Select Committee on Health Minutes of Evidence


Examination of Witnesses (Questions 60 - 72)

WEDNESDAY 25 FEBRUARY 1998

MR CHRIS KELLY, SIR HERBERT LAMING, CBE, MR NICK BOYD, DR SHEILA ADAM and MRS ELIZABETH WOLSTENHOLME

Julia Drown

  60. If you have inflation but you have no growth you have to deal with all the health authorities pressures with no growth monies, but you can plan your services with this knowledge. In local authorities that does not happen. Sometimes you can have a massive cut of millions of pounds and you suddenly have to deal with the fact that you still have all your residents to look after and no money. Would it be helpful to the whole planning process if the health authorities allocation system could be developed for social services?

  (Sir Herbert Laming) Obviously the longer there is certainty about money and particularly about dealing with underspends and overspends, the easier it is to manage services. That is without doubt. I have to say that the SSAs do not change. One of the criticisms we get about the SSAs is that they do not change as quickly as some people would like them to change. The adult one was changed this year because of some concerns. We have already acknowledged that there is a difficulty in handling these matters when there is uncertainty of funding beyond one year at a time.

  61. The adult one did change and has led to some health authorities losing millions. You can see how that is terribly difficult for them to adjust to in one year.

  (Sir Herbert Laming) That is the problem about changing formulas; there are winners and losers. Therefore there has to be some kind of balance between trying to give a degree of certainty in the system but keeping sensitive to population trends over a period of time.

  62. Are you saying that is satisfactory at the moment?

  (Sir Herbert Laming) No, I am saying that we are trying to manage the situation we are in.

Chairman

  63. I should like to raise one area of concern and contention on which I should welcome your thoughts. The issue of the relevance of the existing professional roles is a question which clearly comes into focus when one looks at the way, as we have described, trends at local level have changed quite markedly, the margins are unclear. I wonder whether you see that changing in years to come, in the fairly near future, the traditional roles that we have become used to, certainly since the second world war, within the legislation which applies at the present time. If you feel that, what thoughts do you have on the issue of training for those specific roles and the contentious question which has been around for a long time about joint training, for example between nurses and social workers?

  (Sir Herbert Laming) My colleagues must speak about the health service but on the social care side a very interesting example was the one raised by Audrey Wise earlier on about the home care service. Home care staff are now providing in different parts of the country levels of personal care which are very different and quite intimate care from times past. It is an illustration of the fact that training has to keep pace with trends in the field and the needs of individuals. We are very conscious of that and we would expect and we will try to influence quite significant changes in training for different groups in the future.

  64. Do you see continuation of the distinct roles which exist currently?

  (Sir Herbert Laming) Speaking generally my answer to that would be yes, because our first wish is to create effective multi-disciplinary teams and one of the things about multi-disciplinary working is a recognition of different role responsibilities and different systems of accountability. That is not to say that we see this as being something which is static and permanent but we do see that as being our first priority and within that training will change but it will not revolutionise roles.

  (Dr Adam) I very much agree with that. The White Paper does recognise the importance of health and social care professionals understanding each other's roles better than perhaps they have done always in the past. Certainly I would want to endorse issues around team development and working as a multi-disciplinary team. The other thing to mention for the Committee is the emphasis which we have been giving through the priorities and planning guidance for the NHS to regional education and development groups and local training consortia to work more closely with social services and indeed with the independent sector than has hitherto been the case so that we really are looking at local areas in terms of what their workforce planning should be and how they are resourcing the education and training which is going to be required. We have made quite a lot of progress in continuing professional development, working with teams whether it is primary care teams or whether it is multi-disciplinary specialist teams, training them together, often in their workplace. My own view is that we have probably made less progress at the basic levels of training in terms of introducing joint training, joint education programmes and this very important joint understanding of each others' roles if people are to trust each other, respect each other and work effectively together.

