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Health Committee - Minutes of EvidenceHC 1583-II
Taken before the Health Committee
on Tuesday 25 October 2011
Mr Stephen Dorrell (Chair)
Grahame M Morris
Dr Daniel Poulter
Examination of Witnesses
Witnesses: Julie Jones CBE, Chief Executive, Social Care Institute for Excellence, Martin Knapp, Director, Personal Social Services Research Unit, London School of Economics, Professor Gillian Manthorpe, Director, Social Care Workforce Research Unit, King’s College, London, and Richard Humphries, Senior Fellow, the King’s Fund, gave evidence.
Q1 Chair: Good morning. Thank you for coming. This is our first public evidence session in an inquiry into the future shape of social care, so you come at a good time to influence the Committee’s thinking at an early stage. Perhaps I could begin by asking you briefly to introduce yourselves and tell us where you are coming from.
Professor Manthorpe: Good morning, everyone. I am Gill Manthorpe from the Social Care Workforce Research Unit at King’s College, London, which is a Department of Health policy research unit. I am also associate director of the NIHR School for Social Care Research.
Julie Jones: I am Julie Jones, the Chief Executive of SCIE, the Social Care Institute for Excellence. Our job is around knowledge transfer, trying to find out what works well and getting it out to practice as fast as we can. We are a practice organisation, not a policy organisation.
Martin Knapp: Good morning. I am Martin Knapp. I am Director of the Personal Social Services Research Unit at the LSE and I am also a director of the School for Social Care Research.
Richard Humphries: Good morning. I am Richard Humphries, Senior Fellow in social care at the King’s Fund.
Q2 Chair: Thank you very much. Could I open the questioning by focusing on Dilnot and where you feel we are, following the Dilnot report in the summer? One of the recommendations of Dilnot was that if the Government took certain steps the effect would be to unlock a new source of revenue for social care through private funding-private insurance. How confident is each of you that, if the Dilnot recommendations were adopted, there would be a new market which would grow up and unlock a further source of funds for this sector? That seems to me pretty fundamental as a starting point to this discussion. Who would like to start?
Richard Humphries: They are all looking at me, Chair, so I will kick off. We have been sceptical for some time about the exact contribution private insurance could bring to this, and for all sorts of reasons. No country I am aware of relies, to any significant extent, on private insurers to generate income for social care. Even if the capped model proposed by Dilnot were implemented, many people with relatively modest assets, or even those who are quite well off, would probably opt to take the risk rather than an insurance policy. It is generally a thumbs down, I think.
I wonder if we are barking up the wrong tree a little in terms of how financial products can help with this. We all know-there has been an elephant in the room about this debate, although not in this particular room-about the enormous housing wealth of people over 60, but by no means all older people, which has to be brought into the equation of how we fund the increased quantity and quality of social care we will need in the future. It is about the sort of products which will enable people to draw down on that wealth to help with their care and support costs rather than insurance per se. Housingbased models and equity release probably have more mileage here than straightforward insurance products. That is a long answer to a short question. I am not encouraged, particularly.
Martin Knapp: I would add that there is a terrible myopia about social care needs. People do not recognise the risk that they, themselves, will have social care or longterm needs. Although people may begin to see there could be a £35,000 cost for care, hotel costs would need to be brought into the equation as well. The amount that individuals will have to bear is quite considerable. We need to find ways to encourage and educate people about the real risk they face of needing to use longterm care services in the future.
I also agree with Richard about the equity release model. To me, it feels like the more attractive and viable approach. It has not been any more successful in getting off the ground than longterm care insurance until recently, but I understand there are some experiments under way, and perhaps we can learn from those.
Julie Jones: Dilnot represents an opportunity to move this into its next phase, even if it is not yet the entire answer, because we do not have public confidence, at the moment, in the social care system. We certainly do not have a good understanding of what social care offers, how it is funded and what implications there are for families, for all the reasons that Martin has mentioned. The Dilnot report gives us the best analysis we have had, probably, for a very long time. There is a risk of giving it the thumbs down and saying, "No. It has to go into the long grass," but that would be a very poor outcome.
The baby boomer generation-of which I am proudly one-has an enormous responsibility now. The generation behind us and the generation ahead of us are not sitting on the sort of assets that my generation represents and if we do not have that conversation about making sure we take more responsibility for our own care, it is a lost opportunity. Dilnot gives us the platform for those conversations.
Q3 Chair: In what sense does Dilnot provide a platform for a discussion about housing wealth?
Julie Jones: Specifically, what he does is open up an opportunity to talk about the options. He has come down to a particular set of proposals, but he also has some other proposals in there, such as raising the current entry point, which might be a welcome opening to a conversation about, "Yes, families and individuals will take more responsibility, but not if the system stays as it is." So there are one or two proposals.
Q4 Chair: But if the discussion is just on the cutoff points, then the discussion between the generations, from the baby boomer to the people coming on behind, is, "Raise the thresholds and you pay more than we thought we were going to have to."
Julie Jones: Yes. That is inevitable. These two gentlemen may well be right about the insurance model not giving us all the answers, but what Dilnot represents as a whole-and he did ask us to look at it in the round-is an opportunity not to stay stuck where we are. Stuck where we are is not a safe place for social care.
Q5 Barbara Keeley: I want to ask about two aspects. First, clearly, we know that people do not think about social care and, if they do, they want to put off the idea of funding it. I have seen surveys suggesting people would rather spend their money on today and the near future than investing or saving it for social care. We need to consider how we get the debate going on this, and there were some discussions about that at the Dilnot report launch.
Second, I wonder if there is a sense that we may not get another opportunity to have a debate like this because people only have so much tolerance and interest in these things. On what aspects should the Dilnot report have gone further? Are we settling for too little if we settle for this, even though it is a big step forward? Are there one or two things left out of this that we should have looked at?
Professor Manthorpe: You raised the very interesting point that people do not think about these issues. We know, for example, how few people think about making a will until comparatively late in life and probably have to be kicked into doing something about it. That brings up our growing interest in the vulnerability of people who are on the borders of making decisions about social care and the way in which contracts, advertising and indeed financial scamming become a much greater risk for people making those decisions. My answer to you is that Dilnot opened up that conversation, that if we seize things immediately we will perhaps have to face some of those safeguarding issues about when people make very, very big decisions about their family’s wealth as well as their own individual wealth. We want to do that.
The other point that may be taking issues a little further is this. We talk, all the time, about getting money in the system. But where does the money go? In particular, are we going to continue to found a social care system on the lowestpaid people in the community, on people working for a minimum wage-sometimes even less and sometimes only a tiny bit more-and in only thinking about getting money in? The Dilnot report gives us another opportunity to broaden it out and ask, "What do we really want for ourselves and our families in terms of the people who will care for us in late old age or when we have profound disabilities? Do we want to rely on people with minimum wage levels, who perhaps have very limited English, or understanding?" It is not the purpose of Dilnot to set in place such a system or to reinforce that system currently.
Q6 Dr Poulter: I want to pick up on the equity release point for a moment. You make a good point that the baby boomer generation has a lot of wealth and carries with it a lot of equity in property and other assets. However, there is an issue that, if we are putting in place any financial system to support adult social care, particularly dealing with the challenges of the elderly care spectrum, it needs to be a sustainable system that lasts the test of time. That is true of the current baby boomer generation but there are, as you alluded to, problems with the generation that is coming through that may not necessarily share those same assets and equities. Is that focus on equity release perhaps only, potentially, shorttermism?
Richard Humphries: Possibly. However, if we look at the pattern of housing wealth over the next 20 or 30 years, it is not going to change that much, so we have a good window of opportunity. The key point is that this may need different solutions for different generations. The baby boomers will not have that housing wealth for ever, although they will decumulate some of it to people who inherit from them. We have to flex different approaches according to different circumstances. At the moment, we have the relatively unique opportunity of this massive housing wealth bubble sitting there. We cannot pile all the costs of care on to general taxation because the implication is that workingage people will be paying in taxes for the care of many people who will be considerably wealthier than they are. It is the point about intergenerational fairness in all of this.
Could I make a general point about Dilnot in response to Barbara Keeley’s point?
Q7 Dr Poulter: I have one more followup on that, first. You contradicted yourself there. You were talking, at the end, about intergenerational fairness, but we have to have in place a sustainable system that is going to last. We do not want to be talking about this question again, if we do come up with a solution, in 15 or 20 years’ time. Often, the great tragedy in healthcare or social care policy is that we are always reinventing the wheel when we would like, in many respects, to have a sustainable system that is going to work. The concern you have alluded to is that the equity release system may only last for one generation, or a substantive period of time, but should we not be looking at a more sustainable solution for longer than that?
Richard Humphries: Yes. We have to look at a variety of funding methods, but the value of Dilnot is that he has set out a framework in which the costs can be shared between the individual and the state-whether those individual contributions come from insurance, housing wealth, pensions or whatever. That is the value of Dilnot and that is, potentially, the cornerstone of a new settlement. I do not hear anybody fundamentally disagreeing with that. There is no great intellectual battle of the giants going on out there about how we do this. The almost unanimous support given to Dilnot’s recommendations suggests we are on the cusp of not a total solution, as colleagues have alluded to, but at least a way forward, a way through it. The sources of that money will vary. For the next couple of generations, it has to be housing wealth and then it will need to change. Maybe we will need to be a little more generous in terms of general taxation for the next 20 or 40 years. Again, that will depend on the economy and all sorts of other things. But Dilnot gives us the basic framework which, potentially, can endure throughout all of that.
Dr Poulter: That is very useful. Thank you.
Q8 Barbara Keeley: You were going to come back to me.
Richard Humphries: That was the point. What Dilnot does is set out the framework as to how the costs, at the moment, are shared in a way that is terribly confused and confusing. It is totally iniquitous that people who have more than £23,250, but not that much more, get clobbered under the current system.
Q9 Barbara Keeley: To clarify, you do not think there is any way in which Dilnot should have gone further because, if this is to be a sustainable solution for 20 to 40 years, we are not going to be able to revisit it too many times.
Richard Humphries: I think he could have gone a lot further. There is a history of reports on this subject going back years and years to the Royal Commission 14 years ago. Many of them set out a great vision for the social care system of our dreams. Many of those reports never stood any chance of a realistic prospect of getting implemented. The judgment as to producing a report which does stand a realistic prospect of getting implemented is as much about what you leave out as what you put in. Dilnot could have said more, perhaps, about the underfunding of the current system. But he was not asked to determine the quantum of resources needed. He was asked to come up with a mechanism by which we pay for it and by which the costs are shared. That is the great achievement of the report.
Chair: We do not want to spend all morning on Dilnot, but Rosie and Andrew want to come in. Then, perhaps, we can move on to other subjects.
Q10 Rosie Cooper: You have led the Committee to the point I was going to discuss with you. The majority of people welcome Dilnot. It is an opportunity for this big discussion and one we may not see again for a substantial number of years. Yet, Dilnot is predicated on measuring that unmet need and knowing what unmet need is out there. Do you know how that is or can be measured? What do you think the Treasury’s reaction to that is? Will that not then take you right back to the position you described of a report that may never get implemented, because, at the core of it, is the huge amount of money needed to cover that unmet need?
Richard Humphries: How long is a piece of string? Lots of reports have researched unmet need. I wonder to what extent we would need to measure this in the degree of forensic detail that is being talked about. We know, for example, that 82% of local authorities will only respond to needs that are substantial or critical. We know that, over the last five years, the number of older people using publiclyfunded social care services has gone down. It has gone down even though the older population has increased and the over 85s has gone up by nearly a quarter. We do not need to do any great research to tell us that there is a heck of a lot of unmet need out there.
