocost option. Doing nothing will involve additional expenditure of £8 billion or so by 2026, depending on which figures you use. So the challenge is very much with us and we look forward to helping you with your deliberations.

Dr Altmann: We also felt that the recommendations and conclusions of your report in February were absolutely what we need. We were fully supportive of the idea that, first, one has to recognise there is a funding gap. We feel that there has not necessarily been sufficient recognition of that fact, and it is a fact. We would also be fully supportive of the idea of using the Health and Wellbeing Boards as a single commissioner and getting rid of the artificial distinction between socalled "health" and socalled "care". We think that if people have a care need they are not well in some way, and they have a health need. Therefore, keeping them artificially separate gets in the way of delivering good care and ending up with the outcomes that we would all want, which is for increasing numbers of older people-who need, in some way, looking after but not necessarily in the conventional medical sense-having a better quality of life, if we can achieve that. We think the Committee’s conclusions-also building in housing-were absolutely the right direction.

Anita Charlesworth: The report helpfully crystallised two issues. One is that there is a very substantial funding issue to be resolved, whether you implement Dilnot or not. The second is that funding must be accompanied by reform to better integrate provision and to improve quality. Those two things are where the debate is now at, and they are fundamental.

Since February, the crystallisation of that funding challenge leads us to think, "Where does the money come from?" and the debate is moving on to what the options are for raising revenue for social care.

Q3 Chair: Do you think there are options that have come on to the table since Dilnot that need to be considered?

Anita Charlesworth: I do not think anyone has come up with a very credible alternative to Dilnot. Dilnot-any solution to social care-involves additional public money, and most serious people who have looked at this come to that conclusion. The question is where that public money comes from. Dilnot did not make a recommendation on that. It set out some issues about that, which is what we are all now wrestling with.

Chair: We will come back to that, if we may, later in the evidence session. Virendra Sharma has to go, so we will move on to his questions next.

Q4 Mr Sharma: The Care & Support Alliance has recently published a couple of letters, to which you were one of the signatories. Can you tell us what they were intended to achieve?

Dr Altmann: The continued stream of pressure groups, if you like, and groupings across the whole of the industry-everybody involved in the care issue, whether it is providers, charities, user groups or commissioners-are all trying to signal, as best we can, to the Government at the highest level that this is an issue we cannot afford to leave. The danger seems to be that the longer this slips and the longer the delay in addressing the problem, with more consultations, reviews and debates, the worse the situation becomes and the worse the impact on people’s lives. The aim of that particular letter was to try and force the issue up the agenda for both the Prime Minister and the Deputy Prime Minister.

Another grouping of everybody involved in care is talking about the six essential points that need to be addressed urgently. So far, we have not felt that sense of urgency in terms of action. We have heard lots of words, but we actually need differences on the ground because we are seeing frail elderly people receiving the wrong care in the most expensive way. What we are doing now is probably the worst possible way of doing it. It is a lose-lose situation. We are spending much more taxpayers’ money than we should; increasing numbers of frail elderly people are having a poorer quality of life than they should; and nobody quite understands or is preparing for the needs and the system that we have. Therefore, we believe we have to change it urgently.

Also, we do not think there is an option of not spending money on care. The question is: will you spend the money in the NHS bucket, which is the most expensive way, or will you find a way of transferring those resources to the cheaper and more effective delivery mechanism for many of those people?

Q5 Mr Sharma: So you believe that the third sector has a major role to play in it?

Dr Altmann: Yes. We think there is no one magic bullet, and there is a cooperation of interest that can deliver much better outcomes than we are currently doing. You cannot rely totally on the public sector and you cannot rely totally on the private sector. Partnership is what we need.

Q6 Mr Sharma: Thank you. The Minister of State for Care Services has promised a new "vision for social work" in respect of older people and pledged that there will be statutory support for carers. How appropriate-and adequate-are those proposals?

Dr Altmann: They are certainly appropriate.

Q7 Mr Sharma: But are they adequate?

Dr Fernández: We do not know a lot of the details of how that will translate in terms of implementing the policy. Certainly some of the evolution in policy and social care in recent years is putting some challenges on the body of social work. The whole personalisation agenda, for example, has taken away some of the control and power over the commissioning process from social workers and some of the activities that traditionally social workers would be involved in. So there is a challenge there.

Social workers will need to find their new role in a new system. What that role might be will be a combination of some of their traditional roles of therapeutic counselling but also, critically, using their skills, for example, to tap into local assets in order to be able to construct services which are bottom up and which really use the capacity available at the local level. Qualified social workers are a relatively expensive resource. Therefore, local authorities will be looking at how best to use them, and in which circumstances. But to come up with a new model for the social work body is, I think, an important step. As I say, we do not know yet how that is going to pan out in terms of the specificities of the model.

On supporting carers, if I can carry on with that-again, a very worthy endeavour-we do not know exactly how that is going to translate in terms of entitlement for support and, if so, how it is going to be funded. Local authorities, at the moment, very much feel that there is, here, some gain and if there are new demands, in terms of the resources they have, they will have to change the way they target other resources. What matters is how that is going to be implemented. Clearly, carers are a critical part of the system. They carry out the lion’s share of the work and without them the system would collapse. So supporting them to help them carry on is important. I would say, though, that there are other things carers need, for example, help with their pensions so that by the time they go into old age the risk of poverty is reduced.

Richard Humphries: I very much agree with that. A particular aspect of the social work role that I think will become more important in years to come is in relation to frail elderly people and people with dementia, where there is strong evidence of the benefits of care co-ordination and of helping people navigate through quite complex services and systems. The need for skilled social work in that setting is going to be more important than it has been.

There are some big issues for local authorities in working out what kind of workforce they need in the future. It may be that we perhaps need fewer social workers but doing different things in different settings. There is a particular gap in terms of information and advice, which I think you drew attention to in your last report. It may be that social workers are not necessarily the best people to deliver that. So you need a different mix of roles. But the necessity for professional skilled social work has never been greater.

Dr Altmann: Certainly it is appropriate that we should focus on some of the issues we could do differently in terms of looking after carers or equipping people with new skills-giving people new rights and so on-but, in my view, they are not adequate. There is no point in giving people more rights or promising people more things if we do not change the way that the funding works, because funding is falling. The evidence is there, whatever the Government says. There are cutbacks at council level in the provision of social care because they have annual budgets and they are constrained. They have to meet those annual budgets. They do not have a budget to invest now to save money later and so on. So we need to fundamentally deliver care in a different way. There is money in the health system but we are not taking it from that bucket.

Chair: This is a theme, I think, that will run through quite a lot of the questioning this morning.

Anita Charlesworth: I do not want to add anything.

Chair: We would like to focus now on the evidence that there is about what is happening in terms of demand and supply and the extent of the capacity to meet the demands placed upon it-the funding gap.

Q8 Dr Wollaston: Over the four years-the spending review period-to 201415 the Department of Health is providing £7.2 billion additional funding for social care, including £3.8 billion in NHS spending on "social care activities that also benefit health". Do you have any evidence about what results have been secured from that to date, and how much is reaching social care services?

Richard Humphries: The best and latest evidence we have is the budget survey for 2012 that was published recently by the Association of Directors of Adult Social Services, and that has a number of messages. The first-and this is reassuring-is that the NHS money has got through. They are reporting that £600-odd million has been incorporated into local authority spending plans. What has happened to that money, however, is interesting. What they say is that, of the £600-odd million, £284 million has been used to offset reductions in service, in other words, to bail out budgets that would otherwise have been cut.

Q9 Dr Wollaston: This is by the care criteria, I assume?

Richard Humphries: Yes. The rest of the money has gone into services such as re-ablement, which help the NHS to achieve better outcomes on activity. That was the original intention. Obviously, the point there is: should this have happened? Probably it is in the best interests of the NHS, in many places, for the local authority to use the money to offset budget cuts, otherwise there would almost certainly be consequences for the local NHS. So that may be a legitimate use of resources. The point there is the need-and I am sure we will come back to this-to look at NHS and social care resources locally in the round. It very much supports the argument that you and others have made for having a single local budget rather than this kind of "robbing Peter to pay Paul" approach.

Q10 Dr Wollaston: Following up on that point, is there any evidence that authorities which have put the money into changing the way they deliver services are getting better outcomes overall, or is it not possible to unpick?

Richard Humphries: There is some evidence, but it is largely supplied by the authorities themselves. I do not think-colleagues, please correct me-there is any proper rigorous evaluation yet of the outcomes achieved with the money. The jury is probably still out on that one. But the intelligence I pick up from colleagues out there in the NHS and in local government is that people are getting on and doing the best they can with the resources available. One of the valuable benefits of the decision to allocate £1 billion of the NHS budget for social care was that it concentrated the minds of people in the NHS and in local government on, "Right. What are we going to do with that money?" We may come on to this, but I think there is a bigger challenge of how we apply that mindset to the totality of the health and social care spend, not just the £1 billion that has been earmarked.

Chair: I suspect all our witnesses have contributions to make on this.

Anita Charlesworth: I wanted to come back on one point-I would agree with everything that Richard has said-about the effectiveness of the spend. There is clearly quite a lot of highlevel evidence now showing a relationship between spending on social care and impact on healthcare. Where we still lack a real understanding is as to what sort of models of integration of health and social care really unlock the healthcare spending. Many of the pilot programmes that have been implemented to attempt to reduce avoidable hospital admissions have not delivered the scale of savings that were anticipated and hoped for. So one of the things that we think is very important over the next couple of years is that there is a systematic attempt to understand what sort of new models of care really do unlock those systemwide efficiencies.

