Examination of Witnesses (Questions 580
WEDNESDAY 8 MAY 2002
MR J RANSFORD
580. Perhaps the doctor from Southampton would
like to comment.
(Dr James) Yes, I am aware of the situation in Southampton.
What strikes me is that if you have a private provision and residential
nursing care, and nursing homes are a private provision, then
it is an open marketplace. If there are people who want to increase
their prices and a health economy which needs their services,
then you can almost have sympathy for it being fair game. What
we are doing in Southampton, hopefully, because the residential
care stock is decreasing at an alarming rate, is through public
and private purchasing agreements having 240 beds of our own belonging
to the social services and the PCT, so that we are not open to
these market forces. I would not agree that a £50 differential
is a good thing, nor would I agree that keeping people in a £250
bed in an acute hospital is a good thing either. We are the slaves
of the market, if that is the way it stays.
581. Dr Morgan, you and Mr Leadbetter, both
in your different ways, were saying what a problem it is, particularly
in areas of high employment, to attract staff and that would be
particularly relevant to London and the home counties. Do you
think from 1 April next year the increase in national insurance
contribution is going to help or hinder the attraction of staff
in this sector?
(Dr Morgan) That is a very difficult one to answer
because it depends how you deal with the funding to go into the
homes. That is going to depend on a whole set of things. I cannot
really comment very much about that because I do not think it
is entirely salaries here. That is what the headline is but when
you talk to nursing homes there is a whole set of other things:
there are the expectations of the Care Standards Agency, there
is the issue that empty spaces in the homes are not covered. There
is a whole set of things which are different from home to home.
It is therefore very difficult to come up with a simple yes or
582. I was not necessarily asking for a yes
or no. I was wondering whether it was going to help or hinder
the recruitment of staff in areas of high employment.
(Dr Morgan) My personal view is that it will not make
a lot of difference.
583. On the issue Dr Taylor was raising about
the ADSS evidence talking about the health services aggressively
recruiting from the nursing home market, where that is happening
would it be the norm that as soon as Directors of Social Services
saw that happening they would be engaging with the trusts to say
that would have an impact on the whole of the economy and trying
to get together with the independent sector to agree a way forward.
How much would that be the norm?
(Mr Leadbetter) It is difficult to speak for 150 local
authorities. One would expect that would be a sensible course
of action. It is certainly something we did in Essex and something
we also did with the private sector. We used some of the £100
and £200 million to mount a joint recruitment campaign for
in-house and private sector staff. That addressed not only pay
and conditions, because we increased the rates, but also that
working in social care was a good thing. I can tell you stories
about Aldi supermarkets paying £7.50 for people to work on
the tills, but we advise that social care is a worthwhile job,
working for the public service is good and we are beginning to
see some green shoots of change and more people coming in as a
result. It is very, very early days, but my intuitive sense is
that it is improving.
584. It is improving but initially, as soon
as it happens, was my question. How many Directors of Social Services
would be engaging? Is your feel that half of them would be doing
it, a quarter, three quarters?
(Mr Leadbetter) It is not totally a problem throughout
the country, so I would expect the majority. Remember that Directors
of Social Services or their senior representatives are involved
in PCTs. I would expect that it would be a matter which would
come up at the PCT Management Boards. Also, most of the social
service departments have close relationships with the trusts.
I should be surprised if it were not something which came through
585. So it is a problem which should largely
be able to be managed within the health economy.
(Mr Leadbetter) Discussed if not managed and discussed
in creative ways. What one might move towards is that sometimes
it seems easier to recruit auxiliary nurses. So look at recruiting
auxiliary nurses and have some shared tasks. There are problems
with that because there is a problem with charging. There are
some creative options to get round that, but there is still a
questionand I put it in these termsin that Government
may have to realise that they are going to have to pay more for
586. Mr Ransford was talking about the perverse
incentive that perhaps led social service authorities in the past
to close homes perhaps for their own reasons. You suggest they
were perhaps higher quality homes. Is that across the board? Were
some of the authorities making wrong decisions or was it the authorities
who were pushing right up against the capping limits at the time
and could not possibly have spent another penny, or was it that
they were not prepared to go to their council tax payers and say
this was a service worth paying for?
(Mr Ransford) There was a variety of reasons, probably
including all of those. Like anything else, looking back, they
were seen as short-term decisions. There is no doubt that some
authorities were massively overstocked on residential care at
the expense of other services. There is a finite budget so if
you have a lot of residential care and have not invested in the
capital, for a variety of reasons, or are using adapted buildings,
they simply were not of benefit to potential users, whether they
should be there or not. One of the major difficulties with the
community care introduction with insufficient attention to the
role of housing and particularly more intensive housing schemes,
which we are beginning to see now but nothing like in sufficient
quantity, where you can have your cake and eat it in the sense
that residents get their independence and their privacy but also
the benefit of community living if he or she chooses. I do not
think we saw sufficient of that and sometimes resources were simply
closed for budgetary reasons or for difficulties in other parts
of the service. Where they were closed to re-invest in community
alternatives, we saw some very imaginative schemes developing.
