Examination of Witnesses (Questions 700
WEDNESDAY 19 JUNE 2002
MP, MR RICHARD
700. Even though they perhaps might need a district
nurse going in every day and you could argue that there was an
(Jacqui Smith) This is where the discharge plan helps
us to determine what the overall needs are, where that person
is going and what the responsibilities are, but it is also where
we need the sort of assessment that you can do through the single
assessment process in order to determine what that older person
701. So what would tip the balance? Would that
be a clinical decision as to whether the responsibility was mostly
NHS or mostly social care?
(Jacqui Smith) Clearly there are situations where
what we are talking about is NHS continuing care, where the responsibility
quite rightly lies with the NHS. There are situations where an
important component of care is NHS care. So the situation there
would be that if you have got that balance that we are talking
about, between you need a district nurse, but you also need a
package of care to enable you to live at home, if what we are
talking about is the point at which the charging kicks in, clearly
it would not kick in until the NHS provision was in place, because
there clearly it would not be reasonable to charge a social services
department for something which is not their responsibility.
702. To clarify that, to quote an example I
had recently, I had an old lady who was in hospital for a year
nearly longer than she needed to be, simply because the family
wanted to look after her at home, all they needed were two assistants
to come in morning and night to move her, and Hampshire County
Council could not find, in leafy Chandlers Ford, two assistants
to come in, at the rate they were prepared to pay. In that case,
where the clinicians are quite happy for that to happen, social
services want it to happen but just will not fund the travelling
expenses, that would then become an onus on the social services
department and they would pay or pick up the tab, which hopefully
would exercise minds towards upping the rate for help?
(Jacqui Smith) It is difficult for me to comment on
individual cases, but I would have thought, as you described it,
that that sounds to me like a social services responsibility.
That is a perfect example of where what we need in the system
is an incentive that prevents the sort of buck-passing that prevents
an older person from coming out of hospital.
703. So in those cases, will the departments
be charged for an individual person who is not transferred as
quickly as possible, or will they be charged on a bed-days-lost
(Jacqui Smith) One of the other things we were talking
about earlier was that I was suggesting that where we see a successful
approach to tackling delayed discharge is where we see people
focussing on individuals, what their needs are, when they are
ready to be discharged, who has got responsibility for it, and
making sure that they get where they need to be and that the services
are in place. On that basis I think that we should be developing
a scheme that focuses on individuals and the number of days, if
you like, that individuals are delayed because of the inability
to put in place alternatives.
704. So you focus on individuals, but linked
to the number of days a particular individual was, shall we say,
(Jacqui Smith) Yes.
Sandra Gidley: I just wanted to clarify that.
Ultimately you are charging social services departments. Most
people would regard those departments as being underfunded. Do
you really believe that ultimately that will improve the outcomes
for people experiencing delayed discharge? You are robbing Peter
to pay Paul.
Chairman: I think we have covered this already,
though you were not here, and I appreciate that. I think that
if you look at the record you will see that the Minister has answered
that in some detail. It may not have been to everybody's satisfaction,
but it was answered.
Sandra Gidley: I asked because I was told that
it had not been satisfactorily answered.
705. Neither was mine, Sandra, nor was my question
(Jacqui Smith) And I thought we were getting on so
706. Jim Dowd put some questions about the impact
on social services that were not able to provide. When Wanless
made his recommendation that the merits of this should be examined,
I think one of the criticisms was that the Government appears
to have jumped straight in and adopted it. In examining the merits,
did you examine the comparative levels of spending in Scandinavia
on social services compared with here? I can see a way in which
it might work if there is a sufficiency of resources, but in a
climate where certainly in many of the London boroughs the social
service budget is under such pressure, I think there may be a
difference between a well-resourced system and an underfunded
(Jacqui Smith) On the point about how quickly we have
responded to Wanless, I think when Alan gave evidence he talked
about the extent to which he had the ability to consider this
before we got to the Delivering the NHS Plan stage. I think
we are partly coming back to an issue that we have addressed previously,
and that is, is this a policy that can operate if we do not increase
funding to social services departments in order to allow them
to put in place the alternatives? No, I do not think it is, which
is why we are introducing it alongside the considerable extra
investment that is going into social services departments. This
is quite an important way, moving on from a situation where we
have put extra money into social services departments. We have
been very directive, to be honest with you, about how it is spent
and what it is spent on, but where we have seen the beginnings
of development of the sort of capacity that will be necessary
to make a success of tackling delayed discharge, we are now moving
on to a logical next step. So part of what I am arguing is that
I do not see this as being the first step. What I saw as being
the first step was the £300 million investment that has gone
into local authorities, that has started the development of alternative
provision and has prompted quite a lot of focus on the issue of
delayed discharge, better joint working, better processes. What
is now logical is that we move to a system where alongside the
considerable extra investment that is going in, we design a system
which at a local level puts in place the sort of incentives that
will allow us to continue looking at the problem in the way that
we want to do.
707. Have you looked at the comparative levels
of spending in Scandinavia? Are there significant differences?