One of the fundamental questions for our society, which Dilnot was not asked to address, is: What kind of social care system do we want? What level of need do we think the state should respond to? What do we think carers should do? There is a whole debate about that which we probably have not had. Maybe the current engagement process the Department of Health has initiated will give us some answers to that. Colleagues may wish to contribute.
Martin Knapp: I would only add that we know unmet need or inadequately met need has all sorts of implications for other sectors, and particularly for the health sector. There is research evidence demonstrating the health sector benefits of investment in social care. This is not just an unmet need which somehow disappears into the background. This is an unmet need or set of needs which will have all sorts of implications, including, potentially, quite high expenditure implications for other sectors, or much higher implications for social care a few years down the track. The Treasury or others worrying about this would have to think about those implications as well.
The other thing I would say about Dilnot is that the information and advice recommendations there are particularly important. The more people with needs are going to be responsible for purchasing, accessing and resourcing their own services, the more they are going to need that information and advice which is very badly lacking at the moment. That is another element which would help to address some of those problems.
Professor Manthorpe: The term "unmet need" is one that we are trying not to use very much because somebody is probably meeting it in some places. When we say "unmet need" often we are meaning not by one particular part of the public purse. As Martin has mentioned, it may be the NHS, the criminal justice system or a whole range of other systems and individuals who are probably selfmanaging to a much greater extent than is encapsulated by the term "unmet need". We all know that needs are generally met in some way. Probably the issue concerns the quality of the way in which those needs are met. We only need to think of the way in which needs were being met in the "Panorama" programme about a certain hospital: it was not the fact that they were not being met but the quality of care that people were receiving, or allegedly receiving.
The other point that Martin makes as to information and advice and how sophisticated that will need to be in the new Dilnot world is important. Generally, information and advice go together like a horse and carriage, but in order to give financial advice, in terms of people’s equity, pensions and capital, you would normally have to be registered as a proper financial adviser. It is not the job-and it is not within the capacity-of a very small voluntary organisation to do that. We will probably need to segment out information and advice much more than we do at the moment.
Julie Jones: Yes probably, I have two things to say about unmet need. First of all, local authorities have and will have more of a responsibility to get a better grip on what the needs are in their local areas. They can do that through the Health and Wellbeing Boards, and many of them are doing that already. Not only are they doing that, but they are changing the way they deliver services. They are changing some of the models of care. The best ones are ahead of that, but there is an enormous variation around the country. If you talk to some local authorities, they are much more on top of the sort of range of needs that are being met by different parts of the system and how that might work differently in the future, not least in the way they work with health, which I know we are coming on to later.
Q11 Andrew George: I want to be absolutely clear. You seem to have a collective view about Dilnot, the issue of the baby boomers and the equity release. In other words, there is a lot of money tied up in property. What you are all saying-and you have not said it clearly enough for my liking-or implying is that Dilnot is being too lenient on property owners and not securing sufficient release of equity into the care system. Generally, is what you are saying that the £35,000 entry requirement, as it were, should be set lower or higher? How should it be set?
May I also ask if any of you have looked at the contrast between where we are and where Scotland is-we have two different funding systems-and whether we can learn anything from what is considered to be, obviously, a more generous system which is at least attempting to implement the Royal Commission’s recommendations.
Chair: Who would like to answer on Scotland?
Martin Knapp: I know that Dilnot looked a lot at the alternative models of care in Scotland and other countries. My reading of the report would be that learning the good and bad lessons from those other systems and translating them into the English context was done very well. I am not an expert on the differences between England and Scotland in their systems. The Scottish system may well have attractions, but it might not have attractions starting from where we are today. Part of the difficulty is the perceived affordability of it.
In terms of the generosity of Dilnot-again, I was not party to any discussions-I would have thought he was treading a very careful path, coming up with something which would attract pretty widespread support. Raising that limit from the £35,000 to some higher amount could well have alienated groups that are currently supporting the broader provision. I would trust in a fairly good political judgment.
Q12 Andrew George: You think he has it about right.
Martin Knapp: I think, in the circumstances, he has it right enough to open up the debate in a very constructive way.
Professor Manthorpe: One particularly interesting point is the pride that people in Scotland have in their social care system. It may be, if you unpick it all, that the finances do not add up, but people in Scotland that I have spoken to find it a source of pride that they have made a change to their social care system. How good it would be for England if, instead of all the time spent talking about problems, people would say, "We have really made some progress." That is also a lesson to learn from Scotland.
Q13 Grahame M Morris: This is carrying on from those answers given to my colleague and the five principles on which the Dilnot Commission is based: fairness, sustainability, affordability, value for money and the systems being as simple and consistent as possible. On the point about fairness, what do you think of the suggestion received by the Committee that, in some regards, the Dilnot proposals are regressive in that those with the highest incomes-the most wealthy in terms of their contribution-would benefit considerably more than those on low and middle incomes?
Richard Humphries: If the starting point is a system in which the poorest get their care free, then, by definition, they will not benefit from any further changes in those terms. It is also the case that the richest will probably do their own thing anyway. We are unlikely to see a queue of wealthy people outside the offices of Kensington and Chelsea Social Services Department waiting for their assessment. It is the people in between-and I hesitate to use the term "squeezed" and "middle" in the same sentence-who have more than £23,000 but not much more than that, who are liable for the full costs under the current system, that really get clobbered. They are potentially the group that benefit the most from Dilnot.
As to whether the social care system should be regressive, if we are concerned to ensure that richer older people did not benefit disproportionately from public spending, social care is probably the wrong place to start. As Dilnot pointed out, we spend about £140 billion on services for older people across the NHS, pensions and social care and, of that £140 billion, £8 billion is for older people’s social care. If we are concerned with regressive impacts, the place to start would be pensions and benefits rather than social care. Messing about with the social care funding system is probably not a good way of achieving social justice in terms of-
Q14 Grahame M Morris: You could do it fairly simply by amending the caps that are proposed, could you not?
Richard Humphries: Yes, you could. But if you set the cap too low, it becomes unsustainable. If you set it too high, that middle group still gets clobbered. It is about balance.
Q15 Valerie Vaz: Can we hear the others on that?
Chair: Would others like to chip in?
Martin Knapp: No, I am not sure I have anything else to add.
Q16 David Tredinnick: I want to ask you about the Fair Access to Care Services system. According to the journal Community Care, some commentators have said that the Fair Access to Care Services assessment system-the four different levels-is falling apart and is dead. Do you subscribe to this view?
Julie Jones: It is probably coming to the end of its useful time. When it was established it was in order to do just that, make access to care fairer, and it was a national system. Over time, the interpretation and practice on the ground around those eligibility criteria has become quite varied. There is quite a lot of evidence about how varied that is across the country now. There was an attempt to try and revisit it a couple of years ago to achieve what you are indicating, a fair way of accessing care. When you end up with a system where only the top two levels are in play in most local authorities, it has probably come to the end of its natural life. The intentions associated with it were honourable but, again, it is about the interpretation and practice on the ground as to what that eligibility looks like in Hackney and in Norfolk, and it is probably going to look a bit different. There are some problems about interpretation and behaviour.
Q17 David Tredinnick: You see this as rather emotive language and it is simply that this has reached its natural conclusion.
Julie Jones: I read Community Care most weeks and it often has emotive language, yes.
Q18 David Tredinnick: Are the Fair Access to Care Services criteria applied consistently across different local authorities?
Julie Jones: No. They are not, with the best will in the world. There has been quite a lot of research and evidence about those different interpretations. For example, circumstances that might well end up defined as "substantial need" in one authority may tip into "critical need" or "moderate" in another. It is not an exact science.
Q19 David Tredinnick: Presumably, you would like to see greater uniformity and access across social care.
Julie Jones: Yes. People would welcome that. The balance that people are searching for is between some national entitlement that feels fair and some local interpretation that takes account of where you live and what the rest of your life is like. That is a tricky balance to hold.
Q20 Valerie Vaz: The Law Commission have suggested that maybe there should be a national standardised view.
Julie Jones: Yes.
Q21 Valerie Vaz: How do you get local authorities to follow that? Is that one of the ways of dealing with it, having centrally set criteria that local authorities follow?
Julie Jones: The Law Commission is making those proposals, and the overwhelming response is that that has been quite welcome. To try and come to a point where we better understand what those national eligibility criteria are and that they are explicable to the public so that the public feels they are understandable and fair would be a step forward from the situation we have now. But it will not solve the problem of different interpretation on the ground. That is solved through local management, good practice examples and an understanding of how it looks across the piece so you know where you fit in that story. It cannot be entirely rule bound, in other words.
Q22 Valerie Vaz: Would anybody else like to add to that?
Martin Knapp: The only thing I would add is that, in a sense, you have three levels here. You have some eligibility criteria at the top level, you have what happens on the ground-managers exhibit huge variation in their interpretation of eligibility and there is a lot of "upcoding" so people get more services than might otherwise happen-and, in the middle, you often have a resource allocation system of some kind. That is how local authorities translate their eligibility into resources and there is, again, huge variation across the country. To some degree, that is appropriate in a personalised, locally driven, locally prioritised care system, but that translates, again, into lots of variability. Maybe it is an inexplicable level of variability for people who are facing a need for care services.
Q23 Valerie Vaz: I am looking to the future. How would you tie in local authorities to do that? Clearly, they all have their own priorities, and it is set against their budgets, is it not?
Julie Jones: Yes. At the moment, that is right. They are able to take resources into account. The question that will have to be answered-it is a future question.
Q24 Valerie Vaz: Do you know, as experts, how you would tie that in?
Julie Jones: We have recently commissioned some research to try and get to the bottom of that, "Are there some models that have either been done in other countries or that we think are based on the best practice in this country?" so that, when we come to the point of going from "What are we trying to do?" to "How do we try to do it?", we are closer to being clear about that.
Q25 Chair: But are we just searching for the philosopher’s stone?
Julie Jones: No. I know what-Yes, probably, but you never stop looking, do you? There are some good examples of good practice and how to do that, and one of the aspirations must be to close the gap between the best and the rest, even if it is a philosopher’s stone.
Professor Manthorpe: An example of an area in which there has been lots of different policies and procedures is adult safeguarding, or protection of vulnerable adults. Recently, all the London authorities got together and agreed that they would have panLondon policies and procedures so that if there were allegations in one area they would be dealt with consistently. That was not done by forcing them to do it but because they saw that was a very sensible approach which could roll out to their neighbours in the home counties. There is goodwill among practitioners and among managers who do not want to have to compete, time and time again, with GPs coming and saying, "Mrs So and So gets this at that end of the street and Mrs So and So does not over there." Translation of eligibility criteria and explaining the system to other professionals is part of social workers’ and care managers’ jobs. There is a sense of goodwill about making it clearer to people and for them not to feel bemused by what happens in one part of town and what happens in another.
Q26 Valerie Vaz: They obviously come to us as well. How do you fix that in with portability? Let us say you have people moving from one local authority to another with different criteria. I am not searching for the philosopher’s stone but for a way where someone who is not particularly bright-who is not a lawyer, who is not middle class, necessarily-will be able to access services, and they do not do it now. This is your chance to tell us.
