Select Committee on Health Minutes of Evidence

Examination of Witnesses(Questions 220-239)




  220. I do not want to dwell on the issue of Birmingham because I do not know Birmingham as well as Mr Burns or yourself, Minister, but why has the Government not trumpeted the successes of developing alternatives to care home capacity, because it strikes me in the numerous exchanges we have had downstairs about this issue that we are bogged down in this debate about whether it is 19,000 or 50,000, now revised to 60,000 by the Conservatives. We estimated it was 31,000 delayed discharges. Surely we ought to recognise that there is some degree of success when we move away from the dependence upon care home capacity and the number of beds. Why is the Government not trumpeting that as a success and why are you being so defensive about the reduction?
  (Mr Milburn) We are not being defensive about it. You said we were being defensive! It is like a lot of these things—inevitably, like throwing more beds at the health service—people get terribly focused about the acute sector and not primary care. It is true that care home places are a very, very important element of the spectrum of care that should be available for elderly people. I have said on many occasions downstairs and in Committee that for very many people and very many families a residential care home or a nursing home would be an appropriate choice for that family or for that individual. But, equally, we cannot have a situation where the only choice on offer to people is care homes. Care homes do a good job of work and so on, however, they are not the be-all-and-end-all of elderly care, and what we know from every single survey that either we have conducted or anybody else has conducted of elderly people themselves, their number one choice is to be as independent as possible for as long as possible. That is what we all want. It is what we want in our lives and it is what older people want as well. What we have got to do with the Government, with the private sector and with the local government organisations and so on is to foster a greater choice of provision for people. When I made a statement in the House a few months ago, that is precisely what it was about; it was about stabilising the care home market and, Simon is right, there are problems in particular parts of the country, largely driven by increases in property prices and so on, and if the local authorities can use some of the extra resources where it is necessary to stabilise the market to increase fees, that is a matter for them to determine. We cannot determine that centrally. It would be quite wrong for us to do so because Birmingham is very different from Darlington, Wakefield or London. Equally, we have got to open up more choices and that means more extra care housing, more supported housing, more home-based care, more free community equipment and more elderly people, in time, having a greater choice over how they decide for themselves how care is purchased. The package of measures I was able to announce means that at the end of the period 2005-06 we will have more old people cared for where they want to be cared for which is at home. People always want to do an either/or about this. When I go and speak at a primary care conference, I always get people there slagging off the hospitals. If you go and speak to an audience of hospitals they say the problem is with primary care. We can all give out if, frankly, it is either/or; we have got to have both and crucially we have got to have a spectrum of services in each and every area that allows older people and their families to make the appropriate choice for them, and that is what we are trying to do.

  221. Do you foresee a time when a Secretary of State—and figures come up where we have lost 25,000 beds—will feel able to stand up and say that is an achievement rather than a problem?
  (Mr Milburn) You have got an ageing population. You have not just got an ageing population but you have got more people being more acutely dependent towards the end of their lives in very old age, 85 plus. You only have to go to any nursing home to realise the demographic make-up of a nursing home.

  222. The Minister and I had an exchange when she was last before us on this issue. I pointed out that other countries had a similar proportion of elderly people who do not have any form of institutional care. Do you see a time when we may move towards that?
  (Mr Milburn) That is why we have got to get the spectrum and the balance right. As I said in my statement, we have got to move towards a situation where more and more elderly people have the choice of being cared for as long as possible in their own home rather than facing only one choice which is care in a care home. What we will do, with more intensive packages of support and the gamut of things and more levels of support, too, over these next few years is we will allow a greater proportion of elderly people to be cared for where they want to be cared for, outside an institutionalised setting, and long may that trend continue.