While it is utterly understandable and almost certainly the right thing to have done to have used much of the NHS money to support existing social care services so that very vulnerable people do not lose services, what we would hope to see in the coming few years is innovation on the boundary and that money being used to support innovation. The disappointing thing about the ADASS survey is that you do not see a lot of innovation in this round, and I hope that Health and Wellbeing Boards, as they get up and running, will make it a priority to think about using some of that money for innovative and new ways of delivery.

Dr Altmann: Certainly the evidence that we have seen is that it is only the money that is coming via the NHS-the £3.8 billion-that is actually getting into care spend in many cases. The rest of the £7.2 billion is not ringfenced for care and is not necessarily being spent on care at all. Demand for care is rising. It is inevitable that it is going to cost more and we are going to need to spend more on care, but the evidence on the ground is that the spending on care has fallen. Time and again we are hearing, both nationally and locally, that spending is falling, charges are increasing and there are restrictions of care to those with higher levels of need. All that is storing up more expense for later.

Q11 Chair: In which direction would you look for real data about cost-effectiveness? Anita Charlesworth used the proxy of avoided hospital admissions. What do you think is the best definition of the concept of cost-effectiveness when we are looking at this subject?

Dr Altmann: I think one needs to develop a range of metrics because there will be different elements of savings in different areas. Cumulatively, that could mean a fundamental redesign of the system and a much more efficient and productive system. Yes, obviously, avoiding hospital admissions is one. Early discharge, which we have been involved in piloting, very successfully, is another. But, again, each pilot is a small pilot. You do need to look at rolling these things out. Telehealth and telecare require some investment upfront, but they can deliver big efficiency savings.

Q12 Chair: Presumably we are allowed to look at outcomes as well as cost savings?

Dr Altmann: Obviously, looking at outcomes, you have the problem of saying, "What would have happened if?" So that is more challenging. But we would argue that outcomesbased measures: looking at the proportion of people of a certain age who end up in hospital before you make your changes, and the proportion after, and, as I say, the reduced length of stay in hospital, the reduced cost of looking after them and then the recovery rates for people and the ability to maintain an independent lifestyle, all have value to individuals and to society. We have a system that is creaking at the seams. If we were trying to design a system now to look after large numbers of older people, there is no way we would be even thinking of delivering it the way we do, with a health system that does not even consider cost first-it considers needs first-and a care system that does not even always consider needs first but just looks at cost. But we are where we are and it is going to take a while to redesign. The evidence is there and we need to embrace it.

Chair: I will hear Dr Fernández and then I suspect most members of the Committee will want to come in.

Dr Fernández: The point about outcomes is very important. But we also have to recognise that the healthcare system and the social care system have not been, so far, at the same level in terms of the technology for evaluating their outcomes. Ultimately, what we want is to combine health and social care resources in such a way that we come up with the highest level of outcome for the lowest cost, the most costeffective system. There are, of course, improvements being made currently on the way we can measure social care outcomes, in particular outcomes which can then be compared with the outcomes in the healthcare sector. In healthcare we talk very often about QALYs, the accepted currency for outcomes in healthcare. The equivalent in social care has now been developed, and there is a lot of research trying to compare the value of the two so that we can compare the relative cost-effectiveness of different types of interventions.

In terms of the evidence overall, we have moved on significantly from where we were perhaps 10 years ago. As Anita says, as to the question of whether there is substitution between the two types of services, already there are significant levels of evidence that suggest that, as you provide more social care, you reduce the need for healthcare. But it works the other way around as well, so increases in healthcare will reduce the need for social care. The question is how you best combine those resources. The easiest thing is to put in some sort of new care pathways. Those can be evaluated relatively easily. What is much more difficult is thinking about the mechanisms for coordinating at a more systemic level. We do not have the evidence there, but lots of pilots are being started at the moment. If we talk about this in three years’ time, hopefully we will have much more evidence.

Q13 Andrew George: Do the panel feel optimistic that it is possible to achieve what has been a mantra going on for decades, quite frankly: the need to avoid unnecessary hospital admissions and for effective early discharge, and then for preventive care in the community? You have talked about initiatives and the funding of the £648 million for social care that has a benefit for health, and the various other smart initiatives and care pathways-new initiatives come along time and again-but, without that essential integration between health and social care, do you not think it will simply be a question of pouring money down the crack between the two services?

Richard Humphries: This is where reform of funding has to be linked to the reform of delivery. If you do each separately and on its own, it will not work. One of the aspects of the debate about funding that I think has been scarcely explored is: what is it we are trying to fund? Are we trying to fund simply more of the same or are we trying to fund a different range of services and interventions where we are beginning to develop a picture of what is effective, both in terms of cost and outcomes? That is a system that would almost certainly look different in terms of its configuration with the NHS and in terms of how the housing contribution is brought into play, not only in developing alternatives to conventional models of care but also in ensuring that people do not end up in expensive parts of the health and care system because of relatively minor problems or problems that can be sorted with their current housing circumstances. In short, it is now possible to describe a completely different vision of a social care model of service that is much more integrated, much more preventive and much more geared toward housingbased solutions and the use of technology and telecare. But you cannot do that when you have a system which, currently, is running on hot. You have to sort out the funding.

Q14 Andrew George: Who is commissioning that and who is financially managing this system that you say exists, just over the horizon presumably?

Richard Humphries: At the moment, local authorities and local service planners are in the key role as commissioners. Local authorities probably should continue to have a key role but, increasingly, if we want to see a truly integrated and co-ordinated system across health and housing, then potentially Health and Wellbeing Boards should play more of a leadership role in bringing together people and resources round the table.

Q15 Andrew George: Can the existing structures be made to work or does there need to be some tweaking or major changes in the structures to make them work?

Dr Altmann: I certainly think that part of the problem, if we are honest, is a political one. What we are talking about involves a significant reorganisation of the NHS-shutting hospitals, closing wards, switching spending from acute hospital care to care for chronic illnesses or people who are longterm frail rather than shortterm very ill-which is something that you highlighted very well in your earlier report. One comes back to the situation of: how long are we going to go on spending the money in an unplanned way via the NHS when people fall through the cracks, rather than planning to spend the money in a way that stops them falling through those cracks? We know that the system is not fit for purpose. In a way, lots of the things that are going on are re-arranging deckchairs on the Titanic rather than actually making the ship seaworthy.

Anita Charlesworth: Can I offer two notes of optimism? One is that a lot of work on the health and social care interface has focused on hospital admissions, but much of the interface is between social care and community health services, which has systematically received less attention. One of the things that has happened over the last two years, obviously, is that community services have moved out of the PCTs, and in many cases alongside acute providers. People are beginning to ask more questions, in delivery terms, of community health services. I suspect that there is-I know from my experience at the Whittington-a lot of duplication. People are seeing district nurses three times a day to be helped to take a tablet and social care staff, similarly, three or four times a day. Each intervention is short. It is unsatisfactory for the individual and inefficient across the system. I think one of the things that may offer some shortterm real opportunity is a focus on the interaction between community nursing services and social care. The Health and Wellbeing Boards-the Transforming Community Services programme, which puts more focus now on the delivery of community services via the NHS and GPs-provide some momentum locally. Of course, there have always been some great examples of people, almost despite the system, with section 75 and joint appointments and so on, making this work. It is about getting that to scale and to happen in all of the country, or at least most of the country.

Q16 Barbara Keeley: We talked earlier about the funding gap, but I want to ask about the number of people who need care but are not qualifying for support. I looked back about five or six years and saw that we were talking about 300,000 to 400,000 people then. We seem to be talking about 800,000 heading towards 1 million now. I do not know if you can comment on the scale of unmet need. I know it is difficult, but it is important.

Dr Fernández: That might be coming from some of the results from our model. We have developed a model-a vaccination model-that has informed quite a few of the debates recently on the funding reform. Yes, it is very difficult, to be honest, to define the level of unmet need and the numbers of people with unmet needs. An unmet need, in itself, is a very unsatisfactory concept because you have to come up with "What is need?" and what is the right level of response to a combination of circumstances. We know that at the moment, for example, there are 150 definitions of need because local authorities will have their own. So it is difficult.

There are other problems with unmet need. As a concept, any support you get above that level of met need is not valued, by definition, so there are lots of problems with how you measure that. But if you make the assumption that the current packages that are being provided by local authorities are those packages that will meet your needs, then, yes, we are talking about 800,000 to 900,000 people who are not receiving care. To some extent, that will be because they do not come and ask for that care, or they do not want to pay the charges that are being asked of them, or they have informal carers who are doing a lot of their care. So you have to be careful how you interpret those statistics.

Dr Altmann: It is particularly difficult to quantify the level of unmet need in the way you are describing because, as far as we understand it, local authorities are not tracking the numbers of people who apply for an assessment and are then turned down. If they have applied for an assessment, they obviously have a need. If they are turned down, they still have that need, but we do not believe that local authorities are generally tracking the numbers of people turned away each year. We feel that is a disappointment. First, it would help us understand what level of unmet need there might be. Secondly, it would help them plan for what is likely to be the increase in need coming through over the next few years. If somebody is turned down this year-perhaps they do not have substantial needs-the chances are they are more likely to represent with substantial needs having not had the funding that they require. It would better enable us to plan for what is coming, but I do not believe that that is being tracked.