Julie Jones: The offer at the moment will be that the assessment is portable. The default position, when you move, is that you accept the assessment of the level of need there. What you cannot guarantee is that precisely the same services will be available if you move from one part of the country to another. The guarantee will be with the level of assessed need, if you like. That will be quite a difficult conversation to be had with the public where the expectations might well be, "I can have exactly the same service no matter where I live." That is clearly not going to be possible because the range of local services varies so much.
One of the things that SCIE is helping with at the moment is something called "Think Local, Act Personal." A lot of organisations have come together, led through local government and the Local Government Group, to make a commitment to getting to the bottom of all of that. They are calling it sectorled improvement. In other words, "We will take responsibility for ensuring that those sorts of questions can be better answered in the future than they have been in the past." They have signed up to that commitment. It is a public commitment because that concern is shared.
Q27 Barbara Keeley: Could I raise the issue of the national minimum standards? Clearly, we are talking about a lot of conditions which verge into health conditions, and longterm conditions as well. Is one of the possibilities to have a national specification for, say, a person with Alzheimer’s or any other dementia, which has a certain journey, such as, "People who are exhibiting these sorts of symptoms should be getting this sort of care"? Is that a way along this path? Obviously, you can have all these pathways laid down in a health sense, but why can we not do it in a social care sense so that you do not have the shock of moving somewhere and then suddenly finding that all the services you have become used to elsewhere are not available to you?
Professor Manthorpe: To take the Alzheimer’s or dementia example, it probably is not the symptoms as much as how those needs are interpreted. Moving that on, supposing we had a relative with dementia in one part of the country and we wanted them to live with us, the assessment is the portability because that would be about the needs in the context where it is. If they are living on their own in another part of the country, their needs may be for reduced social isolation and access to emergency health if needed. If, perhaps, they move in with a relative, those needs will be very different. Dementia is a good example of how difficult it is to prescribe social care because it is all very contextspecific and can change rapidly from one day to another. It is around the assessment that we would want that portability, and also to give people greater access, such as those who are really troubled if their relatives are in other parts of the country needing help, that this is the place where they can go.
We cannot go back to the situation of the 1960s in which we had so many beds per thousand elderly and so many meals on wheels per thousand elderly. That never worked anyway. People were always lagging behind and we are probably still paying the price for that in terms of huge inequalities, where there are care homes in one part of the country and none in some parts of the country. It is, as Julie has said, the idea that an assessment will be professionally done, not a guesstimate, and will be thought about in the short, medium and long term. One of the interesting parts about social care is that we do not know how long people are going to be in the social care system. It could be a very small period of time or it could be decades.
Barbara Keeley: My local authority, for instance, to their credit, still offers care at moderate levels. If a person moved from my local authority to one where it was "critical" there would be a big gap in what services they had available to them. Early on in that dementia journey, in an authority where it was "substantial" or "critical", they are not going to get anything, are they? That is the same condition and it strikes me that this is the area which seems very unfair to families and carers.
Q28 Chair: Are we going down the right path, do you think, in trying to assess conditions and attach labels to them which, in some circumstances, can then be translated into money? That gets quite close to how the DWP does different forms of benefit entitlement if you are not jolly careful. That is the direction of travel in the social care arena. In the healthcare world, there is more of a focus on definition of good practice-what the service delivered is going to look like. I wonder whether we would make more progress if we defined what "good" was rather than seeking to put people into boxes where we could convert it into a cash sum, ultimately.
Julie Jones: We are making quite a lot of progress in defining what "good" looks like. There is a much better evidence base for social care than we have ever had before. One of the jobs of my organisation is to make that evidence accessible, not only to the front-line staff, who are our prime audience, but also to the public if they want to access information about what a good quality offer looks like, for example, around dementia care. There is, as I say, a much better evidence base now. It is not an evidence base that is always entirely research based. It is often based on user experience and knowledge of front-line staff. We are trying to pull all that information together so that people know what we should expect "good" to look like. I am more confident about that than I have ever been. Certainly, when I was a director we had far worse evidence to use. The dementia strategy and the commitments that have been made to implement that strategy nationally give us a very good way to go forward.
The other thing that is in the Health and Social Care Bill is a commitment to begin to work differently with NICE to develop quality standards that run across health and social care rather than just in health. Again, that is another good opportunity, starting in that place rather than the place you have described before.
Q29 Rosie Cooper: You have talked about defining what "good" is and I would like to pose you a question about accessibility to "good". For example, how many weeks would it take for a social worker to get to a family to begin that assessment? I know, with one local authority, for a nonurgent-that is, noncritical-visit from an occupational therapist, it is 86 weeks. That is fact. I could go further. There will be others which are better and others which are worse. I know, again, a personal circumstance where a member of a family was showing signs of illness and it turned out to be rapidonset dementia, which was later sorted. Within a week it imploded. It took at least eight or 10 weeks to get a social worker there and it only happened because I threw an absolute fit.
Julie Jones: That is not good.
Q30 Rosie Cooper: It is absolutely outrageous, never mind "not good". You can define what "good" looks like and you can say, "We are getting better"-and I am sure we are-but if families and people cannot get access to it at the point at which they need it, and for a nonurgent visit for an occupational therapist in this country to be 86 weeks, it is darned outrageous. How does that fit in to all these ideas of where we are going if we cannot deliver what we have today? As to giving information and making sure that people have the information, never mind the quality financial advice-leave that aside because that is so specialist-in the first place people might go to the citizens advice bureaux and all these advocacy organisations that are suffering because of lack of money. How do you join the comments I have made up at all in this vision of "We know what good looks like," because that does not look like "good" to me?
Richard Humphries: This relates back to my earlier comment about how access to adult social care has become worse for older people in the last five years. That is the root of it, but there is a lot of local variation as well. Here we have perhaps a policy tension between localism, on the one hand, that says local authorities must set their own priorities in response to local needs-and it may be, for all I know, in that case that local authority said, "We are going to prioritise older people who are waiting in hospital and other people will have to wait," so there is that as well-and wanting to give people a national entitlement, on the other. We used to have a national target for assessment times, did we not?
Professor Manthorpe: Yes.
Richard Humphries: That is not how we do things now, but the information is collected about how long people have to wait for assessment. It would be interesting to see how your local authority compares with others.
Rosie Cooper: What I am trying to reflect is a view that the people out there who are listening to us debate today will be saying, "Pie in the sky. It is all very nice, thank you very much, but what happens here is not like that at all." That is the fear we have to start to address-people’s actual experience and that which we are hoping to get to. The difference between where we are and "good" is so many light years away. I do not want people to abandon all hope in it because they do not see the gaps getting smaller.
Chair: David wants to come in.
Q31 David Tredinnick: Building on what we have been discussing, as a Committee we have been briefed-and this is, frankly, alarming-that over 80% of local authorities are offering access to care services only to people with substantial or higher needs. Do you think that is right?
This is an old building and those strange sounds we are hearing might be the mice in the Members’ Dining Room.
I will go back. Do you think that that is likely to be the case? That is what we have been told, that over 80% of local authorities are only offering services to those who are better off?
Chair: Those with substantial needs.
Q32 David Tredinnick: I am sorry, but I got distracted by the noise. We have been told that over 80% of local authorities are offering access to care services only to persons with substantial or higher needs. Do you think that is likely to be correct?
Julie Jones: Yes.
Professor Manthorpe: It may be an underestimate, I would think. The lady there said her local authority was working with "moderate" but I am finding it hard to count, more than on the fingers of one hand, the number of other authorities who work with "moderate".
Barbara Keeley: It is 15 or 18.
Professor Manthorpe: Of course, there are many interpretations of "moderate". Today’s "moderate" may have been yesterday’s "critical". It is not that it is written in the philosopher’s stone.
Q33 Chair: It works both ways, does it not? If the only cases that get any care are "substantial", then individuals who would previously only have been called "moderate" tend to be classified as "substantial". Is that right or wrong?
Professor Manthorpe: No. Social workers make some very hard decisions with people who they know, very clearly, will be arriving at the hospital gates or somewhere in the system. Such is their inability to meet their needs currently-and many of them will have now to go to a panel to wait for approval of some sort for funding for a support plan-that delays and rationing within the system are very common. That is not what people went into social work or case management for. They certainly did not go in, as Rosie Cooper talked about, to tell people that there would be a delay of 80 weeks, or not to get round to see somebody in crisis.
Q34 David Tredinnick: Who is filling the unmet need for social services? Is there anybody else?
Professor Manthorpe: People are paying for their own care and support. People’s families are paying for their own care and support: people’s families are taking time off work, doing shift work, perhaps bringing in relatives or perhaps going overseas and seeking people to move into their own homes. There are a variety of ways. The unmet need that we talked about before is being met in a sort of way. People are also turning up at the hospital gate and staying in hospital because there are no other resources for them. Also, perhaps, people are moving too quickly to residential care. We have not talked about residential care in the way that-
Chair: We will, if we move on.
Professor Manthorpe: Disappointment means you might end up there sooner than perhaps you wanted to.
Q35 Andrew George: I want to go back over the issue of the concept of "good" care and how substantial those assessments are, and particularly, if the Institute takes a view on this, whether that view-and it is rather challenging-is too superficial, especially in the context of residential care. If we are only looking at the outputs of the service and not at how threadbare the inputs are, we may get an impression of the facade of how "good" the service is but not take into account the fact that the staff ratios have significantly changed to the detriment, the acuity particularly has gone up, as we have defined in terms of the definition of where support services come in-so acuity has increased-and, as others have mentioned already, you are paying staff where you are paring those resources, frankly, to the bone. How sustainable are services? They may be good at the moment, but is there not a proper assessment of the inputs of the service other than the rather superficial assessment of how good that service happens to be in spite of all the challenges that it has?
Julie Jones: I think I said we know a lot more about what "good" looks like, not that it is good everywhere. We have a lot of good examples of that right across the country and in all different parts of the social care system, including residential care. We also know that good quality, judged in terms of the outcomes for the individual, is not always dependent on money. It is a necessary but not sufficient part of the determination of "What does good look like?" If you ask service users and their families what they care most about, the sorts of answers you would get are kindness, compassion and consistency, so low turnover of staff, those things that are about building relationships with the person who is there to provide the care. Of course, that is associated with money, but there is not a direct causal link with how much money you have and how good you are. There is a lot of research evidence about that. We know that, right through the system and across the country, there are good examples of what "good" is, and we celebrate that when we can. There is not enough of it and the gap is still much too wide. What I was saying is there is no excuse for not knowing what "good" looks like, because there is a lot of evidence about what it looks like now. There are often reasons why people do not feel they can aspire to that in their current circumstances. I did not mean to be superficial and, if I was, I apologise.
Q36 Andrew George: Do you not acknowledge that there is bound to be an interrelationship between stresses in the service with regard to patient ratios, pay and other stresses and the good outcomes?
Julie Jones: Yes. But you do, then, have to ask yourself why, in very similar circumstances, with different levels of resources and different situations and similar needs being met, one organisation does it very well and another service does it far less well. There are differences, even when you take account of all those things that you have described. We know that, with the same level of input, you could get better outcomes depending on all sorts of other things that are associated with what "good" looks like in social care delivery. It is not as straightforward as you suggested-that the one over there getting loads of dosh is fine and the one down here that is not is awful. We know that because we ask service users and their families about what it is they most value. What I am trying to say is that money matters a lot but it is not the only thing you should be thinking about in terms of "What does good quality social care look like?"
