Select Committee on Health Minutes of Evidence


Examination of Witnesses (Questions 640 - 659)

WEDNESDAY 19 JUNE 2002

JACQUI SMITH, MP, MR RICHARD HUMPHRIES, MS MARGARET EDWARDS AND MS ANNE MCDONALD

Julia Drown

  640. I have some issues about funding. Is not one of the root causes of delayed discharges the disparity in funding between health and social services—not to say that health has had too much money, but that social services has not kept up with that over the years?
  (Jacqui Smith) I think there are a whole range of reasons why we have delayed discharge. Some of it would certainly be around the ability to develop, within the community—and that could be either the health or social services spending—the sort of alternatives to remaining in an acute hospital bed that would be necessary. So yes, the investment is part of it—and I shall come back to that in a moment, if that is all right—but I think there is also an issue about the extent to which there is good partnership working across the system. I think we are also beginning to think as well of the extent to which that work really focuses down not just on some general idea of partnership at a sort of strategic level, but in relation to delayed discharge how it really focuses down to a concern about managing an individual's pathway through acute and back into community care again. My impression, from having considered those areas where there is already successful work around reducing levels of delayed discharges, is that they do have that very close focus on that management. To come back to your point about is money important, I think we have proved to a certain extent, through the expenditure of the £300 million building care capacity grant focussed on reducing delayed discharge, that investment is important in order to make a difference. We quite clearly have evidence there, from our monitoring, that that has enabled local authorities and their health partners to develop some sort of provision that would be necessary to provide community alternatives and to maintain capacity, for example, in care homes through fee levels and through the way in which they are funding placements. So investment is, if you like, a prerequisite for solving the problem, but I am sure you will not be surprised to hear me say that it also needs to be linked to some sort of reform, and in particular, I think, in terms of the way that in the future we are going to need to consider what incentives we put into the system 1) to create that focus on managing individuals, which I spoke about, and 2) to ensure that that interface between health and social services really is managed in the most effective way and that the investment goes into the areas where it is going to be useful.

  641. You mentioned there the short-term money, the £300 million, and certainly it has been very effective in reducing delayed discharges in Swindon. However, what I hear is that having a short-term grant is not the most effective way of developing services, particularly when there are national and local shortages of people like occupational therapists and community services people that you need to recruit. Should local authorities be assuming that they are not recruiting short-term staff, but that they are coming in for the longer term? How do you get over that problem of wanting to develop services but you cannot, for example, employ somebody or it is not so easy to attract somebody if you are only attracting them for a year's contract or only for an 18-month contract?
  (Jacqui Smith) Firstly, your point about short-term funding is, of course, an argument against earmarking and ring-fencing of funds in quite the ways that we did with the £300 million. One thing that was important about that was that we listened to what the local authorities and care providers were saying about the need for investment in the system in order to solve this problem. We identified those resources and we focussed them very clearly on where we identified the problems, focussing them so that actually more resources went into hot-spot area; in a very centrally-managed way, we identified what we expected that money to be spent on, what we expected and the difference that we expected it to make. By announcing it over two years, we have tried to give some certainty, from the October announcement, that further money would follow in 2003. That was important in order to ensure that people felt able to enter into the sort of arrangements that you are identifying. For the longer term, though, firstly, I do not think it is either sustainable or desirable to continue funding the activity in that particular way and in particular managing it in the way that we did through that grant.

  642. Do you think that authorities should be taking the risk and assuming that the money will come through in another way?
  (Jacqui Smith) What I think authorities should be doing is looking at the Chancellor's announcement about 6 per cent real-terms increases in personal social services over the next three years, and I think they should be looking at the announcements that we have made as a Government about the significance of social care, the important role that it has to play and our commitment to funding it, as represented by that announcement, at twice as big a real-terms increase as we have had over the last five years. I think they should be seeing that as a sign that they ought to be making long-term plans about how to tackle that problem.