Q17 Barbara Keeley: You have talked about signposting, information and advice being vital. I do not know if anybody has done any work on this, but could you comment on local authorities being required to start-not just in a situation of being able to turn people away-to signpost and give information and advice? Is there any concept of what the implications of that would be in terms of service? As you are saying, the assumption might be that either people are managing and doing without the services or are relying on informal carers, but it may be that they have needs and, once turned away, they will not come back. So if they start being signposted-if they start getting advice-what implications does that have for service delivery?

Dr Altmann: That is one of the big advantages of some of the less focusedon aspects of Dilnot’s report. If you were to drive most people through an assessment system in order to start the clock ticking, if you like, on the care spend, it would give you an opportunity to signpost for them what prevention measures they can take, how they can look after themselves and how the system works. At the moment, we know that many local authorities are looking at people and saying, "You have a big house-you have plenty of income-so do not bother having an assessment." They do not have any information or interaction. They are just left aside by the system. There is not an easy mechanism for delivering general information. Most people do not have a clue how the care system works. Saga are putting out public information leaflets-we put together our own free information-but it is not quite the same as a system where you will interact with somebody who will explain how the system works. Perhaps you could do it via a GP. There are arguments for saying that GPs might have a role as a single point of contact in coordinating some of this, even if it is only information-and you do not get money-on how to look after yourself, how to stop yourself needing care later or what might be involved. There is not a mechanism for delivering that.

Richard Humphries: There are some specialist information providers-like FirstStop, Counsel and Care and now Independent Age-that might be able to give you some evidence about that. The problem with looking at the numbers, essentially, is that we do not have any. As Ros points out, increasing numbers of people are not eligible for local authority help, either because they have too much money or because their needs are not high enough-they are not substantial or critical-and we do not know what happens to them. The best information we have is the survey that was done by CSCI three or four years ago which looked at what happened to people who were turned away. We do not have any systematic data that I am aware of for what happens to people who do not get public help, but we know that the numbers are growing. We know that spending, particularly on older people’s services, is going down in real terms. We also know that the numbers of older people using publiclyfunded services is going down and that it has gone down for about three years on the trot. But we know that the elderly population is shooting up and that the over85 population, in particular, has gone up by about a quarter over the last five years. So there has to be a gap there. It gets a little bit into angels dancing on the head of a pin when trying to put a precise number on it, but there is a gap and it is growing.

Q18 Chair: Is there any evidence that this unmet need or unacknowledged need for social care is leading to people directly accessing healthcare because the social care system has lost an opportunity to intervene?

Dr Fernández: We have evidence that the more social care you provide, the fewer delayed discharges, emergency readmissions and so on there are. At the micro level, at the individual level, that means that somebody went without a care package and, as a result, a negative outcome at the acute sector level happened. So there is that sort of evidence. There are also micro level evaluations, which suggest that there is that link between going without, or receiving less social care, and having worse outcomes of that type.

Q19 Chair: In that connection, the phrase "social care" covers a very broad waterfront, does it not? Can that be broken down into services that have a direct effect on demand for healthcare?

Dr Fernández: The range of services we are talking about is home care, day care, respite care and residential care. Those would be the social services. Then, of course, being more specific-and I do not know whether they are, strictly speaking, social care services-an evaluation has been carried out by colleagues at the university of Kent and the university of York of re-ablement services, which suggests there is a very direct link between the investment in those services and the reductions in hospital use.

Anita Charlesworth: We have done work linking at the individual level, individuals who are receiving social care and different types of social care and the relationship between that and their use of hospital care. We find, at the individual level, that people who have high needs who are in residential care are using less hospital care than people who are at home. We do not know whether that is a good or bad thing. It could be that the residential care is providing more appropriate care, particularly, for example, out of hours, and is avoiding inappropriate admission. It could be that health problems, alternatively, are not being well detected among people who are in residential care and perfectly appropriate admissions are being avoided, but we find that there is quite a significant difference in the use of hospital services between people who are getting a homecare package and residential care.

The other thing I was going to mention is the Longitudinal Study of Ageing, which identifies what happens to people with different levels of problems with activities of daily living. I have not seen analysis since 2008 and, obviously, the eligibility criteria in local authorities have tightened considerably since then. But, most worryingly, what they were reporting was that one-third of people who had problems with activities of daily living had no other source of support, either through the voluntary sector, selfpaying or informal care. Obviously, the implications of not having statefunded social care will vary significantly, depending on what your alternative is. Is it you paying, or placing a greater burden on carers, or is it that you receive nothing?

Dr Altmann: There is also evidence-there was a report by the Confederation of British Industry this week-which gives some examples of cost savings in local pilots from, particularly, telehealth and telecare. It was a very good report which quantified the savings-again, small pilots-as £1 million saved on 130 people and £2 million saved for 70 people, depending on what interventions were going on. But there is evidence that receiving care in a different way, whether it is telehealth, telecare or domiciliary care, does save money.

Q20 Barbara Keeley: We talked earlier about the pledge of support for carers, and I guess we were talking about unmet need. I think we would accept that is where they come into play, as the point has already been made. I was slightly confused about that because, clearly, it is a good thing and one is inclined to welcome it, but there did not appear to be a pledge of funding to go with it, which I think you referred to. It seemed to me, if we are talking about a situation where there are 6.4 million carers, that there may be quite a resource issue if we start talking about them having rights that they could claim. Certainly, a very large proportion of them do not get assessments, are not identified and are in this pool of unmet need. That is where they are. My feeling is-and it is like Dilnot, which we go back to-that it is a fine thing to give carers a pledge of support, but do you believe it would have substantial resource implications? Bear in mind that the Law Commission recommendations for carers are that it is all carers and not just those with a significant caring workload; if rights are introduced, that applies to all of them.

Dr Fernández: I would say a very quick, "Yes, absolutely." There is a huge number of carers. I would be surprised, to be honest, if this was the way it was to be implemented, but if there were to be entitlements to support, that would have huge implications in costs to the system.

Anita Charlesworth: There is another point I wanted to make on the back of some work that JoséLuis’ colleagues have been doing: the profile of carers is changing. In addition to thinking about making sure that people have support, there is a question of the right support. Thankfully, male life expectancy is catching up with female life expectancy, but an increasing number of carers are going to be elderly men. So there is a need, obviously, not only to provide support but to adapt that support to recognise that, increasingly, you have very elderly people caring for very elderly people, and elderly men may not have traditionally done a lot of the home-care responsibilities in their house, the cooking and so on, that they are now being required to do.

Q21 David Tredinnick: I want to move from structures to funding. We touched on it, Dr Altmann, when you were talking about small pilots. Could you briefly summarise for the Committee and perhaps lead for the team on what the possible funding models are for social care and what their advantages and disadvantages are, please?

Dr Altmann: Obviously, there is a large range of funding models, from totally selffunding for everybody to totally statefunded for everybody. But if we rule those two extremes out, I think most people would suggest that some kind of partnership, where individuals pay something and the state pays something, has to be a sensible way forward. The natural and normal model that you would think to use, if we were designing the system today, would be one of national insurance.

Q22 David Tredinnick: National insurance?

Dr Altmann: Yes. This is a classic case where most people have no idea, at a young age, whether they will need to spend money on care. They sort of hope that they will not need to, but they could be happy to pay an insurance premium just in case. It is the same as house insurance. You are quite happy to pay the premium, but you do not really want to have to claim.

Q23 David Tredinnick: There are two separate issues here, are there not? One is the level of ignorance among the population about what is available and how they might tap into it, and the other is the structure of the funding model. We have taken out the ends of the distribution-the two extremes, selffunding and state funding-but, surely, we have to come up with some proposals, one or two alternatives in the middle, that are workable. That is certainly what I am looking for.

Dr Altmann: Yes. I think the Dilnot framework makes a lot of sense as a framework. The idea of increasing the meanstested level is fundamentally important. I think it has been a bit misunderstood because that increase in the meanstested threshold means that you are helping the lower to middle income groups. Dilnot’s solution is not only about protecting the inheritances of the wealthy. The very wealthy probably will never use the publiclyfunded care system and probably would not even get an assessment. They will do it on their own, as, very often, they do for health. But those lower to middle groups would be helped. The general message we get from people is that they do not mind paying something for care but they do not want to lose everything. The current system is so dramatically unfair because so many of those who did some saving end up losing all of it.

Q24 David Tredinnick: Are you suggesting a better taper there?

Dr Altmann: This is what is being suggested by Dilnot. You could have it as a proportion of assets rather than as a fixed monetary limit, as the current meanstest proposal that he has would suggest. There are different ways of achieving that aim, but having a cap to cut off the catastrophic costs at the top, which would facilitate some kind of private insurance probably-although I do not think we can rely on it-would be a much better system of encouraging saving for care in later life. Nobody has a clue that they need to save for care. We are all told, if it is saving for retirement, that it has to be a pension. Actually, it has to be more than a pension. It is something different from pensions. So the funding models should include people knowing what their responsibility in the system is going to be and having a higher meanstested cutoff. I am not against the proposals which would suggest everybody pays something if you want to recover it from the estate later, or a national insurance arrangement where everybody pays something into a pot. Obviously, that is a fundamental redesign of the system and is not easily achieved quickly, but we need to land on a framework for funding that will deliver. At the moment, we are stumbling along in the current system, frightened to engage. I think Dilnot provided a sensible framework.

Q25 David Tredinnick: Before I ask some colleagues, through you, Chair, to comment, I am slightly alarmed and astonished by your remark saying that local authorities very often make an assessment by looking over the hedge to see the size of the house without knowing what is going on inside it. Is there not a fundamental problem here in data collection?