Q37 David Tredinnick: What kind of risk do you think individuals face following the tightening of the Fair Access to Care Services system criteria, please? If the criteria had been tightened up-generally speaking, it is harder for certain groups-can you quantify that in any way or is it generally much more difficult all round? You have individuals who are going to be affected by the change in the tightening of the criteria. Do you have any evidence to show that a particular group or range of individuals has been disadvantaged more than others and is there anything you want to tell us on that one, please?
Professor Manthorpe: We would all recognise-and you, in your constituencies, will recognise-that a wide variety of people who are in moderate need will appear and give rise to cause for concern, but there will be many people, and particularly older people, who say, "I am not bad enough." So it will be a hidden population. I am sure we have all met people who say, "I am not that bad" and you think, "My goodness, I think you are." It will be a hidden writ. Whether or not that will be around deprivation or it will apply more in rural areas than urban areas or it will apply for people with conditions that perhaps have some stigma around them and they really do not want to make a public fuss on their or their relative’s behalf is up for grabs. But I do not think we have evidence to say that it will be women or this particular group as opposed to that. It will be locally determined and depend upon the strength of people’s user groups and lobbies.
Q38 David Tredinnick: Thank you very much. This is my last question. To what extent would greater efficiencies and/or renovation in social care counteract access restrictions?
Richard Humphries: If we look at what we know about efficiency gains in adult social care, the sector has generally done very well. Adult social care has probably generated more efficiency savings in the last three to four years than many other parts of the public sector, including central Government, may I say. If we look at the position for this year, we know that local authorities are taking £1 billion out of their adult social care budgets, but they aim to make-I think it is-£788 million1 in efficiency gains. That is the aim. That is a very ambitious and, possibly, idealistic target given that all the lowhanging fruit will have gone by now. Personally, I would be sceptical of how much more can be squeezed out of the existing pot.
There are two areas that need to be explored, however. One is the substantial variation from one local authority to another. We have already heard an example of that, and why it is you are four times more likely to be admitted into residential care in one local authority than you are in another. The other potential prize is around the integration of health and social care, the closer collaboration and some of the gains that will come from that. It is those areas, rather than the pursuit of efficiency as such, where I suspect we have probably exhausted the obvious wins.
Julie Jones: I have two things to add to that. When the Department of Health published a report on the use of resources across local government-and Richard referred to it-which drew attention to that very wide variation, there were two areas where there seemed to be some opportunity for improved efficiency and a more effective offer as well. The first was in the amount of money that is spent on assessments and repeat assessments, with too much money going into the front end of the system-the assessment part. Local authorities are to reduce their spending on assessment by making them more efficient, perhaps by doing them jointly with health, only doing them once and possibly asking people to selfassess as a way into the system. There are some efficiency gains to be had from that.
The other is in the developing service around reablement. In the past, people would have come into the social care system and probably never moved out of it again. Once you are in, you stay in. There was no managing of turnover in the system at all. What the reablement agenda has been able to do is offer people the opportunity to recover as well as they possibly can, as quickly as they can, in order to sustain an independent life. What reablement offers is an opportunity not to get locked in the system with the offer that was made on the day you came in. That, again, is an efficiency gain, but it is also effective. People prefer to be helped to recover and recover their more independent life, too. Those two developments have given us some efficiency gains already, but we are not there yet. There is a lot of variation around the country in how well that is happening.
Q39 Rosie Cooper: I have a couple of questions, but a very quick one for Julie, if I may. CQC, when they were with us, said they did not go to people’s homes to ask them questions about the quality of the service that they received. You mentioned that people tell you about that. Do you have any difficulty in engaging with service users or residents in their homes about the quality of service they get?
Julie Jones: We do not have responsibility to do that directly with the residents. We are quite a small organisation and do not have the capacity to do that. We have to do that through employers-whether that is local authorities or the very large market-and use the material they gather about themselves, or independentlycommissioned work. For example, King’s College may do the work and we might well commission, for example, some of that work. We would draw on material from wherever it is. All local authorities will have good local information about what works well and what does not. If the voice of the service users and their families is not writ large in all that, it is not good enough. You are right to ask, "How do you capture that information?" When designing what we hope is helpful information for the workforce, we would always include service users and their families in the design of the questions to ask as well as helping us with the interpretation of the findings.
Q40 Rosie Cooper: Thank you. That is a big hole at the core of where we will go, I am sure, in the future, but thank you for that.
Very quickly, people are worried that personalisation might be used as a costsaving vehicle, especially in the economic downturn. Do you believe there is any evidence that is happening, and do you think that personal budgets meet carers’ needs more cost effectively? I would go on to ask: does the local authority have a future role in commissioning in a personalised social care system? What is the future in that area?
Julie Jones: The conversation about personalisation always gets stuck on personal budgets. A personalised social care service is much more than the sum of personal budgets, but personal budgets are one of the very important levers. It started with direct payments way back when-a very slow start-and pretty well focused on our people with physical disabilities and then with learning disabilities and their families. Direct payments, now personal budgets, are with 30% of the people who are dependent on public funding and have an assessment from a local authority. We are beginning to get the hang of where the personal budget sits as part of the whole personalisation story. Many people are saying that they do not want a direct payment. That is still growing in numbers, but much more slowly than the number of people with personal budgets. There has been a report published by the Association of Directors of Adult Social Service in the last week or so on where they think they are in delivering the whole personalisation story, which has, I have to say, great support from around the country in terms of, "When it works well, it is what people prefer, but it is not for everybody and it is not all the time." Personal budgets are not designed to save money-that is not what they are for-but what people who have a good personal budget and are using it well tell us is that they spend their money better when they are able to choose and control what makes a difference to their lives than the previous system allowed them to do. It is "popular" and all the research from around Europe says it is popular too.
Q41 Valerie Vaz: Can you describe those sorts of people?
Julie Jones: It started with a big focus on people with physical and learning disabilities. The start with people with mental health problems was slower, where there was a concern about capacity, and also with older people. We published quite a lot of material about, "What are the barriers?" "What is getting in the way of allowing people, in those circumstances, to make good use of this too?" Now we are up to the 30% and the aspiration is to get as close to 100% as possible by 2013. It is inevitable, because of who is in the system, that far more older people will be offered this option. They do not always want it.
Q42 Valerie Vaz: I wanted you to describe people who are happy with the system. What kind of people are they?
Julie Jones: They are often people who are well supported and do not feel stranded with it as an offer. If you are given either a direct payment or a personal budget without any information, advice and support to know how to use it well, then, clearly, that is not acceptable. It is not good practice.
Q43 Rosie Cooper: Do you think that there should be a health care personal budget as well as a social care personal budget and should they be integrated?
Julie Jones: There are some pilots round the country testing this out and there are some early findings about that. I do not know whether Richard or Martin know more about the early findings.
Martin Knapp: The early findings are similar to the early findings with individual budgets for social care. There are various operational challenges in getting things in place. It is changing people’s attitudes to holding those budgets and it is changing the attitudes of the staff they work with to work with them. But it seems to me a very logical development for people with longterm health conditions to be given a much greater say in how the health money is spent on them in a way that has been successfully demonstrated as a potential advantage in the social care system.
The other thing I would quickly throw in is that Gill and I were involved in the evaluation of the individual budgets pilots and there were lots of potentially good outcomes from that as well as some challenges, but, to me, the fact that personal budgets proved to be cost reducing would not be a problem at all. You would not want to set out to design a system in that way. If this was a way of achieving efficiency gains within social care in a system which is, we like to think, outcomes-led, it would not be a bad result-if it meant the money was spread more effectively in other ways-but it would be wrong to set out that that was the primary goal, for sure.
Q44 Barbara Keeley: There are some services, though, that I have heard are being discontinued in my own area that cannot be provided by personal budgets. If you take the services I heard about, there was a good service to carers and people with dementia-it was support for the people with dementia and a dropin for their carers at the same time-being discontinued because of the implementation of personal budgets and a kind of active individual case management being done by a voluntary organisation for older people being dropped. You cannot use your personal budget to buy a dropin to support your carer. There are certain services which might exist because they are allocated across the piece. Everybody effectively chips in a part of it. By giving the money to the family-the one person with that-that service cannot be provided. I know it is a difficulty now, between my local authority and the local organisations that were running services, that services are being dropped. It seems to me that that is not a good outcome. That is not a good way forward. If everybody moved on to a personal budget, how could they buy those things?
Richard Humphries: One of the judgments each local authority has to make is how much of its total resource it puts into universal services-what we call, in the jargon, "the universal offer". That may include things like dropin. It would certainly include information, advice, support and brokerage to help people and how much it puts directly into the pot for direct personal budgets so that people have more to spend. There is an important balance.
Q45 Barbara Keeley: But then we are back to the cuts, are we not? There is not the luxury of hoards of money, is there?
Richard Humphries: No, there is not. But, as Julie Jones has said, we have this-I think it is-£2 billion that local authorities spend currently on assessment and care management. Is that the right amount? Are we spending too much on that to say to a heck of a lot of people, "Sorry, you are not entitled to anything?" Or should we spend less and put more into information and advice? Or should we put it all into personal budgets? These are, essentially, local choices.
Professor Manthorpe: The carers’ dropin centres and the services you describe may not only be the responsibility of local authorities. Clearly, they could be places where there would be colocation with NHS staff, or perhaps rooms for DWP staff to be engaged. As you say, it is impossible for personal budgets to build a carer’s resource brick by brick-that will not work-
Q46 Barbara Keeley: No, it is not a building. It is a service.
Professor Manthorpe: -or to pay for it in that way. It is about saying it is part of the community in the same way as accessibility and information and so on, but it does not necessarily have to come out of personal budgets, and indeed not necessarily out of local authorities on their own.
Q47 Barbara Keeley: I am saying, in my experience as a local MP, that these things are slightly falling apart because of the move to personal budgets. It is an observation. It is not a theoretical thought. What is happening in my locality is that services are being lost because of moves to personal budgets. It seems to me that, possibly because of cuts, if those things should be in the universal offer, then obviously they are not.
Q48 Grahame M Morris: Does the move towards personal budgets work against integration?
Professor Manthorpe: It may shift the level of who is doing the integrating. If you are receiving a personal budget, you may well want to buy some aids and equipment to make your life or your relative’s life easier. You are the integrating force, perhaps, as the consumer. You may find that there is nothing you can purchase, so it is a different take of integration in that you, as your own care manager, or your relative’s care manager, are integrating a number of financial streams.
Q49 Grahame M Morris: Strategically, if health and social care are working together and local authorities and the NHS are designing services together, with integrated pathways, would personal care budgets undermine that, or would they complement that?
Julie Jones: They should not undermine it, should they, if you start where Gill has, with the individual person? The other job of the local authority is to try and shape a local market so that there are things to buy with your personal budgets or your direct payment. It is a very difficult transition that is happening at the moment. To be doing it at a time when resources are so stretched is also very challenging. I do not want to underestimate how difficult it is to try and shift a complete way of delivering services with all of the culture, behaviour and workforce changes that have to go with that at the same time-it being in the circumstances you describe, where local decisions are looking pretty harsh.
Q50 Barbara Keeley: It has been said that this is a move that is going to be very slow and long term. As a general comment for Ms Manthorpe and Martin Knapp, could you tell us if you think that has slowed down? If it was always going to be slow and long term, is it now, because of cuts, slower and more long term?
