Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 600 - 619)



  600. So there might be a bias in the system for local authorities to prefer residential care, to continue to rely heavily on residential care.
  (Mr Ransford) Absolutely and your Chairman is quite right: historically that has been the system. Right back to the Poor Law you can see a line through to institutions. We have moved away from it in mental health, we have moved away from it for younger people with learning disabilities, moving to a much more community based system of care. For older people the situation has changed greatly. Far, far more people with intensive needs are now cared for in their own homes and community than were five years ago, let alone 15 years ago. That trend is changing but that does not mean that immediately we do not need high quality responsive residential care for the right people. It is a balance. It is a mixture. Commissioning is about providing the right services in sufficient capacity for the range of needs you are dealing with.
  (Mr Leadbetter) Yes, it was a fair criticism; it is less so. What is needed is a partnership between primary care trusts, social services departments, strategic health authorities and the independent sector around local forums where all the partners feel equal. It is very interesting in this country that two of the major providers said to us when the ADSS organised a meeting that they would need us for another five or seven years, then the 1960 baby-boomers will start coming through and they will pay for themselves. I thought that was an interesting perspective.

Mr Burns

  601. In Essex how have you broken down the "them and us" atmosphere which certainly tended to exist a decade ago between your department and the residential care home area? How have you brought them together to make them feel that they are an integral part of the discussions on a more or less equal basis?
  (Mr Leadbetter) We have fielded a stronger team. Ten years ago we did not prioritise it enough, so we did not field a strong enough team and to be quite frank some of the private sector were operating in a different league than some of the players we fielded. That was a mistake. We got the politicians on board, so the politicians were willing to engage with the private sector; that was cross-party. Now the traditional "private sector is good, public sector is bad" is going we broke down that barrier. We had full and frank debates.

  602. Only some politicians of course.
  (Mr Leadbetter) Some politicians of all parties. We had full and frank debates with the private sector about their need to be responsible and not come to meetings with individual cases and make a meal of individual cases but raise those outside the meetings and try to help them lift their play to look at the strategic issues and not just difficult one-offs. We demonstrated our commitment, we engaged with the private sector and got some funds from Europe to train staff in the private sector. We put in an equivalence of staff time to match fund. We did lots of creative things but crucially it was a change of heart and mind amongst staff and politicians alike. The private sector are the major players. Unless we properly but robustly engage with them, we are not going to be able to manage this market.

  603. I certainly agree with what you said, from my own experience in the county. However, I was chairing a long-term care conference ten days ago with people from all sectors, including social services, and one of the most significant complaints, certainly from the residential care sector present there, was that they still felt that too many local authorities around the country did treat them very much as second class citizens, did dictate to them either through their bulk purchasing power or through dealing with their concerns. In your role in the ADSS what are you doing, what are the ADSS doing, to try to spread what is obviously good practice in Essex to other social service departments, to break down far more this feeling? Even if it is an outdated perception in some areas, in other areas it will not be an outdated perception and it will still be going on.
  (Mr Leadbetter) We are leading the debate. We have had one meeting and we are planning a second with the Department of Health as observers, including the Local Government Association, to engage with private, residential and nursing home care sectors to have that debate about what is a fair price, about whether there can be even closer co-operation and then through the mechanism of the ADSS raising that awareness. It is a tricky issue. I described it before as a careful dance and it is, because we work in a political environment, there are 150 different local authorities and different perceptions from directors and elected members. My sense is that there is very much a sea change and has been in the last three or four years.

Dr Taylor

  604. Dr Morgan, in your submission you refer to a survey which found out that two out of three health authorities made cash transfers in the 2000-2001 financial year to local authorities and the average transfer was something over £600,000. Can we multiply that out and get the total? Did you keep any control over how that money was spent? Did it actually have an impact on delayed discharges?
  (Dr Morgan) Yes, that money was spent willingly at local level because communities identified this as a shared problem. What this was about was how local communities solve their own problems. If there is a big issue with delayed discharges, and a whole nest of things around them, health authorities and communities made a decision this was the best way to resolve it. Certainly in the communities where this happened, some very tight agreements were raised about where the money went and how the money would go through because it was actually solving a common problem.