Julia Drown

  223. Many members of the Committee would welcome your target by 2005 of twice as many people receiving intensive help at home, but the data supplied to us for this public expenditure inquiry shows there is more intensive help going to fewer people, so how are you going to achieve this turnaround which the Committee have pursued on a number of occasions, and the idea that low-level help may be really effective, preventative help. We have not got the concrete evidence to show that to be true but all the anecdotal evidence would suggest that to be true. How are you actually going to achieve that turnaround?
  (Jacqui Smith) The first thing to say is the Chairman accuses ourselves of not trumpeting our success. You are right—it is a success that we have a 38 per cent increase in those people receiving intensive packages of care in their own homes since 1997 and that we have got more hours of home care being provided in home since 1997. The problem, I think, comes when you define low-level care as only being about the hours that somebody comes in and visits you in your home. My argument would be that in the past sometimes what local authorities have done is to send in a home help for perhaps sometimes as little as 15 minutes a day for something which is really not appropriate for the older person. That goes on for a long period of time and it assumes that no effort is being made to ensure that that older person is enabled to be independent. Some of the other things are not included in that figure of home care, like community equipment services, like the use of occupational therapists, like people going out to day care and receiving support there, like housing adaptations, where we are also with the Office of the Deputy Prime Minister investing more. Those things in terms of low-level support are more effective in providing the sort of care that people need to be independent and, in fact, if you look at those figures, in the last year there is a figure of something like 1.3 million people who have been supported through that variety of low-level care. Perhaps the accusation is we do not record that information properly and I think that that would be a fair accusation. I do not think we do. I do not think our data collection has kept up with the new ways in which we need to provide support for older people, all the various different elements of it.

John Austin

  224. On the ability to support and maintain someone at home rather than in an institution, whether it is high-level care or low-level care, there are many more people, in my view, who could be cared for at home if their home were suitable, but of course the provision of suitable homes, ie sheltered housing, is not your department's responsibility, so in terms of planning for the future and in terms of what level of capacity we need, how does the Department of Health tie in with the other providers of bricks and mortar to provide say sheltered housing whether it be local authorities or housing associations?
  (Mr Milburn) I think there are two things there. I think there is what can be done to better help people stay in their existing homes. You must find it, I find it in my constituency that one of the most frustrating things for older people, and largely their families who come along to surgeries, is about the delay that they face in getting some pretty simple, bog-standard community equipment that makes all the difference as far as maintaining independence is concerned—rails, ramps, showers, and all that sort of stuff. That is a real problem and local authority performance is extremely variable, it has to be said, and of course presently, although we will change this before too long, there is a charge for that fairly low level but pretty vital community equipment. The stuff of handrails and hoists is never going to make the newspapers, with respect, but it is hugely important for lots and lots of elderly people. If we could provide more of it, first of all, and, secondly, if we could provide more for free, which is what we want to do and, thirdly, provide it more quickly which is why we have set some pretty demanding objectives for local authorities, I think that, in Julie's words, is a very simple, good, cost-effective measure that will prevent people necessarily having to go into hospital and indeed remain independent when they want to remain independent. That is point one. Point two is what can we then do for those people who do need an increase in intensive help and support, but outside of the Chairman's institutionalised setting, outside of a care home—extra supported housing and so on and so forth. There are some fantastic and very innovative schemes. I visited one in Leeds in the last year which they put together with one of the housing associations—I do not know which one—which is very good and we would like to encourage. So we are in discussions in terms of what our responsibility as a department is with other government departments and we have been in discussions with housing associations to see if we can migrate them into this market. There are a number of housing associations potentially interested.

  225. But the supply of that will have a profound impact on the numbers of residential care beds that are required.
  (Mr Milburn) I think in the short-term given the capacity constraints that exist, particularly in some parts of the country (and, crudely, the further south you go, the worst the position becomes) then I think we need to see a modest increase in care homes places for the interim period, but we need to see quite a big expansion over and above that of intensive home care support, low-level, home-based support. I said in the Commons that we want to see a 50 per cent increase over the course of the next three or four years in this form of extra services and care enhancement, precisely because it works. It both affords people dignity and independence and yet provides support for people. It seems to me to be a good model and one where we are trying to actively encourage, not just local authorities but housing associations and potentially other players to get involved. There is no reason in theory, for example, why local primary care trusts or the National Health Service should not get engaged in this. If there is a problem with hospitalisation rates or readmission rates, the problem of people being in hospital who need not be in hospital, this is a perfect reasonable thing for PCTs to think about their role in this. Very often when you go into one of these places like the place in Leeds what you find is that the building is one thing but there is a huge focus of different services all providing services there, whether it is leisure or the Health Service with occupational therapy and so on and so forth. There are some models on which we can build.