Professor Manthorpe: I am a 17year person myself. I think most things take 17 years. In this particular instance, the combination of the cuts and the transformation will have accelerated the closure of many things you were referencing, such as both carers’ buildings but also day centres. The work that we have done points to the day centre as being perhaps that buildingbased service which will decline to an extent we have never really seen before, and we will not really know the ripple waves of that. Maybe it will not be 17 years. There will be some very rapid changes within local authorities. I can think of some where there are three main day centres for people with dementia and there will be one very shortly. That will be a huge change to the landscape, not only affecting social care but health colleagues who rely on day centres as the outpatient bit of their hospital and clinical work. They will not be there any more.
Chair: I am conscious that we are running out of time. Dan wants to pick up Grahame’s question about integration and the effects.
Q51 Dr Poulter: I have a couple of quick questions on integration of services. This is going to be key, I think, to the way forward. Currently, what evidence is there that integrated commissioning is taking place between primary care, secondary care and adult social care? How effective is that?
Richard Humphries: There is not much.
Q52 Dr Poulter: Not much, exactly. That is what I am driving at.
Richard Humphries: There are some good local examples but, I have to say, examples that are being a little bit undermined by the current changes.
Q53 Dr Poulter: The national picture is not much, but there are some good-
Andrew George: Undermined by the current changes.
Q54 Dr Poulter: The national picture is that there is not much integration but there are some good local examples.
Richard Humphries: I think your question was about integrated commissioning.
Q55 Dr Poulter: Yes, indeed.
Richard Humphries: There are lots of smallscale examples of integrated services. There are some examples of where PCTs and local authorities have come together to jointly commission, and there are a few examples of where they have come together to have a single integrated commissioning unit.
Q56 Dr Poulter: But it is a bit patchy at best.
Richard Humphries: It is extremely patchy, as is the overall performance of the health and social care and working together.
Q57 Dr Poulter: Would it be fair to say that there are not necessarily the financial incentives or drivers in the system at the moment to encourage integration of care between adult social care and the NHS? For example, we made the point earlier that 82% of local authorities are offering access to care services only to people with substantial or very severe needs. But if we are talking about people who have more moderate needs-those who may trip up and fall over at home because of those moderate needs-and they are not getting access to the services they need, that has a very substantial impact both financially and in human terms on the NHS through hip fractures and those sorts of things. Is this a key problem?
Richard Humphries: Yes, in short, because if you look at the financial wiring diagram of social care in local government and you look at that same diagram for the NHS, it is totally different. The incentives are not there. One positive development recently has been the decision in the last spending review to allocate £1 billion of the NHS budget for social care. That has really incentivised people in the NHS to take an interest in what social care money does for them. It should be much more than the £1 billion. We should be looking at the whole £120 billion or whatever is the current combined spend of social care and health. It is those practical incentives that will drive some of this and encourage people locally to look at what is happening to the money.
Q58 Dr Poulter: The problem at the moment is that you have separate budgets. Do you think having a confluent budget that follows the person or patient would be more effective?
Richard Humphries: Absolutely. The outcome you want is to get the resources aligned to the needs of the individual, whether that is done through pooled budgets, community budgets or placeshaped budgets-as it used to be called-or whether it is done through shared decision-making. The resource does not necessarily need to be integrated. The key thing is that health and social care partners are agreeing about where the money goes. It is about following the money, to put it bluntly.
Q59 Chair: If commissioners are supposed to be driving change through a system at an unprecedented rate, it must follow, must it not, that single integrated budgets are the most powerful weapon that could be put in their hands to achieve it?
Richard Humphries: That would be a logical progression, particularly if-
Chair: It is that bad.
Richard Humphries: I have long given up commenting on logic in matters of health and social care policy, Chairman. If clinical commissioning groups and local authorities can work together in a partnership, there are all sorts of possibilities about bringing those resources closer together that perhaps were not as apparent in the days of PCTs.
Q60 Barbara Keeley: Could you say how the Health and Social Care Bill will impact on that? It has been slow, it is very patchy and it is only integrated in certain places. How will the churn we have currently-
Richard Humphries: In the short term, there is a risk that it will undermine some of those existing good examples of local integration because of the merger of PCTs into PCT clusters. A lot of those positive arrangements in places like Herefordshire, Wigan, Torbay and Blackburn have been around PCT local authority relationships, and that will change and presumably will have to be renegotiated. There is also a danger of a lot of the existing relationships, the chemistry, people that have been in key posts locally for a long time, leaving. That always disrupts partnerships, and we know that one of the success factors is about evolution of trust over a period of time and local leadership.
On a positive note, Health and Wellbeing Boards potentially have the opportunity to bring together all the key players in the local health and care economy in a way that has not necessarily happened before. The arrival of GPclinician leaders represents new kids on the block, and in some places there are some very interesting and encouraging new conversations going on between GPs and social care leaders. In some places it has rejuvenated tired relationships. It has brought in a new set of players. It has always been very difficult, certainly in my professional experience in the past, getting GPs engaged with joint working. The tide may be turning. There are grounds for optimism but there are also concerns about the risk because of the shortterm impact of the changes.
Q61 Chair: Does anybody else want to comment on that? No.
One question we have not covered, which I would like a brief comment on before we conclude this session, is the question of whether you support the extension of Monitor’s role as a regulator into the providers of social care, partly against the background of the discussion we have had of integrating the service as experienced by the service user.
Martin Knapp: There has long been a need for some form of oversight of the social care markets. Social care markets have been far more complex than healthcare markets forever, but we have not had that. Social care markets are still pretty competitive, but there have been some famous difficulties recently which suggest that the local authority oversight of quality in providers has generally been okay but the oversight of economic wellbeing is sadly lacking locally and nationally. I am not an expert in economic regulation, but I would see a crying need for a better system than we have now. Whether that is Monitor or somebody else, I do not know.
Q62 Chair: Do you, in principle, warm to the idea of a single regulator looking across the health and social care arena?
Martin Knapp: There would be advantages in that. There could be disadvantages if the lens that is used is a health lens or a health market lens and does not appreciate the different situation within social care. I have not thought through what those developed risks might be, but there is a long history of people looking at social care through a health lens in other respects, and that has not been terribly helpful in some cases.
Professor Manthorpe: It will have great advantages in looking at the work, for example, of healthcare assistants and people who are called care assistants and really thinking about the ways in which these workforces, which have generally been on different planets, can be brought together and integrated to some extent.
Richard Humphries: We need to be very cautious about applying a model of economic regulation that has been developed in the NHS context to the fundamentally different nature of the social care market where you already have 40,000 independent providers. I am conscious that hard cases make bad law. Before one considers who should do the economic regulating, it is necessary to be very, very clear and think through exactly what needs to be done. Given that we have 17,500 care homes, for example, about 170175 of those each year are likely to close. You need a degree of exit and entry because we want poor quality providers to move out of the way to make way for providers that come in, do a better job and innovate. We have to be very careful to adopt a riskbased and proportionate approach. The Monitor model of a fullblown authorisation and failure regime could make matters worse.
Chair: That is interesting.
Q63 Valerie Vaz: Would you have CQC instead?
Richard Humphries: There are other options.
Chair: The thought going through my mind was that you were drawing a distinction between health and social care and saying in social care it is important that nonperforming providers are exited. I wondered what the distinction was between that and healthcare, but that is perhaps a discussion for another day. Thank you very much for your evidence.
Examination of Witnesses
Witnesses: Heléna Herklots, Services Director, Age UK, Jeremy Hughes, Chief Executive, Alzheimer’s Society and Bruce Moore, Chief Executive, Hanover Housing, gave evidence.
Q64 Chair: Thank you very much. I think all of you heard most of that last session. We will want to cover some of the same ground and some different ground. Perhaps I could ask you to begin by introducing yourselves and telling us where you come from.
Jeremy Hughes: Thank you. I am Jeremy Hughes, Chief Executive of the Alzheimer’s Society. We are responsible for supporting people with dementia through care services, policy and public affairs work and research.
Heléna Herklots: I am Heléna Herklots, the Services Director at Age UK, which is the organisation formed by the merger of Age Concern and Help the Aged.
Bruce Moore: I am Bruce Moore, Chief Executive of Hanover Housing Association, a housing association specialising in housing for older people throughout England and parts of Wales.
Q65 Chair: Thank you very much. Could we start, but possibly not spend quite as long as we did with the previous group of witnesses, on Dilnot and where you feel that process leaves us? First of all, do you agree with the conclusion of the previous board of witnesses? They were a bit sceptical as to whether the Dilnot formula would lead to a major new source of funds through insurancebased products but did think that Dilnot provided a basis on which to look for other forms of private funding and, therefore, get a discussion going that would unlock new resources for the social care sector. I think that is a fair summary of where the previous witnesses got to and I would be interested to know your reaction to it.
Heléna Herklots: Yes. We are very supportive of the Dilnot recommendations in full, partly because reform is so necessary at this point and because we feel the recommendations were practical and feasible, particularly given the current climate. The advantage of what the recommendations are saying is the clarity they provide, both for potential users of services and for providers, and, indeed, for the financial services industry in thinking about possible products. We would see it as an essential step forward. Clearly, there is more work to do on what that would look like in terms of implementation. What it shows is that mix of personal funding and state funding. You can play with the ratios there, but you do need clarity for people about planning. If you look at why maybe things like longterm care insurance has not worked to date, it is because people have a great deal of uncertainty about the system and providers have a lot of uncertainty about how to price their products and what the regulatory system would have been. That has, therefore, prevented some developments that might have been helpful. We think the Dilnot recommendations provide a strong case for reform and the starting point.
Jeremy Hughes: I would support that. Dilnot is the best thing we have on offer. Therefore, we should probably try and make a go of it. Picking up on the earlier discussion, there is a value in looking at the equity release of property, but it is a shortterm value, as was discussed in your earlier session. Of course, an insurancebased product may not yield value immediately so maybe there is a stopgap benefit of something that looks at equity release. The insurance system is more equitable, potentially, but needs to be compulsory to work. To support what Heléna said, we did some recent research that showed only 4% of the people we surveyed had any form of social care insurance and 35% of people had not considered it because they did not realise they were going to have to pay for it. There is a real gap there.
Bruce Moore: I concur. The advantages Dilnot provides are the sense that there is a promise of some point of clarity-some certainty into the system-which allows the other issues to come through. If you have certainty about where the system’s parameters are, the quality and other standards can start to come through. The sense of not having a cap on people’s liability would deter the insurance model from developing or from making other provisions about releasing that amount of equity to address those potential care requirements. The certainty and getting that right balance of personal and state support around that framework is essential.
Q66 Chair: There does seem to be a fairly broad basis of support for the Dilnot formula. Is that something you think could be legislated quickly or is it inevitable that it waits for the broader review of social care and legislation to follow? Have you done any work to look at what we could do immediately or in the short term to get the process moving?
Heléna Herklots: There are some elements of the recommendations which we can move on straightaway and do not require legislation. One key one is information and advice, for example. Whatever the reforms are, people have to know about how the system works and what they can expect. Things like that, where Government can work with the sector, with local authorities and health trusts, are really key.
Other elements of the reforms that would be pretty quick to introduce would be things like the portability recommendation as well. It is probable that there is some work to do to unpick what are the elements that can be moved forward on quickly while waiting for the necessary legislation for other elements. That sense of "Now is the time to move" and getting momentum is really important.
Q67 Chair: Taking your point about getting some momentum behind it, if there were some specifics that could be drawn out and implemented quickly, it would be interesting for the Committee to know what those are, in your opinion.
