Examination of Witnesses (Questions 240
WEDNESDAY 13 MARCH 2002
240. On the other hand, I certainly am talking
to care staff working for my local authority, who are undertaking
procedures which are variously being defined as nursing, such
as catheterizing people or supporting primary care.
(Mrs Robinson) Precisely. That is my point; that where
individuals are undertaking what we would call nursing carewe
call it thatand it is verging on what most of us would
understand by basic care and has always been so, you are absolutely
right, we are then having difficulties in discerning which is
which, allocating responsibilities, and this is ripe for disputes
between the two agencies. What seems to me to be important, rather
than thinking about let us put them all in the same organisation
and give them the same budget where they will squabble around
this budgetat least I think sois to think less about
guidance and think more about the responsibilities and incentives
that could be built into the system around individuals who are
seen to have a mix of health and social care in the terms that
I have defined it, which is to say that they have personal care
and nursing care needs. We do say in our submission that we think
it is worth a cautionary but nevertheless close look to see if
we can build in some sort of incentives for the local authority
to take on responsibility when they need to, and equally for the
NHS to do so. Maybe there is some system of having kind of 50/50
agreements, almost laid down not so much in law but perhaps through
instructions from the Department, around a whole gamut of cases
where it is simply ridiculous to say, "This is social care"
or "This is health care"it is a mix. For a large
number of people you can make that distinction, but there is a
group of peopleand I have given some examples of who they
arewhere we might need really to get down to the basics
and agree that there is to be, say, 50/50 funding, no argument.
241. You would reject the whole idea that it
might be possible to come up with a solution where you completely
abandon this whole issue of division anyway? Having worked in
social care over many years, I just felt it was impossible to
define, as you have admitted, the difference between the two.
I cannot understand how you can sustain organisational structures
that depend on a definition that no one can actually make. I do
not know whether any of the other witnesses has any thoughts on
this; whether you agree with Mrs Robinson's view that we retain
the two separate departments?
(Ms Harding) It seems to me that the two are moving
closer together anyway, with care trusts and primary care trusts,
and it will happen. There is already the potential for pooled
budgets, so that is taking us well down that route. I think the
problem which arises, certainly for the public, is knowing what
is going to be charged for and what is not going to be charged
for. That just creates an immense amount of confusion; people
do not know which falls into which category, and they do not know,
if they have a complaint, which complaints system they ought to
use. From their point of view, it is a mystery and a nonsense
really that we should have those two definitions. I think that
also from the point of view of those people trying to determine
at the sharp end, through the assessment process, what is nursing
care and what is personal care, we now have an immensely complex
administrative system of four levels of what constitutes nursing
care and people having to make decisions which do not seem worth
the effort to make, frankly.
242. Is it not very important that you introduce
the public subsidy into the argument? If it were not for the fact
that nursing care was then covered, in part you would not need
to define it, would you?
(Ms Harding) Indeed, but a public subsidy in what
Jim Dowd: The nursing care element. There is
an argument about the way some care home owners are actually responding
to it, but there is now a payment for nursing care, and the need
to differentiate between what is nursing care and what is not
is now far more technical, far more refined, than it otherwise
would have to be.
Chairman: Which is important. You have always
had that. You have that now in an institutional setting and you
have always had that in the community.
Jim Dowd: Yes. Technically it does not matter,
because now part of the cost that they are meeting themselves
has been met by the local authority previously. Now it applies
Chairman: Whether it is a care bath or a nursing
bath, if it is a nursing bath it is free, if it is a care bath
it is means-tested.
243. It now applies to every case, not just
(Ms Harding) The problem is, we now have a system
which is very difficult for older people and their families to
understand, and we also have a system which is extremely complicated
to administer. It seems to me that we ought to find ways of cutting
through that. I think the distinction between personal care and
nursing care has become a completely false one; it has been a
sliding definition. The distinction sort of slid a long way in
the last few years. We really ought to do away with it. That would
involve making personal care free in the same way as nursing care
244. I notice that the two witnesses on each
side of you were nodding. I do not know if there is anything they
wanted to add?
(Ms Whitworth) I was going to say that I think the
case has now been well made for free personal care as well as
for free nursing care, but that is not the point we are here to
discuss. Can I just make a point about merging organisations.
I think that from the carer and user perspective the issue really
is outcome, and it is whether or not they are receiving a good
service, a joined-up service. I do not think that the case has
been made that demonstrates that putting everything into one would
actually have that outcome. I suspect there are quite a lot of
examples of good practice around the country where you would find
that other types of models are delivering improvements. So I do
think there are other things that could be put in place, and that
would be better guidance around some of these issues, as well
as perhaps incentives that Janice was talking about earlier.
245. Would you accept the organisational distinction,
the distinction between health and social care, the division,
is extremely difficult to determine?