  643. That should be seen as the limit of it, should it? You did say in your evidence that "The new social services cash announced in the Budget includes resources to cover the cost of beds needlessly blocked in hospitals through delayed discharges". Does that mean all beds needlessly blocked in hospital? Again, the feedback I am getting locally is that all community care budgets are deemed to be very depressed because the cost pressures are there in nearly every area of community care.
  (Jacqui Smith) Certainly in terms of that 6 per cent, the way in which we have modelled the need to reduce delayed discharge is in order to meet our target to get down to a frictional level of delayed discharges, and it is on that basis that, if you like, we were successful in getting what is a pretty significant increase in personal social services funding. So yes, with regard to that 6 per cent, that social services settlement, clearly there are discussions that we are still having and there are discussions that we are having with the Treasury about how that money is allocated, how it is used and, for example, what sort of PSA targets we might be setting around it, but our modelling is that that provides us with the funding or provides the local authorities with the funding in order to be able to tackle this problem. For example, this settlement would buy from 2002-2003 to 2005-2006 some 8,000 extra intermediate care places supporting another 70,000 people a year, public support for 7,000 people in residential care, 30,000 more packages of home care.

  644. That is if all the 6 per cent went on this particular aspect?
  (Jacqui Smith) No, that would not imply all the 6 per cent going on this, because clearly there are other cost pressures that local authorities face as well. I think it is 40 per cent of a social services' expenditure which goes on older people, and of course we recognise that if you take children's budgets, part of what brings pressure onto older people's budgets is pressure that feeds through children's budgets, which is why we are also undertaking action to try to ensure firstly that the investment necessary there goes in, and secondly through, for example, our Choice Protects Review that the sort of functions that local authorities are doing helps to ensure that that money is being spent.

Chairman

  645. Do you think, going back to the question I asked on the cost, that there is sufficient awareness elsewhere in the Government of the knock-on effects of investment in one Department's operations on that of another? I am thinking in particular that yesterday some of us went to an extra care housing scheme, which I believe you have been to, in Stoke-on-Trent, and we were very impressed by the impact of work they were doing—at least I was impressed, I cannot speak for others—in the housing environment on health care costs. What is frustrating me on the issue Julia has raised is the way in which there has been insufficient awareness, fairly obvious to most of us and probably to you, of the impact of social services budgets on health. What about the wider aspect of the housing budget and health? Are you happy with the extent of commitment from elsewhere in the Government on areas of policy? You have to be careful how you answer that, I appreciate that. Have we got sufficient cross-departmental working which enables you to stress to those departments that some work on housing can directly impact upon your ability to admit people into acute beds in the NHS?
  (Jacqui Smith) Housing is a very good example—and I think Richard would agree—because it is an area where some of the evidence of where there is successful delayed discharge work often relates to where there is imaginative use of housing resources, for example, to develop extra care housing, or being imaginative about the way in which adaptations are made, for example. So there is certainly evidence that is if you like another link that is very important. Just tomorrow, Chairman, for example, the Department of Health is organising, and I am speaking at, a housing seminar bringing together representatives of health and social services and housing providers precisely to look at how we can develop more of that type of housing provision. One of the examples of where the £300 million has been spent is on some step-down provision where they used some of their existing housing stock and then provided the sort of packages of care necessary to make that appropriate for people coming out of hospital. I am very keen that we pursue this area of work in relation to housing and there is already work across the Government where that is happening. For example, I am sure everybody is aware that in January 2001 with the then DTLR we published a strategic framework for older people's housing called Quality and Choice for Older People's Housing. I say I am sure everybody is aware, and I will not test people, but I suspect there are some people who are not aware actually, so part of what we have to do is get up the profile of that framework and to provide some more guidance and some more push to what I think people are very keen to do at a local level. We are now working with the office of the Deputy Prime Minister on guidance to help local authorities to plan for those housing needs of older people and to meet those needs. We are working on a set of performance measures so we are going to be able to track the progress nationally on extending the choice and quality in housing and care services. We are looking at practical ways of getting good advice to older people about what those housing options might be, and also, because I think this is an important area of our provision generally, practical ways to improve access and provision for older people from black and ethnic minority groups as well. That was all part of work going on across government which was previously work which I was doing with Sally Keeble and will obviously take up with her successor. There is one other issue on this. When the officials came before you, and certainly in the past and in the Next Steps document, we also talked about how we promote new sorts of joint ventures, new sorts of approaches to providing housing, and I think here there is a very good and important role for the co-operative sector for different forms of ownership to help us promote housing solutions. I think it was last week or the week before Hazel Blears had a very good seminar in the Department looking precisely at that type of social enterprise, how to promote that type of work, including organisations who were currently working on housing solutions for older people which linked into health and social care needs as well. So this is an area where we need to and we could make a lot of progress. There has been a good start. Given your question, Chairman, I would not like there to be a suggestion this is not an area where there is no cross-working across government, it is, but it is probably an area where we need to boost the profile and make sure that people are making the most of the opportunities which exist.