Julia Drown

  226. Going back to where we were, I would not necessarily want to encourage a lot more data collection, but I would want to encourage better low-level services to be developed where that is possible. Given the huge pressure on social services departments across the country—child protection, the vulnerable elderly and so on—how will you get those social services departments to find money to spend on low-level services?
  (Mr Milburn) Can I say one thing just to begin with and then Jacqui can add something. As you know, in a sense one could say, although it is an unfair charge, that we created a rod for our own backs, because our commitment is—and I think it is a right commitment to make—that we will move towards less and less earmarking of resources for social services generally. That came up with the Government White Paper published back in December. I think that is right because in the end I cannot decide what is right for Birmingham any more than you can. That has got to be a decision taken locally by local council taxpayers and by the Government through inspection of the councils' accounts. So there is a low level of earmarking overall and I think we are going to reduce earmarking for social services by about 40 or 50 per cent over the course of the next few years. However, within that what we were very conscious of when we came to look at how best to use the resources when we came to look at the spending review was precisely Simon Burns' point that almost inevitably, because there is a statutory requirement on social services, what they tend to put first, for perfectly understandable reasons, is children's services, and there is no argument about that. Life is always full of difficulties and it is difficult in central government and it is difficult in local government. What we cannot have is one set of decisions adversely impacting on other services, which was why there was quite a high level of earmarking for the elderly care bit of social services. There is more, it is true to say, of the elderly care package within social services which is being specifically earmarked precisely to avoid the situation that Simon Burns described earlier, which means in some ways we are saying to local authorities, "Look, these are areas where you need to spend money."

  227. You mentioned there about it being right for local authorities to dictate the shape of the local market. Would that be the case even to the extreme that if there were a complete monopoly, say, by a private provider in a particular area that you would feel comfortable with that?
  (Mr Milburn) I think it is their decision in the end. What is our concern here? Our concern in central government has got to be to ensure that the standards that are being set nationally are being met.

  228. Would that be the same if it was all in-house provision as well?
  (Mr Milburn) That is a matter, I think, for local authorities to determine and they will have to report on both standards and value for money. In the case of Birmingham, for example, Simon has raised a perfectly reasonable point, the local authority will have to explain both locally and nationally whether for the money it is getting both from central government and the local council taxpayer it is getting both better outcomes/improved standards on the one side and decent value for money. In a sentence, we are not prescribing a model that says it has got to be this. However, it would be pretty foolish, would it not, if there is capacity available and organisations which can provide local services for there not to be a dialogue and partnership approach to provision.

  229. Finally on these issues of where is the right place to take decisions, I know it is historical reasons that means there is a national system for deciding for charging for residential care. You had the intention with Fairer Charging of trying to look at a fairer framework for other types of care—for care in the home and so on. But what is the reasoning behind there being ultimately a national approach for charging people when they are in residential care but a local one when you are charging for other services which especially in the light of recent discussions about them being really two alternatives—either being at home or being in residential care—it is hard to hold on to the logic for that?
  (Jacqui Smith) I think there is a certain amount of history here, to be honest with you. I think we also need to look at whether or not that history delivers what it is that we want to see in relation to both of those two areas. I have no reason to think that moving away from a national means test with relation to residential care would benefit us in terms of the sort of objectives we have been talking about today. In relation to non-residential care we have not said we want to move to a position of a national means test, because that is an issue that is, rightly, for decision at local authority level and, of course, some local authorities, a very small number, have decided that they do not wish to charge at all in that particular area. What we have said, and this was obviously a recommendation that came out of the Royal Commission, is that where local authorities are charging for non-residential care that it is right that there is a framework that puts into operation the sort of principles that most of us would think are right round how you design a charging system. That was the reasoning behind issuing the guidance on charging for services. The sort of principles in there are that we should not be charging people on very low incomes, that we should be recognising disability expenditure before we are charging out of disability benefits, we should be promoting what good authorities already do, to ensure that their clients are making the most of their benefit entitlement, which some of them are not, there is a very strong emphasise on that. Can I say one other thing about how we make sure we get to where we want to go, we have done a lot of work in terms of how we performance-manage social services departments—I touched on star ratings earlier—in relation to older people we already have Help to Live at Home, a performance indicator which will be a very important benchmark of the success that local authorities are having in developing that. We will, given the emphasis we want to place on community equipment, want to develop a performance indicator round community equipment as well as an important output measure of how local authorities are delivering on this objective of supporting people in the broadest possible way.