Bruce Moore: I have a slightly different view. There are so many interconnected elements to all these components that you have to have a cohesive package. Quite peripherally, advice is always going to be a requirement for whatever system we have, but that does not get to the heart of any real reform. With any of the bases of reform you need to have a package that has coherence and interrelates, and perhaps Dilnot did not necessarily show where all its boundaries and interfaces were going to work. It needs to be worked up as a package because we know that if you effect something here it has a knockon-perverse incentives or other consequences elsewhere within the system. You need to have cohesiveness to the system for it to be effective. You have residential care, the domiciliary and the other components of that. How those will interface has to be seen as a whole in that process, and the funding and where that comes in.
Jeremy Hughes: To add to the point already made, two aspects of Dilnot could be implemented quickly. First, a change in the meanstest threshold from the £23,000 it is currently at, particularly for people with dementia. With many years of potential cost of social care, they are being hit with what we have called "the dementia tax" because it is a disease that is met through social care support rather than NHS support. The other area is the national eligibility criteria that Dilnot picked up on and which was also picked up on in the Law Commission. Some immediate movement there would produce a far more equitable system that would support people better.
Q68 Andrew George: On that last point, you say that could be implemented almost straightaway. If you move from a threshold of £23,000 to £100,000, it is going to cost the taxpayer a lot of money.
Jeremy Hughes: It will cost something but it will not cost an enormous amount. Also, there are parallel changes in the way the system operates that could be improved. To take, again, a dementia example, which I know, there is a report published by The Health Foundation this month that says if people with dementia moved out of hospitals two days earlier than they currently do, when they have gone in for other purposes, it could save £700 million. That is a significant amount of saving.
Chair: That is assuming you close the hospital.
Andrew George: That is the holy grail that I think all health systems-
Jeremy Hughes: That is the overstaying of people with dementia.
Q69 Andrew George: Can I, first of all, apologise in advance that after these questions I have to depart? It is not because I know that I will be disagreeing with everything you say and walking out in protest.
In relation to the hotel charges under the Dilnot recommendations, the £7,000 to £10,000 per annum cap that should be set, do you see any potential unintended consequences, given your intricate knowledge of the way in which the system works within your own sectors? In particular, for example, within a residential setting, this might mean that certain clients end up with the rooms with no view, eating beans on toast and sleeping in nylon sheets for weeks on end. Could there be consequences? Could there be regional variations? Have you considered whether this is a good thing or a bad thing?
Bruce Moore: It is a good thing. It levels the playing field against residential care versus extra care. At the moment there is an incentive on social service authorities to commission extra care because the housing, the board and lodging costs, are met through housing benefits. They are not comparing like with like. From the local authority’s budget perspective, they much prefer extra care because the housing costs are met through housing benefit and they only have to pay the care costs, whereas, by placing somebody in a residential care home, they have to pay the whole of the cost. It is, again, those differential rates. In terms of Dilnot, I see it as having the board and lodging element identified. If somebody wishes to pay to have a higher quality meal, a better room or whatever else, then they can always top that up, as it were, but having that allowance in there is a positive move. It will make sure that we make more sensible decisions across the piece.
Heléna Herklots: One of the problems is disaggregating those costs. In principle, it is right. Whether that level is correct probably needs a little more looking at, but there needs to be transparency so the resident and the family are very clear about what they are getting for that money. It brings up a wider issue, maybe, about the quality of care in the care home sector overall and the way in which that can be improved, both through contracts and the regulatory process. There are some risks with it, but it will help to drive transparency around costs in care and what the users are paying for.
Jeremy Hughes: The difficulty is in drawing the line between what are hotel costs and what are social care costs. Where does a meal provided become a hotel cost and where does helping the person eat the meal provided become a health cost? There is that blurred boundary. The difficulty with setting a ceiling on it in the way proposed-the £7,000 to £10,000-is whether that is going to reduce quality of things that are essential rather than things that are marginal. The advantages are in getting a level playing field across residential care to domiciliary care, so there is a major plus there.
One of the things that would also need sorting out is the disparity between NHS continuing care, which includes support for all costs, compared to social care funding, which only covers, as we have talked about, the social care costs rather than the hotel costs.
Q70 Andrew George: But there is a clear line. If you are being assisted to eat the meal, that is care.
Jeremy Hughes: We have had different assessments. We have case studies of people who have been assessed in different ways and people who have been moved from one assessment to anther being told that what was previously called "social care" has now become "living costs". There is quite a disparity in the way that is being interpreted.
Q71 Andrew George: Do any of you think there might be a risk that setting a cap might set a cap on what we might, perhaps pejoratively, describe as bog standard services below that level? In other words, people will feel that they would like to top up to above this bog standard. Is there a risk that the cap may be set too low, or even too high?
Bruce Moore: The standards at the moment are very low. The whole benefit of Dilnot is that it sets a framework on which you can then have some certainty and build from. Having said that, there is a base level of what we would regard as an acceptable board and lodging standard which allows people then to say, "I want an enhanced form of that." At the moment, the standards of board and lodging, if you like-the accommodation side-are probably one of the worst in Europe in terms of the standard of residential care accommodation. Anything we can do to enhance that has to be welcomed.
Q72 Andrew George: You think that, concomitant with this, would need to be a clear definition of what standard-
Bruce Moore: What is acceptable that goes with that, yes.
Andrew George: Thank you.
Q73 Rosie Cooper: This whole area of social care funding is a nightmare. I was talking to a director of social services who said to me, "If you guys can, do something to help sort it out, only there are some days I don’t think I understand it". We are expecting individuals to engage in that difficulty.
Listening to your conversation with Andrew and talking about standards and the fact they are very low already, what most people hit on is, for example, that local authorities are reducing the amount they are paying for residential places to £420. I know with one authority it is about £423-very, very low. Costs will be higher than that so, in order to function, that care home will charge any selffunders even more to make up that gap. In the new world of transparency that you are talking about, how would that work? Which fool would offer to go and pay somebody else’s bills?
Heléna Herklots: As soon as you start looking at reform packages, these are some of the questions that come up. That kind of cross-subsidy, if you like, has been in place for many years. I am not sure I can give you an answer to what the implications of that are, but, at Age UK, we certainly get quite a lot of older people contacting us about that sort of issue. They feel it is unfair that, in a sense, they are subsidising other places in that care home.
Q74 Rosie Cooper: Local authorities are driving down the amount of money for their places and, if you have that transparency, people are not going to volunteer to go somewhere and pay other people’s bills. Therefore, is the standard of quality going to go down or do those homes which deal with local authority placements in the majority have a future?
Jeremy Hughes: Part of the transparency should, hopefully, lead to greater public awareness of what is happening and, therefore, greater pressure on the system to improve the standard of what is provided. A concern that we have is that 30% to 40% of a local authority’s budget is spent on adult social care, but most members of the public are not aware of that. They spend more time talking about the bin collection service than they do about adult social care. The transparency is a necessary step towards increasing debate about how the total system is funded. There is a risk of having, in effect, a twotier system and we are already seeing it very starkly in domiciliary care. I was talking to one domiciliary care provider who said that they refused to book sessions of less than 30 minutes for their private clients but on local authorityfunded care they are booking 15 minute visits, which, of course, for somebody with dementia is often worse than useless. You have barely got through the door and you are expected to dress, feed and look after the personal needs of somebody in 15 minutes. You cannot do it. There is a need to expose the failures of the system in order to get change.
Q75 Rosie Cooper: I hear what you are saying but I have knowledge of a person with very serious dementia, who was doubly incontinent, being dealt with on 15- minute visits, with changes and all of that, and the distress there-phhwwt, tsch, tsch, gone. Yet we allow it and we all concur. We know it is happening. How is it okay?
Jeremy Hughes: I am saying it is not okay, but the public need to become increasingly aware of it. An interesting point that came from your previous session-which I think is a really positive element within the Health and Social Care Bill-was about the potential role for NICE to look at quality standards spread across health and social care because, at the moment, we have a real disparity. We have a hidden agenda of what quality standards are expected in social care. It is far less well inspected and policed than health standards, which allows the kind of situation you are describing to exist.
Q76 Rosie Cooper: What do you think of local authorities who charge by the minute?
Jeremy Hughes: Do you mean in principle? It is hard. The charging system exists. We cannot get away from that. We have a charged social care system and we have, if like, an uncharged health system, so we have that disparity. How the local authority calculates its charging again comes back to the point about it needing to be transparent and people needing to see what they are getting for the money they pay or that is being paid for by the state. Exactly how they account it is not the issue. It is about the transparency, as you were saying, and the visibility.
Q77 Rosie Cooper: I must admit to having been horrified, when we were taking evidence from the Care Quality Commission, to find that they are inspecting hospitals and all that kind of thing but not care in your own home, the one area where you are, almost, in a systems sense, at your most vulnerable. Who inspects that? Who sees that what you need is being delivered? The Care Quality Commission relies on the paid provider to tell you that they are doing it. Every Member of Parliament will know, especially in the bad weather and various things like that, people who are supposed to have four visits but will get one, and yet they still pay for four.
Jeremy Hughes: We published a report at the beginning of this year which found that 50,000 people with dementia are likely to go into care homes earlier than they need to because of the inadequacies of the support they are getting in domiciliary care. It is costing us, every month, something like £70 million for those 50,000 people. There is an enormous problem in terms of the costs and the loss of quality of life because, as you say, that system is invisible to a large extent.
Q78 Dr Poulter: I have a quick question following up on that. The Care Quality Commission will look at standards in health care or adult social care in care homes. What is your view of the role currently played-is it adequate-by local authorities in monitoring the contracts and the quality of care in care homes? Do you think there could be an enhanced role for local authorities?
Heléna Herklots: The whole area of quality, both in care homes and domiciliary care, is key. There are huge issues around the funding of care being in crisis, but there is a deeper and hidden crisis around the quality of care. One of the things we have found incredibly powerful at Age UK is involving older people in inspection of care. We run something called the Experts by Experience programme, which is trained older people going into care homes and hospitals. We have recently started some work around them looking at the quality of domiciliary care alongside the formal inspectors. That uncovers things that otherwise would not be uncovered because people will talk to another older person about something in the way they might not talk to a socalled professional. We need to be a little more imaginative about the way in which we assess quality, who we bring into that process and, picking up the earlier point, making sure there are not any closed doors-that people are not isolated and that there is that element of inspection.
Q79 Dr Poulter: That is very useful. To take an example, a local authority would award a contract for a period of five years or 10 years, or whatever. Perhaps concerns are raised by patient groups, as you say, or relatives, about the quality of care that may be provided at certain care homes, or even in the quality of domiciliary care that is provided. Those contracts are fixed for a period of time. Have you any concerns about the mechanism, the quality of negotiation of those contracts by local authorities, or the ability those local authorities have to intervene when there are concerns raised about those contracts? There are also issues of training of staff and all those sorts of things that I am focusing on.
Heléna Herklots: There are two things. One is that it is quite difficult, if you are an older person or a family, to know where to go. If you have a concern, where do you go? Do you go to the local authority or straight to the Care Quality Commission? We can make it easier for people, first of all, to register those concerns. The second is the speed of response. What is the speed of response of looking at that issue? Is it an isolated issue or is it systemic with that particular provider? The contract development process is critical. It needs to look at things like outcomes for users and not just the mechanics of the contract. It should be regularly reviewed and should link into the feedback process on the quality of care.
Q80 Dr Poulter: Have you concerns at the moment that local authorities are doing this in as proactive and effective a way as you would like?