  605. Another example of partnerships actually working.
  (Dr Morgan) Very much so and fitting in with a view coming very strongly from members. As we submitted to the Wanless committee, you have to think of health and social care funding as a whole. It is no good having it out of balance because decisions in one sector affect the other. This is really an example of how the health services try to deal with that perceived imbalance.


  606. One of the interesting areas which this Committee picked up in the last Parliament was the way in which in certain parts of the country the Health Service was actually paying the costs, for example of day care, the social care costs, to the local authority because the individual client/patient could not afford to pay those charges. Is this a factor from your point of view? Is this still happening? Is this leading, if it is happening, to a debate about the logic of charging in such circumstances and the relationship between the two authorities, the Health Service and social care provision?
  (Dr Morgan) I am not personally aware of people paying for things where there should be a charge. It would not be the way most people would do it.

  607. We suspected it was illegal, but it was certainly happening.
  (Dr Morgan) That is why I am careful. It would probably be ultra vires to top up for individual patients. What organisations do is make large transfers for a range of services which can then be used to support people. You cannot do it around individual patients. You cannot top up a care package between health and social care. It is about how you work jointly. One of the problems when you begin to look at the spend between health and social care is that people do not look at it in the round. You have some communities where there is a big expenditure by health on old people's care, but often they are the same communities, whereas if you look at the same expenditure for children it is actually very low and social services pays more. There are so many interfaces between the two organisations that it is very difficult to take a single figure and read anything into it because you have to look at the relationships in the round. What it does demonstrate is that in the best places people, managers from health and social care, are getting together to solve their own problems and that has to be the way to solve this, it has to be at a local level with enough incentives in there to encourage people to want to solve it locally.

Dr Naysmith

  608. I want to ask Dr James something arising out of the evidence which was submitted by the NHS Alliance. You highlight the range of facilities required to allow appropriate discharges to take place, but then you argue in paragraph 25 of your submission that primary care organisations "are finding it impossible to reserve funds for these necessary schemes in the light of other cost pressures particularly linked to achieving short-term activity targets". Could you say a little bit more about that? If you really believe that to be true, what sort of evidence is there that primary care organisations are having these difficulties?
  (Dr James) It is a general comment about people's wish to modernise and reserve resources and finances to modernise services, but finding it difficult to modernise services, putting money into IT or into one workforce or into developing a workforce to take on new roles. It would mean taking money away from other services which have targets set on them and the targets are not allowed to be bridged. This money is shoring up the targets.

  609. Is the building capacity funding not meant to address these kinds of problems?
  (Dr James) Primary care trusts are increasingly frustrated that they hear of money coming in to help primary care and investment by primary care and then never really see hide or hair of the investment because it seems to be promised elsewhere before it even reaches the coffers.

  610. Is that happening in this instance?
  (Dr James) This is a general comment about modernisation and wanting to do things differently rather than a particular comment about delayed discharges. May I twist your question to make a comment that I was wanting to make? A target for our endoscopy services, for example, is that GP referrals must be seen within 13 weeks. Because there is a target attached to that, it means that any other call on those services does not take that priority. Urgent referrals by consultants to endoscopy services have a waiting time of eight to nine weeks and their routine ones are about 40 weeks. Then inpatients waiting for an endoscopy, just for endoscopy, wait for three weeks. They are in that bed for three weeks, so that is a delayed discharge but it is not counted as a delayed discharge. It is a waste but the shoring up of our services is for the targeted service, which is the 13-week wait.

  611. I know of some instances where people have been in hospital for cardiology related things and have been told "For goodness sake do not get yourself discharged or you will go the end of the queue. If you stay in for a couple of weeks, we will get you done".
  (Dr James) That is right, that sort of thing.

  612. Dr Morgan believes that is happening as far as building capacity funding is concerned.
  (Dr Morgan) There are two sets of money. There is the building capacity money, which is tightly audited and I have no doubt is being spent where it should be; no problem. The issue you have here is one of the biggest problems facing primary care organisations. It is about how you develop a whole range of new services and whilst we are on the treadmill of spending money in the acute sector it is hard to release money. What this is about is that primary care organisations want to spend more money on this area and that is the bit they find very difficult to do. The money which comes with a tight label comes with a tight label and is audited to death.