Dr Altmann: Everybody, in theory, is entitled to an assessment but we know, on the ground, that they are not getting it. Very often the local authority will just say to them, "You have plenty of money. You are not going to qualify. We are not going to bother with an assessment".

Q26 David Tredinnick: I am not speaking up for large houses, particularly, but there could be a large house with someone living in the back room and the whole place is empty. So it seems to be a fundamental problem if you are not doing a proper assessment of the needs.

Dr Altmann: That is where a national standard of assessment-portable assessments-and having a cap where everybody is then driven through to the assessment in order to start the clock ticking would be a sensible way out.

Q27 David Tredinnick: Ms Charlesworth looks like she is trying to say something.

Anita Charlesworth: We are trying to balance here the question of how to provide a system which provides support for people who will never be able to afford to selfpay with addressing the concerns about people who have some assets and income. For most people who have looked at it-and one can argue about the detail of the Dilnot proposals-the fundamental insight is that this is a failure of an insurance market, which is a fundamental failure. There are definitely some things you could do to improve information and things like that, but there are some real problems with social care about the profound uncertainty as to what the cost is likely to be for an individual, which make it very difficult for a private sector insurance solution to come through and to be sustainable. That is the experience, I imagine, of most countries. Where we have that elsewhere, the state steps in to underpin the insurance. That is a wellacknowledged solution.

The other suggestion that has been developed over the last 15 years is the Wanless partnership model. The issue with that is that it is more expensive than Dilnot. You can vary that, but, given that we are struggling to fund Dilnot, it is very difficult to envisage being able to fund that sort of partnership model. The thing I would say-and sometimes people say this is regressive-is that what we have at the moment is, in essence, an inheritance tax regime, where the rate of inheritance tax depends on the random probability of your having catastrophic care needs. If you believe that we are undertaxing assets, you should change the inheritance tax regime, and do that based on the assets of individuals, not, if you like, the rather unpredictable chance that you have of a very high care need. So sometimes people are conflating two issues. Do people believe that assets are appropriately taxed? If they do not, levying a higher tax essentially on people who have higher care needs is not a very good way of designing a tax system.

Q28 David Tredinnick: It is interesting that you should say that. You recently coauthored a Nuffield Trust report that suggested additional social care funding should be provided by removing some of the benefits for betteroff older people. Is that right?

Anita Charlesworth: In essence, we are suggesting two things. One is that there is a lot of money at the moment spent by the state in support of older people. Dilnot estimated it is around £140 billion, of which a very small amount-about 6%-is on social care. If you look at how well that money is spent from a taxpayer perspective-are we getting the maximum gain from the pound we spend?-and if you look from the individual’s welfare point of view and what is best for them, is that mix of an underfunded social care system, coupled with the health and the welfare payments, either in the taxpayers’ interest or in the best interests of individuals? If we shifted some of the funding between health and social care and welfare payments for the better-off elderly to social care to implement something like Dilnot, the evidence would suggest that that could deliver a more efficient system with the health and social care boundary, and a system which better meets the needs of individuals as they express them.

The second issue is that the Dilnot principle is an insurance one, and we are interested in funding systems where everyone who benefits contributes. The insight of insurance is that not only the people who need the care benefit. Everybody who is at risk of care benefits because they gain peace of mind and certainty. When I insure my house, I benefit not just if my house burns down, but from knowing that I am protected in that eventuality. So you need to spread the cost, not only to the people who need care, but on all the people who are at risk of care.

Q29 David Tredinnick: Finally, before I hand back to the Chairman, it seems that you are opening up a new area here. You are suggesting that HMRC-Her Majesty’s Revenue and Customs-should be much more closely involved in this and that perhaps we have health, social care and also the Treasury. We know the Treasury is looking at Dilnot, but perhaps you are saying the tax regime itself is fundamentally important. It is not for me, as a politician, to put words in your mouth, but is that not what you are saying?

Anita Charlesworth: As the Office for Budget Responsibility’s report on fiscal sustainability last July-shortly after the Dilnot Commission-suggests, we have, in the medium term, an unsustainable system with the pressures of demography increasing the pressure on public spending and reducing the growth in tax revenues. Unless we are prepared to see ever greater borrowing, we have to sort that out. We have to have a conversation with people about Dilnot and social care about what a sustainable system looks like. That means finding new money. We argued in our report that one of the problems that has bedevilled social care is too narrow a focus, and we need to look more holistically at health and social care and health and welfare payments. In an era of individual budgets as well, it is quite difficult, as an individual recipient, to understand why these different payments come in such unconnected ways and with assessment processes which are so different. It is not coherent.

Dr Fernández: I absolutely agree with that point. When you look at systems internationally and how they are funded, you get some systems like the Austrian system. The Austrian system looks like a more sophisticated attendance allowance system, and that is their social care. It is all cash.

When I now present the social care system in England internationally I say, "We have two systems. We have a social security benefits system that provides attendance allowance through a very rudimentary targeting process, and then we have the meanstested social care system on top." It is a priority, especially in an environment where we do not have the resources to increase taxation and so on, to look at how to coordinate better, and possibly even integrate the resources we are spending on the attendance allowance and the resources we are spending on the social care system. Of course, politically, it is a very difficult thing to do because clearly one is an entitlement system and the other one is a cashconstrained system. Therefore, there are big political issues there. But it seems obvious-and in an era, as you say, when direct payments are going to be used by more and more people and therefore you are going to end up getting cash from the social care system-that we should better coordinate the way we allocate those two sources of streams for the same people, ultimately.

Q30 Chair: So the integration agenda needs to go across the welfare system?

Dr Fernández: Absolutely.

Dr Altmann: I think you have touched on the point that goes to the heart of the whole issue here and why we are all struggling. Partly, the recommendations that you made in your first report, which asks why we have three separate streams to fund people with chronic longterm needs, would address some of this issue. We are all scrabbling around looking for bits of money that we can put into the social care bit of the system because we know there is not enough, rather than saying, "Let us look at this as a whole and design what is needed for the outcomes that we want." Yes, we can fiddle around with the benefits structure. We could say that we are only going to pay the pensioner benefits to those over 75 and not 65. We can start taxing them and we can find bits of money elsewhere, but I think what you signalled in your last report was that we need to look at this in a more joinedup fashion, and that is absolutely right.

Q31 Rosie Cooper: You are getting to almost answering the questions, and we are all getting to an agreed point. As somebody who is a carer, who was a councillor for 30odd years-whatever it was-who was chair of a hospital and is now an MP, I see this debate as taking place almost through different levels of delusion. Everyone has their own deluded bit of this. Frankly, I start with the Minister who came here and told us that there was no funding gap, who thought that it was great that people on the checkout at Sainsbury’s would spot double shopping-someone who was doing shopping for somebody else-and therefore could throw a few leaflets in a bag. I was horrified.

I turn, for example, to my local situation in Liverpool, where an occupational therapist visited my dad. He needs certain aids. She told me that we would be sent a catalogue, which is fine, but I did not understand what the problem was because I can afford it. It does not matter what my dad needs because I can afford it, but no one gets their aids paid for. There is a complicated system about how you get them, never mind how you pay for them-a third of your weekly income or whatever it is-and I asked, "What happens if the elderly person does not get those aids?" The answer is, "I do not come back again." What is this saying about us all? If you want a nonurgent occupational therapy visit, it is 82 weeks. Knock, knock, is anyone in? We have district nurses who, having been asked to do certain treatments by a GP, think that it is not for them to do and somebody else somewhere should be doing it. That is the level at which we are operating today.

The blunt question is-and let us get away from this, and I will come back to a couple of things that the panel have said, if I may-how effective is the current division of responsibility between the NHS, social care and the benefits system and how can it be improved, but without any layers of delusion? I do not know who would like to try that one.

Richard Humphries: Shall I go first? If we look at how that £140 billion is spent-and we know it is not right and it cannot be right because the tiniest sliver, and I think it is £9 billion currently, is spent on social care for a burgeoning group of the population-we have the balance completely wrong. One of the things that we argued on this in our report two years ago was that there almost needed to be-we did not use this term-a "mini spending review" on spending for older people to get a much better and fairer balance across that spend.

Equally, it seemed to us ridiculous that we were spending billions of pounds a year dishing out attendance allowance in a relatively indiscriminate way, irrespective of need and without any sort of assessment of need, yet we were ratcheting up the rationing of essential social care tighter and tighter. Those two things just do not make sense either. We argued that that was a potential source of money that could be aligned with social care spending that would free up then-and we would have to update the figures, but I think two years ago it was calculated-about £3 billion by 2026. So there are practical things that can be done to redress that balance, as you say, between the NHS, pensions and benefits, and social care. We have talked a lot about the benefits of closer coordination of health and social care resources and I think that is a "no brainer." We all accept that has to happen. But I think there is-

Q32 Chair: This is a slightly unfair quote, but the Secretary of State says that we are not going to "slam" the two services together. I guess nobody wants to slam them together.

Richard Humphries: If, by that, he meant forced structural reorganisation, then probably that is correct. It is the money, the resources and the people that we are talking about here, and the evidence suggests that is one of the most effective forms of integration on clinical and service, rather than the past "structural attempts" to force the two services together. The key point is that we can do more here. There are some options for Government but there is an ineluctable truth in all this, that you still have to find more money for the social care bit of it. There is only so much that can come out of a fixed pot.