Mr Amess

  230. I am listening carefully to what is being said but it seems to me as if ministers are being complacent. If you have elderly people who need to be looked after and you cannot do it yourself the manyana attitude is not acceptable. I have to say that ministers are talking about it being patchy throughout the country, perhaps we are just unlucky in Essex and Southend. Certainly in my area we have a lot of people who need to be looked after. Ministers were warned what would happen about the Care Standards Act and the impact in our area is very, very serious indeed. Hardly a week goes by where there is not some argument between social services and the private sector that someone wants to be moved out. I know you have the best intentions of these people at heart, and all members of the Committee applaud what you want to do, try to look after people at home, but locally it does not seem to be working. Finally, can we have some guidance on this? Local government is saying the Government is taking away more and more of their powers. They give members of Parliament the impression that there is a limit to what they are able to do and at the end of day they are looking to central government for funding. Whilst all of these arguments are going on people are suffering. I have many elderly people in my area with no relatives at all, they are just dependent on friends and neighbours, is there not some mechanism whereby the Government, I know you have gone out to consultation again, give some immediate help, if you like, arbitration between these endless arguments—none of this is new—between what the private provider is given and what the local authority is given. In my area more and more of the homes are shutting, and they are basically saying, well we argued about the room being six inches too small or the lifts and all of that, we are not going to wait for further consultation we are closing now. Certainly in our area we have a crisis.
  (Jacqui Smith) Firstly I do not want to repeat myself, this is most certainly not about manyana, this is about recognising what has already happened in the last five years but also recognising there is more that we need to do, more money needs to go into system. You have particularly focused on care homes and it seems to me you have identified two problems, firstly that care homes need to have their costs reflected in higher fees. We accept that. That, of course, was one of the reasons why we introduced the £300 million building care capacity grant which is already, today and yesterday, having an effect on fee levels. It is also part of the reason for the additional extra investment going into social service departments. Heaven forbid we should get into arguments here, one of the reasons why social service departments have had problems keeping up the sort of fee levels they want to maintain quality is because, frankly, the pathetic levels of funding up to 1997 that those social service departments were facing. We are talking about increases from 1992 to 1997 of point 1 per cent in real terms, from 1997 to 2002 of 3 per cent real terms and for the next three years of 6 per cent real terms. Yes, we need more money, we are putting more money into the system. Secondly, you raise the issue of standards. Let us be clear where we came from, we came from a situation not where there were no standards but where there were 250 different authorities imposing a variety of standards on different care homes. Quite rightly care home providers said to the Government, they even said it in the time when Simon was a minister, this was an inconsistent system, they wanted a level playing field. That was the reason for introducing the Care Standards Act. We always said we would look very carefully at the impact that was having on care homes. These standards were introduced in April, we had already taken action in January to make clear to the National Care Standards Commission our view that room sizes, lifts and door sizes should not cause good care homes to close when there was still concern that that was not being reflected in what care homes felt about it. As Alan announced in July we are consulting and we intend to ensure that those good-quality care homes existing in April 2002 will not face new improved environmental standards, even those that were not due to come until April 2007. We recognised even though we have given than long running time there were some care homes that there were concerns about. That is all action that has been taken today and yesterday and which is already beginning to have an impact. Is there more that we need to do? Yes, there is. We have listened where there are concerns and we have put in money where it is necessary. That is already beginning to make a difference.

Mr Burns

  231. I just want to ask because possibly, I know you cannot comment on this at this stage, there is going to be legislation in the Queen's Speech next week which will presumably, possibly, implement one of your proposals that you announced in the House the day after the Budget, I think it was, to take forward the NHS plan and for the fining of social service departments if they did not fit the relevant criteria. You have consulted on that, could you please tell us what your consultations revealed? Did you have, for example, a 100 per cent consultation saying what a marvellous idea this was? Did you have people replying saying they thought there were better ideas and this was not the best idea to proceed with? Could you share your responses with the Committee?
  (Jacqui Smith) It might not surprise you to know that we did not have a 100 per cent positive response for these proposals. However, I think there is a recognition—there was recognition as I said when I came and talked about delayed discharge in evidence given to this Committee—that we do need to have a much clearer idea in the system about where responsibility lies between social services and health. We do need to ensure that we have the necessary incentives in place so that when we begin to get even more of the additional investment into social service departments to provide the sort of alternatives that we have been talking about today to hospital care that we are clear that local authorities will be spending money on those alternatives and we are going to be able to bear down even further than we have already done on delayed discharges.

