Examination of Witnesses (Questions 60 - 72)|
WEDNESDAY 25 FEBRUARY 1998
CBE, MR NICK
and MRS ELIZABETH
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.
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
(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
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
(Dr Adam) I am not quite sure I understand exactly
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?
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
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.
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.
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.
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