Q33 Rosie Cooper: I have been in the health service since about 1970odd. We have been talking about integration since the day I was there till today. I have seen some enforced collaboration, but I have never yet seen real integration. It is simply not a thing that the health service and social care actually understand. As to your comments earlier about local authorities suddenly realising that the way forward may not be paved with gold, when we had our evidence sessions before I sat in incredulity at the comments from local authority representatives who thought that this was going to be the great way out because I knew they were expecting a lot of money to come with it. When the money did not arrive, they were just getting the problem. So that integration is-

Dr Altmann: Torbay is the example that everybody uses and it is working. Unfortunately, the Minister seemed to suggest it was an experiment that never got out of the lab, but the evidence is there and elsewhere. We have other pilots that have happened and have successfully integrated social care and healthcare, brought on by the needs of the local area-their specific circumstances. To suggest that we have not seen it working is wrong. It has worked there. The problem is that it has not been adopted elsewhere.

Q34 Rosie Cooper: I did not go to Torbay so I have not actually seen that. But in the big metropolitan areas, for example, Liverpool and places where I have experience, I have not seen deep integration at all.

Dr Altmann: Part of it is this silo mentality and a completely different mindset, depending on whether you are in the health sector or the care sector. The health sector looks at people’s needs. The care sector looks at hours that we deliver, not even talking about people. It is hours of care and tasks and things. So there is a disconnect, and it has grown up for historically understandable reasons. Nevertheless, we need to move our system into the 21st century. We need perhaps to focus on one point of coordination and it seems to me that the GP is one obvious place. Unfortunately, we do not have GPs working out of hours and we have lost that 24hour "somebody there knows all about you" that we used to have. Nevertheless, we do need that point of contact, a GP prescribing-

Q35 Chair: It is ironic that in Torbay the GPs are the one group that are not at the party.

Dr Altmann: Yes.

Q36 Rosie Cooper: Earlier, you talked about how Health and Wellbeing Boards should play a bigger leadership role, or you hoped that they would. How do you see that happening with the powers they currently have? Rather than it being theoretical, how do you actually see it panning out?

Richard Humphries: I think a lot of this will come down to the quality of the relationship between the local authority and the new clinical commissioning groups. Health and Wellbeing Boards are not part of the management structure of the NHS or local government as such. They are a partnership vehicle. It is not so much about the powers that the board has. It is the duties on local authorities, on CCGs and on other partners to play ball and do what they are supposed to. The idea is that Health and Wellbeing Boards get people together round a table, agree an overall strategy that sets out the framework for local commissioning-and I am giving you the theory now, so I hope this is not too delusional, but time will tell-

Q37 Rosie Cooper: But with no vote and no power.

Richard Humphries: The point is that the boards have the powers to do whatever they want provided that the partners agree. That is the crux. If you want to get to a point where the boards are executive boards-that they could tell people what to do-you would need a very different sort of structure. You would need something like the local public health boards that they have in Wales.

Q38 Rosie Cooper: I do not want anybody telling anybody else what to do but I do want to know-if you are going to ask people to engage and go to a Health and Wellbeing Board and invest their time and experience-that somebody is listening. There is no obligation on anybody to listen, so the CCG could go away and do something else if it so chose and the local authority could go away and do something different if it so chose. That is my problem. It is not that I want anyone to tell anyone to do anything. I want them to be at the table with a voice and almost a vote so that everybody finds that that which is agreed has people going away and doing something. I am tired of listening to theory and people not delivering.

Richard Humphries: Absolutely. My response to that would be to say that the huge challenges facing both the NHS and local authorities and social care compel local authorities and CCGs to work together. They will not get through this without a close cooperative and collaborative partnership. That is the thing that should drive progress-the sense that there is a shared agenda rather than organisational boundaries. I am not sure how you could give boards the powers that you describe when, clearly, they belong to two fundamentally different organisational silos, namely, the NHS and local government. The only way you could get round that structurally is to have a much bigger reorganisation in which the boards become local executive bodies, which I think they are not designed to be currently.

Q39 Rosie Cooper: For the older population, if we do not start getting this right, spending is going to continue going down, isolation is going to increase and the misery index is going to go through the roof. It is absolutely essential that we all get to the table and get this done.

Richard Humphries: It is. It may be reassuring for you to know that, certainly on the number of boards that we are working with, integrated care is one of the top priorities. That is so in virtually everywhere that we have worked. The priority that boards are adopting is better integrated care, particularly as to hospitals and community. The early signs-and we have done some research on this, based on a sample of 50 boards-are that the prospects look quite promising. But inevitably, as ever-and this is part of the answer to the question about why integration has not happened all over the place-it depends on good, strong local leadership. That was very much a success factor in Torbay. Whatever else you do, there is a limit to which legislation itself, on its own, can mandate that kind of local change. Colleagues talked about different mindsets and different cultures. You need strong local leadership. That is the only way to make this happen.

Q40 Andrew George: I do not think that is true. One of the findings from Torbay is that a lot of those chief executives moved on during the transitional process. So there is very much a sort of teamwork going on there. It is not that a mesmeric leader has driven the whole thing.

Richard Humphries: No, it does not have to be a charismatic or heroic individual. With Torbay you had continuity of leadership, but there was still strong leadership. There was somebody who had taken this by the scruff of its neck and said, "We are going to make this happen."

Q41 Rosie Cooper: What happens to those areas-we know what happens-where there is not strong local leadership? I have recently had an opportunity to talk to Ian Dalton and make it clear that, for example, we are not at 2013 yet. My constituents do not choose their doctors. They do not choose who is running their hospital. The services they get depend on them being good, led well and going for the agenda as it is. What happens to my constituents and anyone else’s if the leadership is not where it should be?

Richard Humphries: This is a challenge across the service. You have to have that leadership. Change will not happen without effective local leadership. That is why we have given a lot of emphasis to this in our work on leadership.

Anita Charlesworth: One of the challenges here is how to make integration the path of least resistance-the easy thing for people to do-so that they are not wholly dependent on amazing, inspirational people and circumstances and it diffuses faster. I want to highlight three things which I think, across the system, could help-not guarantee, but help.

One is that in the NHS, as elsewhere, what gets measured matters and we do not measure integration. If you are a chief executive, you get fired if you do not meet your waiting times targets. You do not get fired if you do not collaborate in delivering an integrated service to patients. In the work we did with The King’s Fund, we argued very strongly that one of the key things that the Government needed to put effort into is the ability to measure how well integrated services are from a patient perspective. I continue to feel that, otherwise you are managing blind and you are certainly performance-managing blind.

The second is making sure that the outcomes frameworks being developed by the Department of Health for NHS and social care are well integrated in themselves and have some links and alignments, so that everyone is being judged and pushed towards doing things which are consistent, and that doing what they should be doing in terms of the bureaucracy is also doing the right thing for patients.

The other thing I would emphasise is the workforce. We talked earlier about social workers and the need for change there. It is very frustrating on the ground to look at some of the divisions between what the social care workforce going into people’s homes and caring for people can do and what different elements of the health workforce can do-how their training can come together and how they can work together. It is difficult if you are a bit unsure in an area, or as a manager of a service, about how this will work and do not know whether these people are allowed to do this, whether they can work in that way and all those things, and they do not have the same language. Those workforce issues are important.

The final thing is an opportunity, building on NICE having new responsibilities now to deliver good practice guidelines in social care as well as in healthcare, to develop for people models of what good integrated care should look like that supports commissioners so that they do not have to be reinventing it and breaking new ground all the time.

All those sorts of things do not make integration inevitable, but they make it so that if you are the average performer, if you like, it is easier to do some of this, and it is in your interests to do some of this for the machine as well because that is what you came into the service to do.

Q42 Barbara Keeley: I was going to ask a question about attendance allowance, but it struck me that, although I agree with what you have just said, the workforce issue is a difficult one and the social care staff are now much more atomised.

Anita Charlesworth: Yes.

Q43 Barbara Keeley: I heard Andy Burnham, the shadow Secretary of State, talk about care staff who used to work for the local authority and are now split up and working in the community for an employer with not very good working conditions. The notion that you can drive integration with people individually working out there who now do not work in the local authority where they could work on partnerships is moving away from that, is it not? That is a comment really, but that is a concern because my view-and it is perhaps a little cynical-is that integrated care was a priority for the last Government but it did not happen apart from in three places. So we have now driven an organisational time bomb through the NHS. If we are expecting it to happen in the next couple of years, I do not think it will.

I was interested to ask a followup question on the notion of having a mini spending review on older people, which is in the news as of today. Thinking back, the difficulty, particularly for charities, about giving up the attendance allowance or having it means-tested or affected in any way-and I think it was fought when it was last suggested-is using that as income to fund Dilnot. My problem with Dilnot is that there is always talk now about moving the cap from £35,000 to £50,000 or £60,000 to bring the costs down and you then, perhaps, need to manage an attendance allowance. But in areas of the north, the value of a property is £50,000 or £60,000. It is not £400,000 or £500,000. So there is a great unfairness, it seems to me, in taking a group and trying to take the attendance allowance away from them when, in fact, they will not get the same proportional benefit. When we were into Wanless, we were talking about percentages, but the problem with the cap, and certainly as it moves up to £50,000 or £60,000, is that it is very unfair in terms of the geography of the country and the value of assets. You look at that and see it is difficult, and you are looking at something you are recommending to politicians. It is a political minefield, is it not?

Richard Humphries: Yes, absolutely.