(Jacqui Smith) I have not looked at comparative levels.
What I am concerned about and the Department is concerned about,
as we made our bids to the Spending Review, is what we thought
was necessary to provide those alternatives to enable social services
to take on the responsibility for people coming out of hospital
into alternative community provision, and that is what we focussed
on. Earlier on I gave you some examples of the sort of provision
that we think the extra spending could provide in the community.
708. Minister, you will realise that I have
been studying carefully the document Delivering the NHS Plan.
In there, in paragraph 8.12, it is stated that the relationship
between health and social services will be kept under review,
and that if more radical change is needed you will introduce it.
Does that suggest some kind of implicit threat that some more
radical restructuring might take place if some unspecified event
takes place or does not take place? It is a little reminiscent
of the bit in the Bill which fell before the last election, which
talked about compulsory merging. I was on the committee stage
of that Bill and it talked about the compulsory merging of social
services and health services, coming from either side, if things
did not work properly. Is that an implicit threat that you will
(Jacqui Smith) No, I do not think it is about threat,
what I think it is about saying is that all of us have to put
at the centre of our thinking not the sensitivities of those people
who are in particular agencies at the moment, whether or not that
is local authorities, or primary care trusts or acute trusts.
What we have to put at the centre of our reckoning is what is
the most appropriate way to deliver better services, in this case
for older people, for making sure that they get out of hospital
when they need to, for making sure that they have got the services
in the community, the alternative in terms of long-term care that
they get. We will do what is necessary to make sure that those
older people get the services that they need. As I suggested earlier,
where partnership delivers that, that is good. I am less concerned
about people wanting to maintain their set of boundaries than
I am about what we need to do to get the services for older people
that are necessary. Now that is not a threat, that is just a statement.
709. It was seen as a threat in the original
Bill before the election, certainly by local authorities. I just
wondered why that was removed. Obviously it was removed because
the Bill had to be got through before the election took place,
but why that particular bit of the Bill?
(Jacqui Smith) Partly, of course, you are right, new
legislation depends on its process through Parliament and the
way in which we listen to what is being said to us. If you are
saying to me, does the Government now not think that much better
joint working, use of health flexibilities, care trusts where
appropriate, are a good thing, the answer is that we do and we
will give further consideration to what incentives we need to
put in place to develop that further. That is not about threat,
that is about saying all of us can work together to make sure
that there are better arrangements in place where they are going
to deliver for older people.
710. A question was asked about the joint budget,
and would not one budget be better than trying to form a partnership?
The question arises again, is it not best to get rid of this and
have one budget and one service?
(Jacqui Smith) In many areas I think it is very good
to have a budget or a care price for older people,
and that is why in many areas people are moving towards it and
why, as I suggested earlier, people are already bargaining on
the £300 million spending being spent to improve healthcare
flexibilities. The way in which we get there depends, I think,
on our judgement and the local authorities' and healthcare communities'
judgement of what is going to deliver the best services for people.
What we do not have truck with are people who would be in a situation
where what was at the top of those people's minds is "maintaining
our barriers simply because we've always had those barriers".
I am not saying that because I think that necessarily exists.
I think that, as we have already seen, there is a lot of good
movement towards developing those partnerships. I think that everything
that we are planning for the future will promote that even further,
and it will promote it because it is by having partnerships, or
by having pooled budgets where that is appropriate, that you actually
get better services and better response.
711. Is not the entire policy to move towards
one common system? When I talk to people such as home carers and
district nurses, their work is coming closer and closer to care.
In my own area we have professional carers who are now doing very
clearly nursing tasks in relation to stoma care and a whole range
of areas that would not previously have been a social care provision.
It is only ten years ago that the other party had as a compulsory
option the integration of the health and social care system. Have
we gradually come back in that direction which was seen as so
radical by many people? When you talk about buck-passing, you
would need to buck-pass if you were in the same organisation and
had the same budget. You would need to fine one element of the
department if you were actually under the same authority. It just
seems to me so obvious. Have I missed something here? I cannot
understand why on earth we do not take the most logical step possible,
which is what Doug has just said.
(Jacqui Smith) This is obviously the second area of
policy today which has emanated from your work ten years ago.
712. I did not say "new policy", but
you guessed it.
(Jacqui Smith) I am not sure there is much more I
can add to what I said about my view and the Government's view
about partnership. Clearly we think there are significant benefits
in pooled budgets and in care trusts, otherwise we would not have
legislated to enable them to happen. How we get to a situation
where the partnership that is right in those particular circumstances
develops I think does differ from area to area, and it is important
that people go forward and make that partnership in the most effective
way, because it is quite complex, is it not? For example, if you
look at the four care trusts that currently exist, one of them
commissions and provides services for older people, the other
three are around mental health services. So there are a whole
range of considerations that I know are actively happening at
a local level, supported by Richard's team and supported by the
thrust of government policy, about how we get to much better joint
working. I would not necessarily go all the way down the track
that you are suggesting as the objective, but we do have a clear
objective that we have legislated for and that we have put in
place the policy levers for to develop much better partnership
Chairman: If I can look at my own area and elsewhere
where I deal with officials who are doing a broadly similar job,
in two distinct chunks, much of their time is taken up in trying
to determine who does what. If those barriers were removed, you
would not need two officials in a similar capacity, you would
only need one. However, that is something the Committee can look
at. Now we want to talk about care home capacity.