  613. Basically the building capacity funding is not enough in some situations.
  (Dr Morgan) It is not enough and if you talk to the health community, what they will tell you is that the way to change the nature of the Health Service to make it truly sustainable and be the sort of service we would all feel proud to use every day is to invest more in the community sector and less in the acute sector, making the acute sector really intensively looking after people who need high technology. The issue, once you have your money in there, is how to get it out to develop these new alternatives. You need the new alternatives before you can get rid of the beds in the acute sector. You are back on this continual cycle of how to find the space and capacity to double one to allow you to get off the petard you are hoist on.
  (Dr James) Thee is a great concern about building capacity just for capacity's sake, because we need it, without really acknowledging that delayed discharges are a social care problem. They have been through the potential for medical care improvement, they may have got there because of inappropriate medicalisation. Rather than getting into the treadmill of being medicalised, being in hospital, being institutionalised maybe, then requiring residential care, we really need to be looking at the alternative referral destinations, alternative treatments, treatments from home, keeping these people out of hospital so they are not in this situation. Rather than building capacity with the inherent dangers of warehousing and elderly patients because it is a tidy solution to a crisis, we need to be building individual care plans to keep them independent and hopefully well in the future.

  614. That is what people are supposed to get, is it not: individual care plans?
  (Dr James) Mm.

Jim Dowd

  615. Looking at intermediate care and rehabilitation, my questions initially are to Mr Leadbetter. I want to look at your survey of last spring, 12 months ago, where you welcomed the new investment in intermediate care. Who would not? Of the returns, a number specified lack of transparency in tracking compared with what we have just heard about the additional funding, but also the negative incentives which appear to exist in the way the money was being allocated, inasmuch as it rewarded poor practice rather than advocated and advanced good practice. Could you comment on that?
  (Mr Leadbetter) Much of this has been referred to previously in the response colleagues made. Paying additional money to people who are struggling with capacity, on the one hand is fine, but many directors said to us that it was not fair, they had invested extra money in this (building capacity) and they were being penalised. Others countered by saying—and I am thinking particularly of the Kent, Sussex and Southern and South East authorities—they had done everything possible and they simply needed more money to pay more to the private sector. There are two views on this, both have equal validity and it is a difficult choice. I would probably err on the side of giving more money to those authorities providing it is properly audited. I would probably part company slightly from health colleagues on the question of additional money. The phrase we use in social services is that some of that additional money which was intended to be targeted for intermediate care appeared to have sticky sides. It seemed to go in different places. There was the tranche of intermediate care money, £250 million, a couple of years ago. We did a survey amongst authorities and lots of authorities said they had not seen the evidence of how that was spent. Remember, it can be spent on pre-admission planning as well as post-admission planning.

  616. Have you seen who was spending it?
  (Mr Leadbetter) I have not seen it spent and targeted on what we thought it should have been, which was creative use of it to improve intermediate care, to stop people going into hospital, creative day care, discharge planning, hospital at home schemes. Bristol, for example, have used the £200 million to create a team where people who are not well enough to stay at home but not acutely ill enough to go into hospital, go somewhere separate. That was done with the money targeted at social services, not with the money targeted at health some years previously.

  617. The negative incentive you identified was actually not rewarding those who really made the effort, merely bringing up those who were the slowest.
  (Mr Leadbetter) Yes.

  618. So what is the message for the future? Do not bother doing anything because the Government will bail you out ultimately.
  (Mr Leadbetter) That could be a perception.

  619. It would not be the only area where that is the perception either. Looking at the winter pressures, your survey identifies the expanded home care packages as the most beneficial element of the additional funds. What does this say about where we target any additional or further expenditure in the future?
  (Mr Leadbetter) Two views on this. The LGA would argue, and Mr Ransford can represent that view, that the money should come to local government with few strings and we will spend it wisely. There is evidence of that in that the money which came, the £100 million and £200 million, was spent wisely. We did have a target of reducing people waiting by 1,000 and we achieved this. The ADSS would take a slightly different position in that not all authorities are as kind (given appropriate regulation) to social services as the majority, so targeting some of the money on specific schemes with ring-fencing or hypothecating makes sure it goes to where it is needed.

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