Dr Altmann: That is where the higher meanstested threshold kicks in and is such a neat solution. That would catch those people. You could take it as a proportion of the value of their property, but if you have the higher meanstested threshold, if your house is only worth £50,000 and the meanstested threshold is much higher, you will not lose the whole value of your house.

Richard Humphries: Yes. Attendance allowance is one of a number of things you could look at to find the money. It might be helpful, Chairman, to step back from the question slightly. When we talk about the funding problem in social care, what do we mean by that? I think there are three separate parts to it, and sometimes the three get intertwined.

The first is: what is the overall quantum of resource that you need to fund a decent system that offers people dignity and an acceptable quality of care? What does the overall package cost? Secondly, how does the cost of that system get shared between the individual and the state? We have moved forward on that. There is now a broad acceptance that there has to be some sort of sharing and there are various models to do that. This is, in part, the Dilnot question. The third, in terms of the state we have reached in the current debate, and probably the most important now is: where does the money come from, given the fact that there is not a nocost option and that we would know from the answer to the first question-how much does it need-that just running the current system into the future will cost X billion more by 2026?

In answer to the third question-and this is where the debate needs to be now-we have researched and analysed this problem to death over the last 10 years. There are bookshelves groaning with reports about funding models, evaluations, research and briefings. To put it bluntly, it is now "make your mind up" time.

We have a good model with Dilnot. In the past, one of the problems has been that people could not agree. In the Sutherland Commission, for example, back in 1999, there were various disagreements about the best way to do this. But we have reached a point of consensus so now it is the third question which is the most important. How do we pay for it? Where does the money come from? Attendance allowance is one of a number of ways that various people have pointed out. In our report two years ago we talked about attendance allowance and about looking at some of the other universal benefits. We floated the idea of looking at a new settlement for older people by looking in the round at all spending.

There has been further work by the Institute for Fiscal Studies, and the Nuffield reports have set out a number of ways of paying for it through existing spending, new forms of taxation, care duties, inheritance tax and means-testing or taxing universal benefits. There is a whole range of options for doing this. The priority, we would argue now, is to get on and make the decision, given that there is a bill that is going to be picked up somewhere in the system anyway. Absolutely, attendance allowance is a specific way that you could do that. The absolute guarantee there that we argued for was that it must stay within the system. It must not dribble out to pay for cuts in DWP spending. It must stay within the care system and add to existing care funding, not be subtracted from it.

Dr Fernández: The key issue with attendance allowance and disability living allowance for older people is that if we were to start afresh, with a blank sheet of paper, we would never end up with what we have. If you think about how it is targeted, somebody living in London will get exactly the same as somebody living in the north of the country. It is very bluntly targeted. In a situation where you have few resources, it is partly about asking, "What should be the total envelope?", but it is also how best to use the resources we already have there. As to how that is redeployed in a new social care system, you could still end up with some sort of universal level of provision, but the point is that it would be important to come out with something which allocates or uses those resources in a much more effective and efficient way.

Q44 Dr Wollaston: Before I go back to asking a further question on Health and Wellbeing Boards, I would be interested to know from each of the panel what you currently estimate the funding gap is and what we would need to provide a decent level of social care so that we can see where you all feel we are at the moment on that. Is it impossible or too difficult a question?

Dr Fernández: I have been working on this for the last I do not know how many years and I still do not know. At the end of the day, this is a political decision on how much we value this. The point I would make is that all the modelling that we have been doing for the last I do not know how many years is based on the assumption that the current packages of care-and those are dwindling-are the right levels of support that these people deserve. We are talking about people who need to be fed and washed and cleaned. We are talking about people who are in very dire circumstances and the packages of care that they are receiving are very limited. All the calculations that we come up with to say, "The shortfall is X" are already based on an almost false assumption, which is that the packages of care that we are providing are correct.

Q45 Barbara Keeley: What is the range, if I could ask that?

Dr Fernández: I could give you a number that we know is impossible to implement, given the-

Q46 Chair: There is a further question here, is there not? Going back to one of the points you were making earlier in your evidence, that spending on social care achieves savings in healthcare, is there a poundforpound relationship there, or what is the pound’s relationship? In principle, if you are looking at an integrated system, at the very least, the additional spending on social care-meeting unmet need-if your other piece of evidence is right, would lead to reduced spend elsewhere in the system.

Dr Fernández: Yes. What you seldom find, though, is that £1 spent somewhere is going to lead to more than £1 gain somewhere else. What you often find is that it reduces expenditure somewhere else by a proportion. When you also take into account the fact that the investment you are making is generating outcomes, and, at the end of the day, we provide social care not to reduce utilisation in the hospital sector but because that is a valued commodity in itself-when you put all that together-it looks like it is a very costeffective and worthwhile investment, but you seldom find that investments in one area will lead to more than 100% returns in some other area.

Q47 Chair: Do you agree with that, Ros?

Dr Altmann: No, I do not agree with that necessarily. Obviously, in some cases that will be the right answer. But if you look at certain areas of spending, such as accelerated discharge-you take somebody out of hospital who would otherwise be there for two weeks in a very expensive setting and you look after them at home-every pound you spend on their social care at home saves about £4 at least.

Q48 Chair: Yes, but subject to one important condition, which is that you can save the money in the hospital.

Dr Fernández: That as well.

Dr Altmann: That is where we come to the political decision, which means that if you are going to reallocate some of the spending that we currently do via the NHS in an inappropriate way-and in a perhaps least effective way for the outcomes for the person involved-to social care, you will save money as long as you have not then replaced that person, one for one, with somebody else in the NHS. That is why looking at it in silos is not going to work. You have to look at it as a whole, whether you take older people out and look at them as a whole or just people with chronic longterm conditions as a subset of people who need what I would call a health intervention, getting away from the distinction between this thing called "care" and this thing called "health". You can cut it different ways, but the reality anyway-the elephant in the room here-is that if we do not get this right and if we do not start spending money on care for those who need some lowlevel intervention as they get older, the health service will fall over. We know that. We all know that in this room. It will not be able to cope with the fallout of people who need a bit of care not getting it and ending up costing a lot of money via the NHS. The NHS provides an inheritance tax protection for a significant proportion of the population who happen to end up with a health need that is defined as health, instead of a health need that is defined as care. This is madness to me, and it is not sustainable.

Indeed, we have a situation where we are deluding ourselves a bit with the spending and the savings that we are talking about because the spending on social care that is happening at the local authority level is not, in many cases, covering the cost of delivering decent care. So either we are not delivering decent care or we are asking private payers to subsidise the underpayments by local authorities. It is not only that we are not spending enough or we are not helping enough people. Even with those we are helping, we have not actually covered the cost of meeting their needs. How much can you afford to pay someone when you get the kind of local authority rates that are being paid? Care homes are finding that the councils are squeezing the amount they are willing to pay, so they are ending up jacking up the prices for the private payers.

Q49 Dr Wollaston: This has been set out time and again, but what I was trying to get at is-because the Treasury like to have budgets and numbers-how much is this going to cost?

Anita Charlesworth: As a former Treasury official, shall I have a go?

Chair: You are on cue.

Anita Charlesworth: Recognising absolutely that this is based on some very limited and reductionist views of the service, the Dilnot Commission in its report estimated that in 200910, demand would cost about half a billion more than current expenditure. If you take some of the ADASS figures and what has happened in the two years since then, if you were being very conservative you would say that probably that figure has grown by at least £250 million, if not more, when ADASS talk about how much of their savings were cuts to services. So you are talking there, I assume, in the starting point of here and now, of a gap of somewhere between £750 million and £1 billion a year. But then there are demand pressures from rising demography, both for older people but also younger adults with, in particular, learning disabilities who are a very big cost pressure in the system because their cost per person is much higher. So as they are growing in number, they are consuming an everlarger proportion of care.

You need to add on some extra for the demand pressures unfunded through this period and the debate, then, is how much of that might be met through productivity. The DH are suggesting that there are big productivity opportunities. In essence, the variation between local authorities suggests that there are some, but the work that colleagues have done previously is suggesting a service-which is a people service, with people on minimum wage-where, despite telecare, there are quite limited opportunities for technology to substitute for labour, and productivity gains are always going to be less than the whole economy. So the 3.5% looks pretty unrealistic and you are going to add in, say, another billion even if you had good productivity for that. The Dilnot estimates, if you funded that, would be around £2.2 billion at the end of the period-if you did Dilnot as suggested. We have suggested that you could shave some of that cost, but I estimate you are in the £3 billion to £4 billion figure by 201516.

The scary thing, if you are Treasury, is that, because of the demography, that number goes up and up and most of that rise has nothing to do with Dilnot. So by 202526, they are saying, without Dilnot the numbers-and I should not say this because JoséLuis produced all the numbers-would go from a baseline spend of just under £15 billion in 201011 to £23 billion in 202526 because of the underlying demography.

In essence, there are things we know, but if we are to sort this out we need a funding profile that does not scrape through the minimum amount of money but works out how that slice of the cake grows because of the demographic pressure.

Q50 Chair: The real efficiency issue here, surely, is not greater efficiency in the delivery of social care. It is greater systemwide efficiency along the lines that Ros Altmann has been talking about using resources more effectively in the right part of the system?

Anita Charlesworth: Yes, absolutely.

Q51 Dr Wollaston: Can I ask my question that goes back to Health and Wellbeing Boards? I wondered whether the panel had any examples around the country of where Health and Wellbeing Boards, together with CCGs, are currently planning to appoint a single commissioner for health and social care and housing or a joint commissioner. Are there any pilots that we should be watching out for?

Dr Altmann: Not all three.