713. Before we do, it is rather interesting
listening to what you are saying to the last three of my colleagues
who questioned you, where you rightly placed a great deal of stress
on working together, partnership, to push forward the policy,
which is absolutely correct, but working together involves social
service departments, local health trusts and the Department of
Health. Why do you think it is, in the spirit of working together,
that on the proposal which has aroused a great deal of controversy
in its own field for these financial penalties on delayed discharges,
you did not consult before announcing what you were going to do?
(Jacqui Smith) I think, Simon, that you understand,
do you not, about budgets and the sort of consultation that goes
on as you come up to budgets. I think there is a difference between
stating, as we did, what our clear objective is, which was completely
in line with everything else that we have said about the NHS,
which is that we need to develop a system where there are incentives
in place alongside the investment to tackle, in this case, the
problem of delayed discharges. There is nothing that is out of
kilter with what we have said across the whole of the system.
So in terms of saying that that was what we want to legislate
to put in place, I think we are very clearly in line with other
things that we have said. The point now is that I think that we
already have worked with, and we certainly will continue to work
with, a whole range of stakeholders to talk about the details
of how we deliver that incentive system, but I do think it is
right that Government, in setting down the way in which the system
should work, should state clearly how they think it should work
and then should work with stakeholders in order to make sure it
delivers what I think is probably a shared objective.
714. On care home capacity, there is, of course,
one problem. You were talking about the extra money, which no
one can dispute, but if you talk to the other side, particularly
social services departments, they will say that what they actually
need, to stand still, is another £1 billion, and that with
the problems of the closing of capacity in the care home sector,
where often it does not reflect where there is the least need
for care homes, more often than not because it is not spread thinly
and evenly over the country, you are having a problem in certain
parts of the countrynot all by any meanswhere there
just are not the beds for residential care, which is causing problems,
where people are either having to be placed far away from where
they have lived and been brought up or are having to be put into
inappropriate or less appropriate care. So I am not convinced
that your thesis has reached the stage yet. You said about extra
money, which is why you can now move ahead with the correct policy,
but I think that might be a bit premature. If you talk about the
capacity, why do you think there are such variations in the number
of places claimed to have been lost in the last five years? If
you look at it, if you see the independent analysis, what it will
say is about 50,000 beds. If you listen to the Prime Minister
it is either 26,000 beds or 19,000 beds, depending on which day
of the week he is answering the question. The Secretary of State
is somewhere inbetween those two figures. Why are there all these
different figures being bandied around, which one do you think
is the correct one and why do you think it is the correct one?
(Jacqui Smith) The Department's analysis suggestsand
these are our figures for Englandthat between March 2000-2001
there was a reduction in residential care places of 4,700, there
was a reduction in general nursing and mental nursing home places
of 6,500. That is 11,200, 2 per cent of capacity, but that is
for the last year. The 50,000 figure which you are very keen on
715. We would like independent figures rather
than government onesthey are usually more accurate, we
(Jacqui Smith) So do I. So if you use the Laing &
Buisson figures, which are the basis for that 50,000 figure, of
course, what Laing & Buisson say in that market survey 2001
is that between 1996-1997 and 2000and these are figures,
incidentally, which relate to the whole of the United Kingdom
and only to the independent sectoras I understand it, there
has been a 51,147 places reduction because of deregistration,
a 1,280 reduction because of other net changes (that could be
things like changing into different forms of care, for example.
So you like to use that figure. Where I would dispute with you
is that what Laing & Buisson also show in their analysis is
that there have been new registration places of 33,522, so the
net figure therefore is 18,905, which is where we get the 19,000
716. So it is gross versus net?
(Jacqui Smith) Yes.
717. Basically, that is the difficulty?
(Jacqui Smith) Yes.
718. Which is what I think we calculated at
the start of our inquiry.
(Jacqui Smith) It is gross versus net, and occasionally
it is political mischief versus the truth as well.
719. On that point, can I question this, because
we been given breakdowns by various people, but my understanding
was that the 50,000 figure did take into account the pluses and
minuses, but also included the long-stay NHS beds. Would you care
to comment on that?
(Jacqui Smith) That is not my understanding of the
care figure. There is another figure around.
Sandra Gidley: The figures I have are: number
of residential home places in 1996 307,500, estimated in 2001
297,600; number of nursing home places in 1996 220,200, estimated
in 2001 196,800; number of long-stay beds in 1996 47,900, estimated
in 2001 31,500. I have done a bit of maths, and if you just take
the residential and the nursing home bedsthat is, 33,300and
add in the NHS beds, then you come to a figure of over 50,000.
Chairman: Are we talking there about England?
Sandra Gidley: I think this is UK.