I do not think there was the level of overall planning that we
see now. Link that to some of the workforce issues you have been
raising with other witnesses. Occupational therapists has been
one issue which has bugged me throughout my career. Throughout
the 30 years I have been in this business, we have never had sufficient
occupational therapists, never. We have been moving them from
hospitals into communities and back again; we have not planned
that particularly. They are often absolutely crucial to ensuring
people's homes get the right equipment and the right adaptations
quickly. That is something which is not to do with what is happening
in the supermarkets, it is to do with overall planning and professional
587. A couple of questions arising out of the
evidence the LGA submitted. We have touched on a lot of related
topics already but it would be worth clarifying them. You say
in your submission that short-term funding exacerbates the capacity
problems in the residential care sector. I am sure we can all
understand that. Money is used to raise prices that are paid to
care providers in order to secure extra capacity in the short
term. In the longer term this creates further problems, trying
to make placements at a fixed price. What evidence do you have
that this is actually taking place?
(Mr Ransford) We know that usually the people who
are assessed as being able to be supported in the community have
long-term needs. They might vary in intensity over time, but there
is usually a continuing cost. Short-term resource will run out
and the cost of that placement will need to be found elsewhere.
We have lots of examples of that: partly it is demographic because
people are living longer, the quality of care and the quality
of treatment is supporting people's longevity, so that results
in longer-term needs.
588. I am talking really about the short-term
needs and the short-term prices affecting the long-term contracts
which can be negotiated.
(Mr Ransford) We would all agree that all prices are
being driven up for a variety of reasons, partly shortage in the
markets, partly increased costs of providing better facilities
for disabilities, more staff, better paid staff, a whole series
of things force up costs. That short-term cost tends to be sustained
because for other reasons people do not tend to move into any
form of residential care for a short period and then move back
to their own communities. Their housing may have gone, they may
have other needs. Short term expenditure often turns into long-term
589. Quite often these short-term contracts
become long-term contracts.
(Mr Ransford) Yes.
590. It cannot be a good thing.
(Mr Ransford) We start by looking at the needs of
the individual, but the needs of the individual do not fall neatly
into predictive contractual arrangements and in making a needs
assessment you have to take into account not only the physical
and the mental and the social needs of the individual, but their
wishes and conditions as well and their social networks.
591. You also mentioned in your evidence the
conclusion of a Laing and Buisson survey that private care home
providers are looking for an increase of £100 per person
per week, per resident. You appear to imply that you accept this
as a reasonable figure. Is that the case and what would you recommend
central government does in these circumstances?
(Mr Ransford) One answer to that is that central government
provide more resources in the system. There are many driving factors
but two in particular. One is that certainly in terms of what
is known as spot contracting, buying a place, the contracting
regime has usually been last year's figure plus some allowance
for inflation. There is a whole series of other cost drivers on
top of that which creates a higher rate of cost for this area
of service than the general economy. The second is quality standards.
Everyone is looking to provide better facilities, some of which
are insisted on by the now independent regulator, the National
Care Standards Commission, others of which I think we would all
agree in terms of dignity and support are a right people should
receive. There is no question about that but it comes at a cost.
Certainly those costs have to be properly examined and rigorously
addressed, but we know that most contracting has been carried
out on the basis of what local authorities have been able to pay,
rather than a full assessment of what the requirement is for those
individuals. If you have a finite budget, you can only do two
things. One is that you can restrict the amount of payment you
make. Secondly, you can pay more and restrict the number of placements
you make and both of those create difficulties.
592. What I am trying to get at is whether you
think £100 per week is a reasonable increase.
(Mr Ransford) One hundred pounds will depend on the
amounts individual authorities are negotiating on what is needed.
It is reasonable to state that, if we are to sustain and develop
a proper care capacity system of sufficient quality, that you
or I would be happy to use, then there is a significant cost increase.
593. What you are saying is that you reckon
for many occasions £100 is right.
(Mr Ransford) Yes, I could not argue that the system
is going to break down unless there is a step change in the amount
which is paid for care in certain circumstances rather than the
age-old business of just adding a bit on for the prevailing rate
594. How would you make certain that this money,
say you get it, is used for the purpose for which it is given?
(Mr Ransford) First of all, we must agree on what
quality standards are going to be developed for that. We cannot
as agencies responsible for public money just invest with no return
for the quality we receive. There have to be agreed quality standards,
the providers have to meet those standards and develop them, they
have to provide services for people who have substantial needs,
they have to provide a proper staffing regime, they have to provide
a reasonable environment. All of those have to be taken into account
and calculated in a price which is seen as fair and reasonable
for the commissioner and the provider.
595. Accepting that increase, which you say
is necessary, how would you make sure, if you got it, that it
was spent on what it was being given for.
(Mr Ransford) That is the real purpose of the commissioning
responsibility which the placement agency, usually the social
services department, has. You have to make sure that, if there
is going to be a step increase in resources, all the factors which
are taken into account and which drive up the quality of care
are actually delivered. What we cannot afford to do is invest
in the system and force up prices so we get a new norm for the
same level of service. There has to be a return for the community
in quality as a result of that investment.