Richard Humphries: I am not aware of anyone that is doing the single commissioner model, but that is not to say it is not happening. We could make some inquiries and get back to you on that.

Q52 Chair: Could you put out an inquiry at large and share any answers that come back with us?

Richard Humphries: Yes. But I think they are all looking at integrated provision in one way or another.

Q53 Dr Wollaston: In our last report we recommended the model of bringing in housing as well. I was wondering whether that has been taken up anywhere, but not as far as anyone is aware?

Richard Humphries: No.

Q54 Dr Poulter: I want to pick up on a number of points, but particularly discussions about commissioning and incentives. It seems to me that good commissioning is absolutely key to this, both at a local level, but also having the right drivers and incentives nationally to influence what happens locally.

Mention was made earlier of NICE, but we know at the moment, for example-and it is probably an appropriate week to mention them, or perhaps it is not-on GP incentives and QOF payments, that we have a QOF system that does not incentivise integrated care; we have a system of how costeffective drugs are that does not look at the social care benefits to drug analysis; we have a hospital tariff system that only rewards acute treatment, and very rarely-although some changes have happened immediately post discharge recently-but does not incentivise integrated working effectively; and we have a workforce planning issue in that we do not have a workforce planning arrangement between the NHS and social care that encourages integration either.

The drivers for some of these can happen locally, but it seems to me that the primary driver has to be a national driver to say, "This is what we recognise as being good commissioning at both the national level across the country and at a local level focusing down on Health and Wellbeing Boards and GPled commissioning".

Dr Altmann: I completely agree that incentives are key. Incentives will make a huge difference and we do not have the right incentives in the system. Nobody in the system seems really to have an incentive to save the NHS money on acute hospital care for people who do not even necessarily need to be in acute hospitals for longer than a day or two for an assessment after they have had a fall or whatever. That, in itself, is an obvious potential source of success, going forward, if we could incentivise commissioners to save money on the care of each patient or incentivise parts of the system to save money to other parts of the system, even though they are in different buckets-or preferably put them in the same bucket.

Health is considered at a national level. Why is it considered acceptable to leave care to individual local authority decisions? If we believe, as a nation, that we need to look after people with chronic needs in a certain way, or that they should be entitled to a certain standard of care from society or a certain set of rules from society, then that does, unfortunately, conflict with pure localism. Again, that is a political decision. I understand the difficulties, but are we trying to deliver care or are we trying to help councils meet budgets and ration?

Q55 Dr Poulter: The other thing I want to pick up on is at the local level and how local authorities look at commissioning care at the moment. Their commissioning and monitoring of what care is provided locally are quite variable. Certainly, nationally, the Care Quality Commission is taking a more proactive role in looking at some of these issues. Nevertheless, there is a strong argument that if the local authority is giving out the cash, it should take a more proactive role in making sure that those abuses in the care system, which we see far too often highlighted in the press, do not happen and that they are monitoring properly those contracts for care, be it community based, residential care or other care that is provided. I wonder what your view is on that. Do you think local authorities should be doing more, perhaps as they do in the planning system, not only to provide planning consent but to enforce planning? Should they be doing more to enforce at a local level in the care sector?

Dr Altmann: Certainly what we are seeing is that the authorities are looking at, as I say, hours and minutes of care delivered. They feel they have discharged their responsibilities if they are providing a certain number of visits or minutes of care without looking at what is being delivered and what the outcomes are for the individuals in need. It is a completely different mindset from that which you would normally expect in terms of looking after somebody. The person does not feature. As Anita said, what gets measured gets managed. If you are measuring minutes of care, that is what people will focus on. If you are measuring outcomes for frail older people and helping them live better in their own homes and avoiding expensive hospital visits or visits to the GP and perhaps even avoiding moving into residential care, then that itself, if you start monitoring it, would be a very valuable step forward, I suspect.

Q56 Chris Skidmore: Is there a natural progression point-and maybe not immediately now-to look at whether local authorities that place the political priorities of their voters ahead of what are the care needs of, admittedly, a minority of the population, are best placed to be delivering social care in the longer term and that it would be better to remove local authority provision, full stop?

Dr Altmann: If we were designing the system today-if we were Beveridge sitting here in the 1940s and we knew what was coming-I do not think we would have left it to the local authorities to decide how to look after the older people that happened to live in their area and have this separation, differentiation and postcode lottery that we have today. But we are where we are. It is not easy to move from where we are today to an integrated national system, but I think Dilnot highlighted that that is what we need, and I agree.

Richard Humphries: I think we need to be a little bit careful along these lines. The NHS track record in looking after older people is not wonderful. The key issue is how you get the resources together to meet people’s needs effectively. The root of the problem is that the financial wiring of the health service is different from local government. You will be well aware of this. The paymentbyresults mechanism in the NHS has worked in terms of ensuring the flow of money and activity into acute hospitals, but it does not work when you want organisations to work across boundaries. I think we need-and we touched on this in our work with Nuffield on integrated care-new currencies as well as incentives to commission. So instead of, for example, commissioners commissioning a single episode of care for someone with diabetes in hospital, you commission a year of care. You give people a capitation funding.

Q57 Chris Skidmore: A personal health budget?

Richard Humphries: Yes. That is another way. There are different mechanisms to ensure that the money is freed up to flow around the needs of individuals rather than to support an organisation. The other thing that is missing from current arrangements, which is important, is a single outcomes framework. Colleagues have mentioned outcomes a lot and it is very important, but at the moment we have three different outcomes frameworks-for adult social care, public health and the NHS-and different organisations are measured differently according to their performance on each of those, whereas we need to measure the performance of organisations across their boundaries in meeting those outcomes. We need change across commissioning currencies, contracting methods, financial incentives and outcomes frameworks so that we have a genuinely joinedup approach to supporting local organisations to offer really good joinedup care.

Q58 Dr Poulter: We talked about Dilnot earlier. There are many good parts to Dilnot, but one thing that is important to highlight is the hotel costs bill, if you like. That is the issue that often goes under the radar. Sometimes there can be a misconception, that the idea that there will be a cost on care means that is it, that people have to meet only £35,000 or £50,000 of their care when, in reality, if someone were to be in residential care, there is no cap on what the cost of their care could be. What are your views on that aspect of the Dilnot report? It may well mean that we end up effectively catching people who will, in fact, still have to sell off their own home, and if they only have a home that is worth £150,000, they may lose their home to pay for relatively shortterm care costs. I wondered how you saw that and what you saw the advantages specifically to be.

Dr Fernández: There is almost a normative question there: do you think the state should be paying for people’s accommodation costs? The Dilnot Commission took the view, which I share, that there is a responsibility on the individual. Then what becomes very important-and this is where the details of the Dilnot proposals are very important to what you get-is at what rate you put it. £10,000 is something that most people would be able to afford from their pensions.

Dr Altmann: That is what he says.

Dr Fernández: Therefore, the implication is that, if the aim of the Dilnot proposals is to safeguard your assets, your assets are not really at risk from that. There are other elements. If what you are going to get from the state is a limited payment-let us say that the average cost in residential care in England is £550 and you get the difference between the £192 of hotel costs and the rest, but many people will either live in an area where the costs are higher or would want to get a better quality than the average home-that is where I think people’s assets would still be at significant risk. Where the different thresholds and levels of the arrangements are set is critical to the outcomes of the model.

Q59 Dr Poulter: It may well be that people’s pensions could contribute towards the hotel costs, but are we saying that, for the state pensioner who has no other additional income but perhaps own a house, a little bit over £100 a week is going to cover all the hotel costs? I am not sure whether that stacks up financially.

Dr Fernández: The idea was to have it means-tested. You know at the moment anyway that somebody who is in residential care and who has some income is going to lose everything but £20. So the idea was that the solution would be equivalent to that. You would have to contribute all your accessible income up to that, and most people would be able to just about cover the hotel costs.

Dr Altmann: If you assume that we are going to move forward with a kind of flatrate state pension around the £140-a-week level and Dilnot was talking about £7,000 to £10,000 cost of accommodation and if we are serious-and I think we are-about providing a basic minimum state pension that people can live on without means-testing, it is inevitable that that state pension would have to be enough to cover somebody’s accommodation costs. So it should be that there would be an income stream from the state pension that would contribute to that. It would not necessarily give you the top luxury end of the residential care home sector, but then that would be a personal choice. So I think there is a lot in Dilnot that has been misrepresented and misunderstood. It is a problem that people do not realise necessarily, that the cap does not cover accommodation costs, and an explanation is required. But the fact that there is a stream of income coming from outside the private resource that should be able to cover that addresses that point.

Q60 Dr Poulter: That is a good point. Nevertheless, at the moment, we have an aspiration-and I am sure it is something that will be realised-of £140 a week of basic state pension and what you have highlighted for me is the fact that this idea of hotel costs needs to be properly costed and looked at before the Dilnot proposals are adopted wholesale. It appears to me that there could be some potential injustice in that aspect of the proposals.

Dr Fernández: If I could give you an example, in Jersey they are talking about setting hotel costs at more than £300 per week. Of course, it is a very specific sort of area.

Dr Altmann: If you live in Jersey, you can probably afford it.

Dr Fernández: Yes, probably.

Dr Altmann: The other thing that has been missing from the whole debate about Dilnot is that we absolutely need to think about incentivising people to save for longterm care-whether we get Dilnot or not. Even with Dilnot, people are going to need a pot of £30,000, £50,000 or whatever it is to cover care, whether it comes from their home or from other savings, and there is nothing in our system that encourages people to do the saving or even know that they need do the saving. So I do think we are missing something here, perhaps as an industry but also in the national debate, that saving for retirement needs to encompass the possibility of care needs later.