  Chairman: I am reassured by your answer. It is now ten years since I was on the front bench developing this area of policy with my housing colleague, Mr Raynsford, and it seems to be very slow coming forward. I welcome the fact that you have clearly personally recognised the importance of this area of policy. My concern is that we have so much emphasis on the private sector, but the private sector does not recognise the importance of this area and certainly the local authorities I speak to also seem to be very slow in coming forward—and it is probably wrong to generalise because we came across a local authority yesterday which really was in the front line on this—but I can see no reason why we could not do much more in that direction, and I welcome the point you have made.

Dr Naysmith

  646. Before we move off this area of additional finance for social services, there have been a couple of reports from your Department, the Emergency Care Report 2001-02 and Delivering the National Health Service Plan. In the first of them it was indicated by the end of March 2002 the target reduction of a thousand delayed transfers of care since September 2001 had been achieved, and that is a 20 per cent reduction and that is very commendable. Then the report concluded that winter pressures had been dealt with by improved planning, expanded capacity and by major new investment including the specific funding to tackle delayed discharges. So that was the reason that the Department achieved its reduction. If that is the case, that recent progress has been achieved in reducing delayed discharges, and it has been due to targeting the resources, central intervention and close monitoring of progress. Why is it that in the document, Delivering the NHS Plan, which was similarly not long ago published, it states in paragraph 8.7 that this approach would not be seen as sustainable in the longer term. Why is it that what you think is a good solution is being rejected in a very similar document? The reason I am raising it now is because you have touched on it in what you said.
  (Jacqui Smith) Yes, I did. We had seen some success in reducing the delayed discharges but, for all the arguments which we talked about earlier around the whole system, it was important we made further progress in reducing delayed discharges and we really got a grip of the problem and tackled it. That was the reason why we identified the £300 million extra investment and that was a very important part of helping to tackle delayed discharges. I have said, Alan has said, this is a good example of where investment makes a difference in the Health Service and delivers. My argument was not that we did not need that investment, we do, and that is part of the reason for continued investment in social services, my argument is, is it sustainable in the long-term to tackle it in the way in which we did.

  647. What is the answer to that?
  (Jacqui Smith) I do not believe it is because, for example, quite a lot of hon. Members, my hon. Friends, came to me and said, "Look., we've got an extremely successful local health and social care system, very good partnership working, real focus down on delayed discharge, we've been really successful in tackling the problem, and therefore we're not getting as much money as we would do if we were a hot-spot area." I do not make any apologies for focussing that money as we did. Every authority got some, but we did focus it on 55 hot-spot areas, and for those hot-spot areas we had an extremely top-down approach to monitoring and to ensuring that that target was met. We expected a specific target. We expected specific outcomes in terms of the way in which that money was spent. We had, I think it was, weekly meetings—it seemed like that often—between Social Services Inspectorate and officials in the Department and representatives from those local health and social care communities. That focus and that money made a difference.

  648. But has that partly made a difference because that is where the problems were, because if you are suggesting that other areas did not have the problems, that they were not the hot spots, why should they get the money?
  (Jacqui Smith) There were problems across the country, and every local authority, of course, got part of that £300 million. Even in those areas we were less strict about the way in which we monitored it and inspected it. In the long-term, though, what we have said in Delivering the NHS Plan—the next steps on investment and reform is that we now need—and this is really the whole approach that we are taking to health and social care—to put into the system the sort of incentives that deliver what we need to see in the system, and we need to devolve responsibility down to a local level, alongside the extra investment that is going into health and social services. I do not think in the long term, therefore, that that type of very close, top-down management monitoring is a way in which we are going to achieve success, which is why, of course, we are now thinking about what we need to do both to devolve that responsibility and to put in place incentives through the system that will enable us to tackle delayed discharges. If what you are saying to me is, is investment important, yes, it is. The question is, how do you direct it and how do you set up the system to deliver what you want to come up the other end.