Heléna Herklots: I suspect my answer is similar to a lot of others, that it is patchy. There are examples of good practice, but also, particularly where local authorities are managing a lot of contracts, and maybe where they have a diversified supply market, it can be difficult in terms of having the focus.
Jeremy Hughes: Can I add a comment? An additional point is the need to ensure that the standards against which providers are being measured are not just the standards within one local authority area but the standards that are applicable beyond that local authority area. Certainly the research we have done is that people are more concerned about a general level of standard than they are about localism. Of course, many providers operate across more than one area.
Dr Poulter: Thank you.
Q81 Valerie Vaz: To move the debate on slightly, all three of you said you were here earlier listening to what was said about basically releasing equity in people’s homes. You run a particular scheme, so I wondered if you could touch on the kind of things that you are doing and maybe also focus on why you are only dealing with housing and not necessarily care.
Bruce Moore: I will deal with that last point first, which relates to the discussion we have been having. We are a housing provider. We are one of the largest providers of extra care, but we do not provide the care in any of those extra care facilities. That is partly because, "Who is monitoring the quality of the care that is going out?" Our role is being another set of eyes and ears to see the quality of the care. We have intervened with the local authority and had a care provider going into one of our extra care schemes removed because we would not be able, as professionals, to articulate where that was falling down and address that.
In terms of our general housing, a lot of people will have a carer coming in and we can monitor whether they are coming four times or just once and feed back. We are a trusted source to say, "Actually, that is not going right." Our view was that the dynamics of providing the two services are very different and, more importantly, we are a safeguard in that process. By sticking to the housing side, we can still have an interest and be an advocate for people if their care support, coming into that environment, is not as it should be.
Equity release is a fraught area. One of the best forms of equity release is moving somewhere smaller, if it is the right thing to do. Rather than taking out a loan and having all the accruing of interest and all that side of things, it is much better to move somewhere you want to live that is more suited to your needs. That is the best form of equity release that is possible out there. Most older people are home owners and most retirement housing is rented rather than home owning, so our concern is with finding a mechanism to allow that to happen, and people are not going to fall off a cliff edge, as it were, when they are making those transitions. We are trying to introduce a process whereby people can buy a property but release chunks of their equity into renting. It is like people getting on to the housing ladder can get equity by using shared ownership to get up to owning their property but almost helping that ladder going down, rather than falling off a cliff edge in that process, is what we would like to see.
Q82 Valerie Vaz: That is quite good if you have an area where perhaps the grandparents can afford somewhere. But you cannot necessarily say that they are going to be able, having built up their personal relationships, and with their family, to find a property that is near these support networks, and most of them want to stay in their own home. How do we do that? How do we release that? How do we have that conversation about it? Could you describe a bit more about what you are currently planning and what you are doing?
Bruce Moore: We are a retirement housing provider so we would be providing the right sort of retirement housing that suits people’s needs. Some of that is with an estate manager-somebody to provide that sort of focal point on site.
Q83 Valerie Vaz: Do you sell their house?
Bruce Moore: No. They will sell their own house or estate agents will sell their house for them.
Q84 Valerie Vaz: Yes, but describe how it works.
Bruce Moore: Somebody moving from their family house to our house would sell their house and buy into that. We are also offering, on our previously rented estates, the opportunity to buy a property. If, having bought that property, you want to sell or find you need some of that equity you have invested in the property to do other things, you have the potential to release some equity. The issue also is that people will sell their property and have a stack of money released, or maybe quite a small amount. They have sold their property and have maybe £70,000 or something else there but cannot afford to buy, outright, a new property with that sum of money. Having the money sitting there takes them out of eligibility for lots of other services. They can invest part of it in their property, rent the balance and allow that process to migrate into more renting as they are releasing cash for their social care needs or other requirements they have in that process. It is easing the process of transition between being an owner and a renter rather than these two worlds which will never meet. We have a lot of estates which are only rented and a lot of estates which are only home owners.
Q85 Valerie Vaz: What do your members think of that?
Heléna Herklots: We have done some research on equity release, seeing what people use it for. About a third of people are using it to clear debts and quite a lot of people are using it for house maintenance. There is an interest in it. The whole issue around giving people the right advice and looking at how any decisions may relate to the benefits to which they are entitled is very important, but clearly it is an area that people are interested in. If you can enable people to think through, financially, how they can stay in their own homes, equity release might be an element of that. It may be about helping them maintain their house or making some adaptations for the long term as well as releasing some income to help them stay there.
The issue of moving is a key one. We know that a lot of people want to stay not necessarily absolutely in their own home but within their local community where they have their friends or networks, unless they have made a decision to move nearer family. There you get into the whole issue of housing supply. Are there smaller bungalows, flats or retirement complexes for people to move to within their local community? Asking someone to uproot and move many miles, if they do not have a network there, is very difficult. It is a key area potentially, but we should not overstate what equity release can do because sometimes people have a misguided view that their house will pay for any care they need, their pension and pay off student loans for their grandchildren or whatever. There is only so far it can go.
Jeremy Hughes: To build on what Heléna said, from the point of view of dementia the situation is even starker. It brings us back to the meanstest threshold and Dilnot. Typically and obviously, one member of a couple with dementia might well go into nursing care and be there for a long period of time, costing up to £200,000. You have then also to support the other member of the family, or the couple, in some home of their own. There is a limit to how much you can release through an equity release scheme and ensure that you are providing the right level of support. It brings us back to the need for the Dilnot proposals.
Q86 David Tredinnick: May I come in on Valerie’s point? I find this very interesting with all these different options. All of them are good ideas, but I go back to Bruce Moore’s point about suggesting that one might move to Westmorland as an example, which I think is an extremely remote area. To go back to what Valerie was saying, the support networks of family are crucial as one gets older and if it is a housing issue, that is what we have to address. The idea that you can move 10 counties away and be happy at that age in a totally different environment is, for me, a bit of a stretch. I wondered if Mr Moore would like to elaborate on that, please.
Bruce Moore: Most people who move to our properties are moving within their local community. We operate across 600 locations.
Q87 David Tredinnick: Forgive me for interrupting, but it was your example that I am picking up on. You said, "For example, a move to Westmorland." I am pretty certain you said that. To move to Westmorland from the south of England or even the midlands is quite a long way to go.
Bruce Moore: I did not mean to say any location. It is moving within your local community. I am sorry if I have given the wrong impression. I cannot remember the exact words I used.
Q88 Chair: One has a vision of oneway trains to Westmorland.
Bruce Moore: It is about moving very locally, very much keeping connected with your family, friends and other support networks. People do not move very far at all in terms of retirement housing. Very occasionally, people move across the country with children but, more often than not, they stay within a mile, or a maximum of two, of where they have previously been living.
Q89 David Tredinnick: I am sorry, but I had the visual image of snowmobiles with milk churns on the back.
Bruce Moore: Not at all. In fact, a couple of streets can make a difference. The wrong side of a main road can sever a lot of normal ties and relationships.
David Tredinnick: That is particularly so in Leicestershire and the east and west midlands.
Q90 Rosie Cooper: We have talked a lot about unmet need in the earlier session, so I would like to ask you questions about, for example, local authority charging. Lancashire county council, for example, has recently upped the charging astronomically for day centres and services like that. I believe that is quite typical. To what extent do social care charges vary across local authority boundaries and have you any examples of that? Perhaps you could describe the impact on the people who need those services.
Heléna Herklots: There is huge variation. What we have seen, particularly in the last 18 months, is the situation where a number of local authorities have removed their maximum cap on domiciliary care charges. Sometimes what people have found is that their costs as an individual have risen hugely. Someone might have had a cap of £250 a week but that has gone and they might be asked to pay £400 or £450 a week. Often, on limited incomes, that is extremely difficult. What we are hearing through our advice line, for example, is that, because of the level of charges, people are reducing what they take in terms of that formal help and are relying more on informal help. There is an example with a husband and wife where the husband was getting quite a lot of caring, but they could not afford those higher charges, so the wife started doing more and more, cutting back on the extra support. The issue there is that that gets to a breaking point-you are putting a huge burden on that carer-and probably the costs then escalate because of a sudden admission to hospital, for example, if that caring relationship breaks down. We are certainly seeing, in terms of the contact we are getting, real impact on people’s lives as a result of this. Quite often it is also hidden because people just cope. They are facing a really tough time and we might see more of the impact a little later as those sorts of crises come through much more. But there is huge variation, and whenever we have done research with older people on this, there is a consistency of people saying, "Why are these charges so different? Why is there that variation? We want much more consistency so we know what to expect to pay."
Q91 Rosie Cooper: Can you give us any idea of-I will pick day centres because it is the one I have mentioned, but you can give any other examples you have-what the gap would be between, say, the bottom 10% and the top?
Heléna Herklots: It is difficult to say. It is probably something on which we would come back to you with a note, but there is a growing difference, I would say. Certainly, Community Care did a very good survey earlier in the year on the difference in domiciliary care charging, which gives a good indicator. With day care, sometimes it is more difficult to tell because, if voluntary organisations are running it, they are staffing it with volunteers and absorbing some of those costs. The charge to the individual may not be an indicator of the true cost.
Q92 Rosie Cooper: How do you think that impacts people who want to move from one local authority to another? I have people who have been assessed and are having a level of service, for example, in areas other than Lancashire county council who move in and the amount of hours they are given are cut dramatically. Have you any examples of the degree of impact that that has on those people in their choices about moving and in what they receive?
Heléna Herklots: The issue about moving out of a local authority area is a relatively small part of the overall picture in terms of older people moving. With the decision to make that move, people will not think, "Are the care charges different?" It would not cross their mind, on the whole. Therefore, it could be that they are moving somewhere where they find there is more care available and it is cheaper or it could be much more expensive. We do not have enough evidence to build up a true picture of this one, but it comes back to that general point which older people feed back to us all the time about wanting consistency in what to expect, whether that is about staying in their own area or moving.
Jeremy Hughes: From our experience, it is not only about cost variation, a charging variation, but it is also about quality variation. There are enormous differences. You can go to a situation where none of the costs are met because there is a different definition and different assessment level of what is interpreted as appropriate for local authority spending, but even if things are met you can find the quality of the support and the amount of provision is very different. Certainly, as I mentioned earlier, there are people who are moving into residential care earlier than they need to because of the inadequacies of support in the community.
Q93 Chair: It is very difficult to devise an insurance product that could come close to meeting this threedimensional chess, with its variation of quality, charges and access. How do you design an insurance product that deals with those variables?
Bruce Moore: If you are paying in the market, you are taking the local market cost. It is when it is dependent on the local authority as the gatekeeper that you are subject to these different charges. That is where a lot of the uncertainty is. By saying you have so much money or incapacity it helps that process in terms of unlocking that certainty.
Jeremy Hughes: One of the challenges we have, and it is a slightly different point but it is fundamental, is that there is not only a difference in what is available and the charging, but there is a difference in terms of the information. There is a real information deficit. Some of those issues could be addressed in terms of giving people universal access to information about good social care, even people who are likely to be selffunders because they are below the substantial or critical need. But if we could get more people diagnosed early-we know that only 40% of people with dementia get diagnosed and we have 60% of people with the disease who do not get diagnosed-and we had an assessment which helped them selfnavigate through a system that they were largely going to selffund for at least the initial years, it would be a more powerful way of supporting people well within the constraints of the financial system.
Q94 Valerie Vaz: The Law Commission now says there should be a main definition passed down to local authorities where we are seeing differences and changes of how people are assessed. What is your view on that and what are your members saying? Are they finding it much more difficult now to get past the definitions?