Ann Keen

  65. I would agree absolutely; we do need to continue with the team education. I would not just say that is social workers and nurses, that is actually the team and that must include the GPs it must include everybody, because there is such a great misunderstanding in some levels of the team of individuals' roles. We long to see the end of the day when the GPs say they are going to send their nurse to pop in and give somebody a bath. That is still going on and it is a totally, totally inappropriate use of the team. Also, at the other end of the scheme, we do not want to hear people saying-I know he has now left a senior position at the NHS Executive-anybody can hold the hand of a dying person. That is not the case either. It can be very, very complicated to care for somebody at home. It is not about just sending a care assistant in to do any sort of task. Everybody has a valuable role to play in that team and I hope that we do now see within the White Paper that coming forward in education and vocational qualification terms. Do we know that there is anything specific going to be put aside to make sure that is going to happen? We have talked about it for years and years.

  (Dr Adam) I am not quite sure I understand exactly your question.

  Ann Keen: Are we specifically going to focus on the training of the multi-disciplinary team right across the team bringing in the doctors along with social workers, along with nurses, along with the care assistants?

Chairman

  66. I think the point is that the White Paper raises the question of collaboration in primary care in terms of training and understanding of individual rules. That is the area Ann Keen is concerned with.

  (Dr Adam) The White Paper clearly emphasises the fact that we are not going to develop and deliver integrated health and social care unless we have the type of training that Ann Keen was talking about. To be honest, the White Paper does not go into a lot of detail in terms of what that actually means. We will need to develop that further through thinking about service development, thinking about workforce planning, thinking about education and training, but bearing in mind that we are approaching a position where there is nobody working in health or social care who is not working as part of a multi-disciplinary team. When I was talking about teams I was definitely including medical staff as well as everybody else. It is much better recognised throughout undergraduate, basic and postgraduate training. It is one of those issues where it is going to be a long haul before we have this pervading all the education, training and development we do. It is very much recognised within the Department that integrated care means closer relationships through education and training programmes at whatever level.

Julia Drown

  67. The Health Service Journal did a survey in November looking at mental health. They surveyed managers in mental health and 50 per cent of the managers said that one of the top three obstacles to improve services was the psychiatrists who were not prepared to work positively in multi-disciplinary teams unless they felt they were in control. Clearly there are major obstacles on the ground which are being felt now. I can see we are tackling this problem for the next generation of psychiatrists but there is clearly a job to be done on the ground for existing psychiatrists.

  (Dr Adam) Traditionally the vast majority of consultants in the health service have been institution based and it is a very major shift to become part of a multi-disciplinary team based in the community. It is not easy for people at the latter stages of their career to make that shift but I would agree with you that the important thing is that the people who are now being trained, who are becoming consultants, who are working as young consultants, are expected to work in that way and are supported to work in that way. One of the issues referring specifically to mental health services is that we do need to think about the support systems required for people working in community teams. We see a small proportion but a significant proportion of fairly recently appointed consultants who throw themselves into working as very enthusiastic leading members of community teams who actually cannot do it for more than a few years. The job is actually an extremely demanding job. We are working for example with people like the Sainsbury Centre to look at just how we can build and sustain teams. Simply putting them together and expecting people to do it is not going to be enough. There is a continuing process which we also have to have in place and that must be there for the medical staff just the same as for everybody else.

  68. I would just say we cannot wait. It might be the priority to develop the new ones coming up but we cannot wait the generation; there are people out there who need the services and need the multi-disciplinary team now. Work does need to be done to ensure they are also encouraged to work in positive ways.

  (Dr Adam) There certainly are good examples of older consultants working very well as fully fledged members of teams. It is not impossible.

Mr Lansley

  69. It is important at this stage that we understand how you foresee the White Paper influencing some of these issues. In that respect may I return to the question of the interface between the two authorities of health and social services and characterise it as there being two issues. One is eligibility and the other is priority and they are not necessarily the same thing. Perversely perhaps may I start with priorities. Although one may be clear about which authority has the responsibility in given cases, differences in priorities-and you refer to this in your memorandum where you say that agencies and professionals do not always share the same sense of what is important; that is true institutionally, it is also true year by year in terms of resource allocation, as those priorities change on either side of this particular boundary-can influence, often in a very unhelpful way, the response in the other authority. What do you think the White Paper is specifically going to do to try to ensure that there is a shared sense of priorities on either side of this particular health and social services interface?