596. I do not know what the figure of £100
per week per resident times the number of people in such places
would come to, but as far as I can see it would be a substantial
amount of money. If that substantial amount of money were made
available to your members to deal with this issue, would you choose
to invest it in adding to the costs of residential care as opposed
to looking at investing that money in alternatives?
(Mr Ransford) No, we would have to invest in alternatives.
597. Basically you are saying that this is not
(Mr Ransford) No, what I am saying is where we use
residential care, in my submission for more focused cases, as
is argued for acute care, making sure that residential care is
used for the right people in the right places at the right time,
there is an increased cost. We also need to invest heavily in
a whole range of community alternatives, particularly housing,
to ensure that we have the right system to avoid the perverse
incentives we have been talking about.
(Mr Leadbetter) Three points. A £100 per week
increase for Essex would be £17 million. We are talking about
big sums of money if you multiply that across the country. I am
not saying I am against it or for it. The second point is that
it should not really be rocket science to work out what exactly
is a fair price for care, what the expectations are. The Scots
have done it based on a model which did not look at a sufficiently
wide range of homes, but what are the imperatives? Number of staff,
hourly rates, planning for the future, seven years' time, NVQs,
room sizes, fair return on capital, openly declared, is that 10,
15, or five per cent, negotiated with the commissioners? I believe
we are entering into a very careful dance with the private sector
to begin to explore that, to see whether we can engage with the
Department of Health to commission some work. I know of two models:
Laing and Buisson have one. Price Waterhouse Coopers have another.
The Price Waterhouse Coopers model seems to come out slightly
lower than the Laing and Buisson model, but we should be able
to find an appropriate model. Audited accounts can be used, the
commissioner can then use audited accounts to see that the money
is going on care and not going inappropriately on unfair return
on capital. There are ways of doing that. Finally, may I take
a number of steps back to the policy area which you were discussing.
There is a very interesting policy debate. Why is it that we assume
people with learning disabilities or people with mental health
problems live in small homes or small communities and we never
debate the issue of why we consider it appropriate to place older
people in 40-, 50-, 60-bedded homes and encourage providers to
build bigger and better because there are economies of scale.
There is an implicit ageism in some of the policy imperatives
we live with and never challenge. I know that would be a huge
increase in cost, but it is something which needs to be on the
Chairman: You will be encouraged to know that
at the last session I was told off by the independent sector for
using the term "institutional care". Personally I think
that is an appropriate term and I think you are making that point.
598. We have taken evidence from some in the
care home sector. They feel that the partnership between them
and social service departments is not working very well and they
are very much the junior partner, or they are not even a partner
at all but are dictated to. I was wondering what the LGA are doing
to track whether it is a justified complaint and how the situation
may be being improved or how it can be improved. While Mr Ransford
is answering that perhaps Mr Leadbetter could think from his experiences
as Director of Social Services and of the other social service
departments he has dealings with around the country, whether it
is a fair criticism, or it was a fair criticism but things are
moving forward, or whether they are not moving forward at all
and far more needs to be done to improve so there is a genuine
partnership. I should have thought it should be a tripartite one
with health as well as social services and the care sector on
an equal footing.
(Mr Ransford) The answer to your first question is
in what you said at the end. This will only work better if all
the key players see themselves as partners and work jointly on
the issues and appropriate solutions to them. One of the reasonsand
it has been made to me many times and I have some sympathy with
itwhich the independent sector gives is that it is because
they are treated in the contracting regime as pure providers with
no stake in the care and the style of operation and it becomes
a very arid discussion as I suppose we have been having about
price and suspicion and getting the best price for the arrangement
in an area. That does not typify many of the arrangements I am
aware of, but it is the stereotype which is built up. It seems
to me of course that when you are dealing with public finance
there has to be a reason for the payment made and ensuring best
value for public money to the public purse. That relationship
can be dealt with in a true partnership to ensure that the arrangements
are made. If you do that, people accept their responsibilities
and do come up with imaginative suggestions jointly about how
this system is managed. Certainly all our evidence and all our
experience is that the best arrangements work like that. The problem
in recent years is that things have become so tight for financial
and other reasons, that there has been a lessening of trust, an
increase in suspicion and we have the wrong results out of it.
We must not panic about this; we must take it seriously but we
must not panic and we must get back to an arrangement where we
have shared responses to shared problems.
599. Being the devil's advocate, is there any
cause to be concerned that it might be easier for the local authorities
just to use residential care homes? It is such an easy solution
all round. It is out of sight, out of mind and we can put people
in there, pay the fees and no-one has to worry. Is there any reluctance
or difficulty in getting people to come back into expanding home
care services because it is just more awkward as a way of delivering
care to older people?
(Mr Ransford) Certainly there is no doubt that it
is more difficult to provide mixed responses, community based
responses which are there seven days a week, 24 hours a day in
people's own homes, in own communities, provide all that appropriately
and safely, rather than gathering everyone up and providing that
in one place.