(Ms Whitworth) It is unhelpful from the point of view
of a user or carer, but I would observe, as I think I have said
before, that in terms of traditions and practice, the distinction
is there, and that it is important to take it into account if
you are thinking about merging. One of the concerns is that social
care is so small alongside the NHS that many of the advantages
and the things that have been learnt by people working in social
care could easily be lost in a merger.
246. Ms Herklots?
(Ms Herklots) I hear what has just been said. I think
it is important having social services working together, and I
think we need to see how the new flexibilities in the Health Act
really play out and what sort of benefits that has. There are
a couple of points I would like to make. One is that whatever
the structure, I think there are going to be lots of cultural
issues that need to be tackled and overcome. You need to go back
a step and look at things like training and joint training between
health and social care staff or whoever they are, whatever jobs
they are doing. The other point I wanted to make is that there
is a danger, in focussing on health and social care working together,
that we exclude two other essential elements of, if you like,
the care package for older people, which are housing and access
to benefits and monetary help. So I think we need to be careful
not to put too much focus on health and social care working together
and forget about the importance of housing and access to income.
247. Mrs Robinson seemed to be saying that if
we were just to merge health and social care with unitary budgets,
all we would wind up with is a different set of anomalies to what
we now have and simply displace one with another. I understood
you to be saying as well that precisely because of the concentration
primarily on the acute sector, perhaps one could say that primary
care was therefore competing for the same budgets. Did I understand
(Ms Herklots) Yes.
Jim Dowd: Thanks, fine.
248. While we are on the personal care issue,
given that those with low incomes do get personal care free at
the moment, would that be your top priority for the next bit of
government money, to make personal care free, or would it be to
look at services, or would you do a bit of both?
(Ms Harding) There are real problems with setting
those two in opposition with each other. There are real problems
with paying for personal care, one of which is that people turn
down services or refuse services even when they meet those very
high eligibility criteria because of the cost. We know that happens.
A fifth of people limit or turn down services because of the cost
of those services. I do not think you can say, "Do you want
better services or do you want free personal care?" That
is like saying to a bare-foot man, "Do you want the left
shoe or the right shoe?" I think we need both and I do not
think that is divisible.
249. A couple of points to Ms Herklots. You
mentioned the low level of local authority fees generally which
covered some of the questions I wanted to ask about the consequences
that has for people and their families. You call in your evidence
for a comprehensive review of the way residential home carers
are funded, which I presume is an allied field. What would you
want that review to cover and is Age Concern open-minded completely
about it or does it have some views of its own about what this
ought to achieve?
(Ms Herklots) This has been a problem for some time
and it is becoming acute. What there is not clarity about is what
good residential and nursing home care costs. What we do know,
for example, is that the levels that are paid for older people
in those settings are considerably less than for other groups
of people who might need residential or nursing home care. You
could well argue that is age discrimination because it is allowing
lower costs for residential care than other age groups. One area
we would like to look at is what is the cost to provide quality
care and, importantly within that, to look at the issue of staffing
and training, because one of the problems is that residential
care could be seen as a place that no-one wants to go to in terms
of to live or no-one wants to work in. Neither of those things
are totally true but it does have a bit of an image problem. For
some people residential care is a choice they want to make. For
too many people it is the only option that they have. It is part
of the system, as others were saying earlier, perhaps for people
who have severe dementia who need that sort of environment. We
do not have enough information about how the funding is going
in terms of free nursing care, for example, and what sorts of
fee levels you need to run good quality residential and nursing
care, and that is what we would like the review to look at.
250. When you say the way they are funded, do
you mean who funds them rather than the way they are funded? The
way they are funded at the moment is that most of them are private
undertakings that have to cover their overheads one way or another.
Not the way they are funded but who funds them rather than any
(Ms Herklots) There are some complex issues here around
how homes set their fees. For example, the fact that if you are
a self-payer you are likely to be paying a higher fee than if
you are funded by the local authority and therefore in a sense
you are cross-subsidising that place because they are charging
two different levels of fees. We also know that homes run by voluntary
and charitable organisations are having to put their own charitable
funding into them. It is those sorts of issues we want the review
to look at.
251. In my own constituency, Abbeyfield, which
I am sure you have come across, said exactly that; they were funding
each local authority place to the tune of £100 plus a week.
Okay. Mrs Harding, you have referred in your evidence repeatedly
to the under-funding of social care and the problems that creates
and we have been through those earlier this afternoon and the
fact that social care is severely rationed. What is your estimate
of how much that under-funding amounts to?