  (Mr Kelly) Part of it is the various mechanisms which are intended to help produce a shared vision, which is the beginning of it. Procedurally, not in the White Paper but consistent with that, it is quite notable that there is a planning and priorities guidance for the National Health Service but there is nothing equivalent to that for social services, partly reflecting the different constitutional position. There is a very real discussion going on at the moment about whether or not there should be a similar type of document on the social services side which would of course have to be consistent and congruent with the document published by the National Health Service. Apart from that there is a series of process issues like most of the ones we have talked about, like the joint investment plans acting as a catalyst for helping people to establish joint priorities through those processes.

  70. May I move on to the second point relating to eligibility? We talked about good practice and places, not just places which work well but sometimes individual functions within authorities which work well together. Have you looked at the possibility of taking good practice and deriving from that national protocol or national eligibility criteria so that good practice is not simply disseminated professionally but is disseminated bureaucratically?

  (Mr Boyd) In a way the guidance which was issued a couple of years ago on continuing care was based on some good practice work so that is an example of that process taking place. You have hit on a very genuine problem which needs to be acknowledged about the eligibility criteria which are applied by social service departments as opposed to health service. I actually think that eligibility criteria are being used in slightly different ways between the two because, going back to an earlier discussion, the two agencies actually have slightly different functions because of the existence of a means test on the social services side. Social service department eligibility criteria are related to need but they are also inevitably related to the gate keeping role which social services have because they are operating a cash limited budget in that way. There is a very real problem about prescribing from the centre eligibility criteria which both agencies need to pursue while not addressing the underlying financial systems issues. Having said that, coming back to what we were saying before about joint investment plans, it would seem to me absolutely essential that joint investment plans are based on an understanding of commonly shared services between the two agencies. As we mentioned before, we are actually in the early stages of developing joint investment plans and the question of whether there should be some national prescription of what those eligibility criteria should be I would say is an open one. There are arguments against doing that but there is no doubt that joint investment plans should be based on a common understanding of eligibility for the services those plans are covering.

Dr Brand

  71. A very short point on the continuing care eligibility criteria which you cited as a good example and I think was an awful example. It might actually be very useful for the Committee to see the instructions which were given to local social services and local health authorities to cobble something up which would be acceptable to them locally. It created all sorts of different eligibilities all over the country; some of them were nonsensical, some of them were sensible and there was no feedback. It was a very bad example of the Department just ducking out of their responsibility.

  (Mrs Wolstenholme) We could probably spend two hours on the previous administration's continuing care guidance. It was an attempt to bring eligibility criteria to a system which takes us almost full circle to the comment Mr Kelly made at the outset, that if you arrived from Mars you would need a history lesson. A lot of the issues which are around the disparity in eligibility criteria around the country reflected very much the history and the historical starting points in different localities. It was a very difficult exercise. I do not think I would share the view that it was an unmitigated disaster otherwise I think I would pack up and go home. It certainly did lead to friction in some places because it brought into the open the discussions around some of the issues we talked about this morning, it brought them out onto the table.

  (Sir Herbert Laming) We continue to promote as good practice and that is rather different from a protocol because the circumstances round the country vary enormously along the lines that Ms Wolstenholme has said. What we want to do is to make sure that health and social services at a local level do joint assessment of need and develop these proper plans that will actually address those needs. What we will do, we will be monitoring those plans to make sure that they are effective and the people have actually signed to them jointly.

Chairman

  72. Do any of my colleagues have further questions before we conclude? Do any of the witnesses have any further points they would wish to make, issues we have not touched on which you felt we should perhaps have touched on?

  (Mr Boyd) May I make a comment in the interests of the accuracy of the record? If I could go back to a comment I was making in response to a question from Julia Drown about assessment delegation, I realise that I got hoisted on the petard of the complexity of it. I gave an example of a practice nurse as being somebody the local authority could delegate to. In fact strictly speaking that could not be because they can only delegate to someone who is the employee of the health authority or a trust, which the practice nurse would not necessarily be. Could the record use the example of a district nurse?

  Chairman: We are grateful for that clarification because we were particularly interested in this example. We are likely to be visiting Scotland to look at a situation similar to the one you described. I did not want to press you on the Scottish issue because the law is somewhat different but we are grateful for that clarification. May I thank you all for your very helpful evidence? We are most grateful that you have been willing to cooperate with this inquiry. I hope our eventual conclusions will perhaps be of some use to you in your own deliberations. Thank you very much.


 
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