  232. That was not exactly the question I asked. I will rephrase the question to press you further, what proportion of responses to your consultation, in percentage terms, expressed support for the Secretary of State's proposal for fines for social service departments?
  (Jacqui Smith) I do not know. I know, as we usually do with consultation, we will make that consultation public.

  233. Let me broaden it a bit, I suspect you have a rough idea of the answer to this question, I will be amazed if you do not. Broadly, were the responses more in favour of the Secretary of State's proposals or more against them?
  (Mr Milburn) They were more against them.

  234. Thank you. Was it overwhelmingly against?
  (Mr Milburn) I have no idea at all.

  235. It was more against.
  (Mr Milburn) It was more against, so nobody is surprised. However, there is a funny old thing about being a minister, you must remember this, you have to do what you think is right. Sure you go out and consult, you talk to people, so on and so forth, people have a right to put their view and in the end we have to decide what we think is right. I will tell you what I think is wrong, it is fundamentally wrong, in my view, where you have confusion about responsibility. This Committee under the chairmanship of Mr Hinchliffe has argued more cogently than anywhere else in this place that what we need is one care system where people accept responsibility for what they do, particularly for the elderly person, not just the elderly person but those with a mental health problem or learning disability or whatever. Partnership is a really, really nice idea and it is a very, very cosy word to use and we are all terribly in favour of it, I am terribly in favour of partnership, but in the end what it means is that somebody somewhere has to accept their responsibility because otherwise it does not work. Despite extra money going in, despite the fact there are a number of people whose discharge from hospital is needlessly delayed, as it, it is falling, we have far too many people needlessly in hospital because somebody somewhere is not accepting their responsibility. We have to find a way of putting that right. If we do not put it right what you are doing is condemning individuals to being in the wrong place in the system at the wrong time and you are condemning the system to further pressure. I think that is fundamentally wrong. We have consultation, of course we listen to what people will say about this but make no mistake about it, we have to find a structural solution to what is, in my view, a structural problem.

  236. Broadly most of what you just said is absolutely right. If we can get back to the question of fining, given that you said in your response you want the best system possible for people to take responsibility to ensure that people are not languishing in hospital unnecessarily but are getting appropriate care, I do not think anyone would disagree with that. You also said that as a responsible person you listen. So you have admitted and accepted that a majority of the consultations were against your proposal for fines. You are listening. Presumably these people have not just written in saying, "we are against. . .", they have given you a rationale as to why they are against it. As you are in listening mode can you share with the Committee, are you going to make any revision to your announced intentions of the fine system in the light of consultation representations you have received?
  (Mr Milburn) We need to wait and see. I am not going to prejudge anything that may or may not be. You asked about the Queen's Speech, I am not going to prejudge anything as far as that is concerned. I will tell you, I have found while doing this job, being a minister in general, that very often you are faced with quite a wealth of decisions that you want to take, that is because there are difficult decisions to take. What I have to do, what Jacqui has to do and what we will do is take the right decisions.

  237. Lovely.
  (Mr Milburn) We will take the right decision bearing in mind there is a structural problem that requires a structural solution. Where partnerships work they are great but where they do not work it is a disaster.

  238. I am glad you mentioned partnerships because that leads on to my next question, where partnerships are working well—obviously the whole emphasis has to be encouraging the development and the working of partnerships to the best possible levels—what damage do you think is going to be done to them with the introduction of a fine system?
  (Mr Milburn) None. I think it will enhance the partnership, not diminish it, because everyone will be crystal clear about their responsibilities.

  239. I am not in a position at the moment, because the system is not in place and if it is introduced we will find out whether that answer is right or not, it will be extremely interesting if the system goes ahead, as envisaged, whether partnerships benefit, because I suspect that it will put unnecessary and undue strains on partnerships. We will see.
  (Jacqui Smith) Can I say, Alan's point was right, we are all in favour of partnership because it delivers results.

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