Q61 Chair: It is, in truth, part of pension provision and of course-

Dr Altmann: It should be, but it currently is not.

Q62 Chair: -all the same points you make about longterm care costs can also be made about pension provision.

Dr Altmann: There is a difference. With pensions, as we have seen, if it comes to the point where you need a pension and it is not there, you can tell people that they might need to wait or they might need to work longer. With care, when it comes to the point of need, you cannot tell them to wait. They actually do need to have the money. There is no other option.

Q63 Chris Skidmore: A lot of the talk-and, apologies, I had to leave the room-has been about Dilnot and that being the only game in town. But in terms of a possible White Paper and a forthcoming draft care and support Bill that might appear, say, at the next Queen’s Speech, what other measures do you think are vital that should be included as a package? You began to mention, Dr Altmann, the need for greater information, advice and strategies for saving. In terms of the mechanics-I know you have said we are where we are with local authorities and the patchwork of care provision-and, for instance, looking at the Law Commission’s report and the definitions of "ordinarily resident" and how we get around the issues of portability of care packages and assessments and reassessments, what would you think, leaving Dilnot aside, are the next vital steps that we have to put in place to ensure care needs are met for the future?

Richard Humphries: There will be the White Paper and we expect there will be a separate document which sets out what is described as a progress report on Dilnot, and I think there will be a separate response to the Law Commission recommendations. What we should expect from a whole package of reforms is a way forward in relation to those four questions that I posed earlier. The first is: what kind of care and support system do we want for the future: what quality, how does it fit with health, what is the role of housing, the role of prevention, telecare and so on, and personalisation? What is the kind of operating model that we are going to have? The second is: what is it going to cost? The third is: how are the costs shared? That is the Dilnot bit. The fourth is: where does the money come from?

As I have indicated, there is a whole range of potential sources. We recognise the political and fiscal difficulties. Nevertheless, there is a bill that has to be picked up. What we would hope for from the White Paper and the associated documents is a sense of momentum, a sense that this issue has been put off for years and years and it is now decision time because the pressures are mounting and will not go away. It is a direction of travel and almost a longterm roadmap for reform. We appreciate that none of this is going to be changed overnight, but it is important that some kind of start is made.

Q64 Chris Skidmore: Just a quick question on that point. In terms of, as you say, the roadmap, how much of that has to be Treasury and how much has to be Health? So if you are talking CSRs, and in the future CSR2 and CSR3, the point you made earlier about healthcare-

Richard Humphries: I think it has to be across Government.

Q65 Chris Skidmore: Yes, but that necessitates probably looking at a realterms decrease in healthcare spend if you are talking across departmental budgets, unless you break out of that mould, which I think is unlikely.

Richard Humphries: I would not see it as a decrease. The whole point is that we look at the total pot of resource across the NHS and social care as a single entity, not as "This is what we are going to do for the NHS and this is what we are going to do for social care." That is what has happened in the past and we have had differential-

Q66 Chris Skidmore: The financial and political reality in the Treasury on all their balanced books would mean a negative in the column of the NHS.

Richard Humphries: I think that depends. This is why reforming the delivery is so crucial to this because you have to redefine those boundaries in new ways so it is not seen as gainers and losers but a wholesystems approach.

Anita Charlesworth: I will come back to the money bit. I want to see three other things in the White Paper. One is that both Dilnot and the Law Commission talk about much more consistency in the assessment process, which aids portability considerably, but also all the things that we have talked about in terms of integration are very different when you have such widely differing offers. It is very difficult for individuals to plan if you provide advice and guidance when it is so variable and opaque. You could still have local authorities in the lead in terms of commissioning and having a key role to play in delivery but within a much clearer national framework of assessment.

The second thing is that the alignment of goals, performance management, much better transparency about what is being delivered and the metrics, which are real metrics which link to patients and are consistent with metrics being delivered for outofhospital care for the NHS, are all important enablers of some of the things that we want to do.

The third big area would be the workforce issues across health and social care. Again, I very much agree that has to be an issue of national leadership. You cannot do all that when it is spread across.

On the money, I strongly endorse what Richard has said. Typically, spending reviews are done behind closed doors. If what we need is sustainable settlement for social care that looks at the relationship between social care funding and healthcare and tax and benefits, I do not see how you can do that in a sustainable way behind closed doors and then just present it to people as a fait accompli and expect them to get behind it when they do not understand, in many cases, how the social care system or any of these things work at the moment. So it seems to me that one of the things I would really want to see in the progress report on funding is a commitment to engage with people about the set of choices because a politically sustainable solution is one that commands widespread public support. You will get that only if you start to have an honest and open discussion with people about what is involved, and I would like to see a different process which does not kick this into a traditional spending review.

I would also like to see the Department of Health commit to doing some serious work to understand what sorts of models of integration unlock the efficiency. There is no point in moving the money if the delivery is not in place behind that. That is what I would like to see.

Q67 Chair: That is an impressive wishlist.

Anita Charlesworth: Yes.

Q68 Chair: There was one question earlier about whether there were any examples of a single commissioner, and I am grateful to Gerald Wistow, who advises us that there is one known in northeast Lincolnshire who is coming to see us next week. So we shall be interested to hear further what that means in practice.

I have one rather detailed question that has been nagging away in my mind as the morning has gone on. Looking beyond the big issues in the White Paper, development of a single commissioner process relies on using section 75 flexibilities. Are they fit for purpose? Is the aspiration to a single commissioner deliverable in current legislation? Unless you know the answer to that question straight off, you might want to write to us.

Dr Fernández: We will write to you.

Chair: Are there any other questions?

Q69 Chris Skidmore: We have talked a lot about the demand side of care needs. In terms of the supply side needs for the future, but just looking at the development of care homes particularly around highlevel care needs and dementia, that does not seem to be there at the moment. It does not seem to be there unless the private capital funding is leveraged in somehow. I do not know if anyone wanted to make any comments about the supply side issues that we face in addition to the demand side issues in social care.

Dr Altmann: Part of the problem on the supply side is the lack of knowledge and understanding among the general population as to what the system actually is, which means that nobody is really planning for it and nobody is putting money aside. So anybody who might be thinking of building or developing something does not see the demand and it all happens at the point of need. One of the benefits of having a more sensible system and a system that is not so dramatically unfair that you would probably be frightened to explain it to people-because if they understood it they would hate it and so they only find out when they have to engage with it and do not have a choice-would be that we could end up planning much better for the needs that we all know are coming.

One of the things I would have put on my wishlist, if you like, for the White Paper is that the money that has already been earmarked for care-this £7.2 billion, of which we know only some has been spent on care-could be ringfenced perhaps for prevention and some measures that encourage people to avoid needing care. Whether we can act in that way, I do not know, because of the localism agenda, but we need to look at different ways of talking about the issue as well. This is not only about old people. The narrative needs to be that this is about families. This is about all of us. It affects us and our loved ones, whether it is our individual need or someone else’s need. Maybe that would help people generally understand that we do need, importantly, to engage in this.

Q70 Chair: The concept of ringfencing is one that I-

Dr Altmann: It has been vigorously-

Chair: I have suggested in our private discussions that it is much talked about and profoundly ineffective as a Government control because it is-whatever it is-£3.8 billion that is tagged for this and if you ringfence it, the local authority will find a way to ease off on some other expenditure. It is almost unenforceable in practice. The real issue is the level of spend on the delivery of services.

Dr Altmann: In that case, it would mean requiring local authorities to demonstrate what they have done for prevention, for example, and that goes back to the question of budgets. You will, perhaps, have to invest some money short term and then you will find the savings longer term. You will not find a poundforpound or a 20pfora-pound save necessarily this year, but you know that the money will be saved over a five or 10year cycle.

Q71 Rosie Cooper: I totally agree with that, but where will we find that money upfront? When we look at the current CCGs, Cumbria is held up as a really good example, yet when I asked questions about whether they had a stock of money to enable them to do it, yes, they had had a great deal of money. It comes out to more than £20 million. That money is not available to all the other areas as they progress, so where will that, if you like, upfront investment that will almost lever out your savings, in this current climate, come from?

Dr Altmann: It has to come from some sort of incentivisation to save money to the NHS which is tracked over a longer period of time. The reality is that if somebody falls over and gets into hospital, the NHS will pick up the cost. We are deluding ourselves if we think we are not going to end up spending the money.

Q72 Chair: The truth is that somewhere in the £140 billion you can free up the money to do that if you choose to.

Anita Charlesworth: There is an NHS underspend at the moment.

Barbara Keeley: That is very important. You started on the point about the Care & Support Alliance members raising the issues that you have done and keeping up the pressure. But I think, judging by the debate this morning, the more it involves the Treasury, the more you are going to have to resist this argument that there is this featherbedded set of older people with a fantastic amount of assets who are sitting around wanting solutions that are going to tax everybody else. This argument has been put in an appalling way, without the thought that these are not featherbedded older people wanting to hang on to their assets, but your grandparents, your aunt and uncle and your neighbours. They are all of us, when we get there. I think that is important because once these arguments setting groups against each other, or the intergenerational argument, take hold, it is quite difficult to resist them. It really needs stopping. We had a very bad example of it on the radio this morning.

Chair: It is a disincentive to get up early. Thank you very much for joining us this morning.

Prepared 6th February 2013