(Ms Harding) I think it is quite hard to arrive at
252. That is why I asked you!
(Ms Harding) The local authorities themselves say
they are over-spending to the tune of £1 billion on older
people's services. The total gross cost of local authority expenditure
on older people's services is £5.6 billion and the net cost
something like £4.1 billion. If we made up that £1 billion
pounds extra that local authorities say they are paying for now,
we would still be falling short. We would still have the same
level of rationing. We would still have the same lack of access
to care and not enough care for people and not the kind of quality
that we are looking for. I do not know how much more it would
take to bring it up to the kind of quality that we would want
to see. I think we need to do that exercise.
253. So it is at least £1 billion to not
solve the problem, so it is beyond that to start dealing with
(Ms Harding) Exactly.
254. What kind of cost factor would making personal
care free add to that?
(Ms Harding) The best estimates we have got on that
are the Royal Commission on Long-Term Care's estimates and they
also came up with a figure of around £1 billion. I think
we have got to take into account the potential savings. We are
here talking about hospital discharge after all and emergency
admissions and the cost of that to the NHS. We have got to look
at that whole cost-benefit analysis in order to decide what we
ought as a nation to spend on supporting older people and meeting
their social care needs.
255. You bring me to the final point I wanted
to make on delayed discharges. In your evidence you say two-thirds
of all acute patients are older people. Therefore, those affected
by delayed discharges (these are the ones that cannot get into
the acute beds for treatment) are disproportionately older people
in the same ratio, I imagine?
(Ms Harding) Yes, who will be waiting for their hip
replacement or their knee replacement or their eye operation which
will enable them to keep their independence. It is a very complicated
calculation and I would not pretend to second guess it.
256. Going on to premature discharges and readmissions,
first to Age Concern: how much of a problem is this?
(Ms Herklots) It is a problem. Certainly one of the
issues is around people's home situation not really being sorted
out for them to go home. So they might be medically fit but if
they are discharged back and the care support is not there, then
there is a likelihood of readmission. There has been some work
done in Leicestershire looking at reasons for readmissions and
one of the findings from that work showed that people discharged
on a Friday were more likely to be readmitted, not surprising
perhaps. We know that if you are discharged on a Friday there
could be problems in getting the right sort of care available
at the weekend. But this is not rocket science to solve, it seems
to me, and we ought to be able to sort out a system so people
are not being discharged when people are less likely to be there.
It is an area that we ought to monitor quite carefully particularly
around the cut-off point on intermediate care and to look at the
reasons for readmission.
257. Have you any idea why the figures throughout
the country vary? In the league tables it was Preston and Chorley
who are best at 3.9 per cent and St Bart's worst at 8.7 per cent.
(Ms Herklots) We have not done a study of that. It
seems to me that one of the factors of readmission is what sort
of community support is available. If you are in an area where
a lot of funding is channelled to acute care or institutional
care and there is proportionally less community support available,
that might be a factor, but we have not done any thorough study
258. Could I bring in Diana here and the Carers
UK experience of readmissions?
(Ms Whitworth) Yes. There are two issues here. One
is that early discharge can actually have quite a bad effect on
the carer's health, if, say, somebody goes home too soon, without
proper support at home, without proper help in lifting or the
right adaptations to get a wheelchair into their house. That is
not an unusual situation, for somebody to be discharged having
had their leg amputated on the Sunday over a bank holiday weekend,
with no arrangements to get them into their house, to a home where
the carer was also elderly and had had a stroke recently. So that
is fairly typical of the experiences that are reported to us.
In fact that happened to my friend's mother, and I imagine that
there are many of us who could cite similar stories. Of course,
it is also an issue for readmissions. When we were looking at
the experience of carers at hospital discharge last year we had
the benefit of being able to compare it with a similar survey
that we carried out in 1998, and it was done in a survey by Melanie
Henwood in 1998. We found that the proportion of people who had
had to be readmitted within two months of being discharged doubled
from 19 per cent in 1999 to 43 per cent in 2001. Obviously as
to the cause and effect of that, I cannot guarantee the cause
of the readmission was early discharge, but in addition to that
the proportion of carers who felt that the person they were caring
for had been discharged too soon rose from 23 per cent to 45 per
cent. So there is an issue, and the link between early discharge
and readmission I think looks fairly evident.
Dr Taylor: Thank you.
259. The Committee wants to look a bit more
at the issue of support at home. I know Age Concern has expertise
particularly with its "handyperson schemes". I wondered
if you could tell us a bit more about that, why they have come
about in some areas and what the potential is for wider use of
(Ms Herklots) Yes. Age Concern does run some handyperson
schemes. A lot are also run by Care and Repair and Staying-Put
organisations across the country. One of the issues there is that
not every area has that sort of service available, and we would
certainly like to see care and repair schemes in every local authority
18 Note by witness: The £1 billion overspend
is for the whole of social services, not just older people. I
think older people account for around 21% of that, according to
the latest GLA/ADSS figures. Back
Local Authorities themselves say they are overspending to the
tune of £1 billion on Social Services as a whole-of which
about 20% is on older people's services. Back