  649. The next question is what further targets for reducing delayed discharges are to be introduced following the success in meeting the target since September? What sort of targets are you going to have?
  (Jacqui Smith) We clearly have a national target to reduce delayed discharges by March 2004, so we have national targets and we will maintain a focus on delayed discharge, but we will ensure that it is delivered in a different way to the way in which we incentivise that activity at a local level.

  650. So do you think you will be able to get delayed discharge down completely, or is it at a level at which it is acceptable? What is it?
  (Jacqui Smith) There is what I think we describe as a frictional level of delayed discharge.

Chairman

  651. Did you say "frictional" or "fictional"? I heard you use the term before and I was not quite sure I heard it correctly.
  (Jacqui Smith) "Frictional". Nothing about this Government is fictional!

Mr Burns

  652. Pull the other one!
  (Jacqui Smith) It is a frictional level of delayed discharge—that is, the argument is that there will always be a certain level, but tackling delayed discharge is—

Dr Naysmith

  653. What is that level?
  (Ms Edwards) It is just about the natural process, in the sense that there will always be people going through the system, people who have been admitted to hospital inappropriately, and even in an ideal world, given appropriate admission, appropriate care, an approach that recognises that they are going to need a nursing home or some other sort of care, there will always be patients waiting one or two days for that sort of care. So even in the ideal world, with the numbers of patients we treat—6 million patients going through the acute sector every year—there will always be one or two of them, a tiny proportion of them, waiting for the next process, and one of the aims is really to try to get an appropriate approach.

  654. There must be some places where that level has been reached already. Have you any idea what that might be?
  (Ms Edwards) We are nationally saying somewhere around 2500, which is about 2 per cent.

Mr Burns

  655. I briefly wanted to ask the Minister a question, because I was fascinated by her saying that a lot of her hon. Friends were coming to her to say that they had excellent schemes in their localities where health and social services were working extremely closely together in this important field, which is a) a very positive step, and b) one to be encouraged for the future. What I was wondering was, did she think, or did any of her hon. Friends who came to her to discuss this mention, that possibly these very good relationships and working together might be strained or damage might be caused to them as a result of the proposal, in effect, to penalise social services departments for delayed discharges?
  (Jacqui Smith) Actually, they—

  656.—welcomed the proposal, did they?
  (Jacqui Smith) Actually, they did not.

  657. I thought not.
  (Jacqui Smith) They certainly, as do we, believe that tackling delayed discharge is more effectively done where you have good partnership, but I am sure that, like any of us who have constituency surgeries, at the centre of their concern is what we need to do in order to ensure that older people are getting the right care at the right time and in the right place. None of my hon. Friends, as far as I am aware, came forward with this suggestion, but I am aware that the hon. Member for Westbury—

  658. Hang on a minute, before you get on to Westbury, just for one second, I did not quite understand what you were saying. Could you repeat the first half of that sentence, before you get to Westbury?
  (Jacqui Smith) The first part of what I was saying was that my hon. Friends share my view and this Government's view that we need to take the necessary action, through both investment and reforming the system, in order to make sure that older people are getting care where they need it, when they need it.

  659. With respect, that was not what I was asking you. What I was asking you was, do you think that the proposal to place financial limits on social service departments who are involved in delayed discharges is going to enhance or impair the good working relationships that some of your hon. Friends have raised with you of health and social services working closely together in partnership to deal with the problem of delayed discharge? On the second part, before we get on to Westbury, you may not have heard it, because presumably you were not in the House of Commons when the Secretary of State the day after the Budget made his statement on carrying the NHS Plan forward, but if you were to read Hansard—as presumably you were not there—you will see that a number of your hon. Friends expressed grave misgivings about this one aspect of the Secretary of State's proposals in that document. Perhaps I could have an answer to the specific question about will those penalties or proposed penalties improve and enhance or damage the relationships that have been forged in such a positive way between health and social services?
  (Jacqui Smith) Improve.


 
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