Jeremy Hughes: Certainly the feedback we have-and we have a report coming out shortly on personalisation and personal budgets-shows an enormous confusion because there is not that single definition. People are finding it very difficult to know what to expect. They are appealing against decisions and are getting decisions reversed. They are thinking, "How can this be, when my needs are exactly the same, where it is very selfevident that I, as a person with dementia, or I as a carer, can show what it is?" There is an example I was reading recently of somebody who has spent six months and gone through three reassessments with a different outcome each time, thinking, "But my needs have not changed. How can this be?" There is an enormous amount of confusion and a need for that universal understanding of what quality is and what the assessment is.
Q95 Valerie Vaz: Who will assess that? Who will draw up the criteria?
Jeremy Hughes: It is back to the suggestion of there needing to be some national assessment, whether it is through NICE or through another body, which sets a standard so that we know what "good" is. Then we can measure performance against "good". At the moment we do not know what "good" is or we do not have a universal definition of what "good" is.
Q96 Valerie Vaz: Is it getting worse for your members?
Jeremy Hughes: As the purse strings get tighter, people are finding it more difficult to get what they need. Going back to the example I gave of 15 minute visits for domiciliary care, they are finding that, even when they are assessed, what they are getting provided with is not meeting their assessment. There was an example I was reading of somebody who was given a personal budget and the local authority said, "We are giving you a personal budget because we cannot afford to support you through the local authority system. You might as well have the problem yourself." There are examples of where it is becoming much more difficult to get what people need.
Q97 Valerie Vaz: Who are the advocates for people like your members?
Jeremy Hughes: We are, collectively, as our organisations, and Members of Parliament clearly are. Interestingly, I do not see as much evidence, and it does not come through to us, of the local authorities being the advocates as much-and certainly the elected members. Going back to the earlier discussion, there is a hope-but I do not know whether it will be a fulfilled hope-that Health and Wellbeing Boards will provide a forum where that message can come through more loudly and clearly. I am slightly sceptical about whether HealthWatch, even if it were to cover social care, will make a lot of difference because some of the people who sustain an existence in HealthWatch are the long-suffering people who have survived through all the changes since community health councils and somehow hang on in there rather than it being a real way of reaching out to the experience of service users today.
Q98 David Tredinnick: Earlier on, you touched on early assessment and I want you to expand on that a little. It seems to me that what you are saying is, "If only we could get to people earlier there would be less of a problem anyway." My own experience of dealing with another form of integrated healthcare, which is complementary medicine, and looking at herbal medicine, for example, is that there are a whole load of remedies out there which are available-maybe not a whole load but some specific remedies-to help people with dementia and they are not available across the country because there are not enough people to deliver them.
Jeremy Hughes: You are absolutely right. Early assessment and diagnosis is fundamental and then putting, as it were, the power in the hands of the consumer to decide what is available, working alongside charities like the Alzheimer’s Society where we can develop innovative services in the community that look at improving the support provided to people. Those can be picked up over time, sometimes through local authority funding. We have services in Wiltshire, which initially we entirely funded, called "Singing for the Brain" groups that are now spreading around the country. We funded that entirely from voluntary income initially, but the effectiveness of it in supporting people well in the community means that it is now being fully funded, in a very good example of an integrated way, by Wiltshire local authority and the NHS.
Q99 David Tredinnick: I have one other question. Do you think the role of the Public Health Officer is key in this process?
Jeremy Hughes: The Public Health Officer and Public Health England could be key. The worry is the level of resourcing that they are going to have and whether they are going to be sufficiently open to the input of expert advice and knowledge. Public health has always been the Cinderella in the system and its relocation within the provisions of the Health and Social Care Bill does not suggest to me that is necessarily going to change. So, yes, a wellresourced, wellinformed public health system could be the vehicle through which you get this support to people.
Q100 Rosie Cooper: Going off this slightly, I fear where we are going because of people’s understanding of what they are having to deal with. You described before, for example, continuing care. I know of someone who had dementia and was in the hospital, very close to death. Whiston Hospital did a grand job and the lady was a bit better. They were then assessed by the social workers for continuing care and the family were invited into a room. The social worker and somebody else asked the questions, filled up the form and then said, "Oh, dear. No. Refused." The family questioned it and they were told, "You were in the room. You were there." They said, "No. You had the papers. You filled up the form. We were present but that is about all." That lady was denied continuing care. She was transferred to a nursing home and died within five days. She was not able to feed or do anything else. They are the very people-families who see this-we are trying to get to engage in the system. Are there sufficient advocates at all levels-the phase from the early days of needing social care right to the end of that when you are talking about continuing care? How do you help people through it? The family even asked whether they could FoI the form and were told, "Oh, we don’t know what that is. No chance," because I was telling them to ask for that. It is outrageous that people are treated in such a way and are not able to engage fully.
Heléna Herklots: I agree with everything you have said. One of the challenges is that, because the system is so complex, to be an advocate you need to know a huge amount about how it works. You need to know what the legal framework is, what are people’s rights, when you can push and challenge and when you cannot. That advocacy role needs training and needs people to do that. It is something that the voluntary sector is very strong on. It is also an area for which it is incredibly difficulty for the voluntary sector to get funding on a continued basis. It is an area under threat at the moment just when, probably, it has never been more important. Certainly for local Age UKs across England, one of the biggest things they do is provide advice and seek to try and help people potentially through that advocacy route as well. It is about creating the awareness that there are organisations people can turn to who may be able to help. It is also about recognising that if advocacy is hardwired into the system it benefits everybody. It should not be a "them and us" thing-an advocate versus the statutory authorities. It benefits everyone because it brings clarity and fairness into the system. That whole area links it to Dilnot’s recommendation on information and advice. It is critically important.
Jeremy Hughes: You can get it right. There are some good examples in the National Dementia Strategy where dementia advisers have been put in place and are the trusted adviser that follows somebody through from point of diagnosis onwards. Those are good examples to look at.
Q101 Rosie Cooper: How many of those are there?
Jeremy Hughes: They are increasing. We have 30 in the initial tranche and they are meant to be rolling out. There has recently been some more funding made available from the NHS to local authorities and to health authorities to increase their numbers. It can work but we need to do more of it.
The other point is an interesting parallel with children and young people. I have not been involved in that area for 20 years, but I remember when I worked for NCH many years ago the guardian ad litem, the whole support system for vulnerable young people. We do not have the same system of support for elderly people. Maybe there is something to learn from what we have in place for children and young people. Should we have that in place for vulnerable elderly people, people with dementia?
Rosie Cooper: That is a good point.
Chair: Could we move on to integration?
Q102 Dr Poulter: We talked about integration with the earlier group of people who came along to speak to us. Specifically, in respect of looking after older people and, more specifically, with dementia-and I have a couple of questions on housing later on-are there examples that you can give of where there is good integrated care in this country?
Jeremy Hughes: There are very few. There are some examples. The best examples, and the one people come across most commonly, are around endoflife palliative care support. There are good examples of health support being brought into somebody’s own home alongside the social care support they are getting and it is providing a continuum of support without somebody being moved into hospital for their final days. There are some examples of that happening and some examples where there are combined budgets. There is the example I gave earlier of Wiltshire local authority and the health authority working together to fund some services in the community, but they are patchy. A lot of it is to do with the separation of the systems-inevitably, we have two systems and two cultures-and getting people to talk together. It is the whole story about, "Why has Torbay not been replicated?" As far as I can see, the reason why Torbay has not been replicated as an integrated approach to health and social care is that chief executives do not talk to each other. They do not speak the same language. They do not get on the same wavelength. So there are not many examples.
Q103 Dr Poulter: That is a good point you have made, but is it not also the case that it is going to be difficult to get that integration of social care and NHS services to happen if the financial drivers are very different and have different financial habits?
Jeremy Hughes: Yes.
Q104 Dr Poulter: For example, hospitals are paid by payment-by-results, as we know, so preventing admissions loses the hospital money, if you see what I mean, in crude terms, which means the hospital loses some of its income. Similarly, with adult social services, the major savings will impact on the NHS but not necessarily on social services. Is this perhaps the crux of the matter, that where you have divided budgets, and almost silos in terms of both culture and budgets, that is hindering delivering the integrated service that we want?
Jeremy Hughes: Absolutely. You have hit the nail on the head. The perverse incentive is that hospitals want to fill their beds and social services cannot afford to support people, so you end up with the fact that one in four adults in hospital are people with dementia. They stay there longer than they need to because there is not the support in the community. It is partly about integrating the budgets, so you can look at one pot of money, but I do not think that works simply by, as we have seen this year, a transfer of a slug of money from the NHS into social care. It is also about following through the money. For example, with the dementia strategy, some research earlier this year showed that twothirds of PCTs did not know what had happened to the money given to them for implementing the Dementia Strategy. There is an issue about tracking the spend even when it is within one part of the system.
Coming back to the Torbay example, it is also about culture and the willingness of people to see the perspective of the service user and the patient rather than the perspective of the system.
Q105 Chair: Do the social housing people ever get invited to these integrated service discussions?
Bruce Moore: Very seldom. It is important that health and social care work together, but if you do not have the right housing environment, then we use the example of a sink. You have the hot and cold taps of health and social care but, if you do not have the plug in, it all goes down the drain. You can spend an awful lot of money without any lasting benefit unless you have the right environment, and people are going to stay in hospital beds or stay in more expensive care environments because they do not have the right home environment that links to that. All the issues you have talked about, in terms of the silos and the incentives of the funding system, apply equally in that situation as well.
Q106 Dr Poulter: I was about to come on to the point the Chairman made about the role of housing. There are onuses that are put on new housing providers in terms of disabled access and those things. This is not entirely about the traditional way we look at adult social care and the NHS, but it is crucial in terms of how houses are adapted. Is there a role for, say, the Department for Communities and Local Government to put more of an onus on local authorities to look at this issue more seriously, about how houses are adapted, houses for life and that sort of agenda, in this respect?
Bruce Moore: Absolutely. There are two elements. One is the physical adaptation of the property. With housing there is a huge amount to do with the squeezing of the eligibility, or the criteria, for the disabled facilities grants and local authorities not necessarily funding those. It is a mandatory grant, but they are not making it available as they should. There are issues there. Also, there is the role housing providers have in providing information, advocacy and other support. It is about getting the physical home environment suitable and also being the best place to make a lot of those connections, because that is where somebody lives. What do you need to enable somebody to live there effectively? Is it about where you get the access to the benefits and the access to the support provider? It is connecting all those bits up. The physical side of it is very important, but I concur with the comments that Heléna made as well about the advice element that sits alongside that.
Jeremy Hughes: It is also about using most efficiently the resources we have. If you have housing officers going into somebody’s home enabling and supporting them to make an assessment as to what the change in the environment should be to support, say, somebody with dementia, which can be as simple as having a coloured toilet seat, it can make all the difference to being able to live in your own home or not. There was a great example a few years back where the Kent Fire and Rescue Service-as do other fire brigades-had a programme of visiting people in their own homes, particularly elderly and vulnerable people, to see if they had smoke alarms. They trained those fire brigade officers going into the homes to also make assessments about what people were eating and how well they were living. They did an initial whole assessment and it identified a lot of vulnerable people who were isolated and who were then able to be followed up, either by voluntary organisations or by the local authority.
Q107 Dr Poulter: We had the same service in Suffolk. Do you think leaving local authorities to their own devices on this is going to be sufficient to get them to act in this integrated way with housing? Or do we need to have, particularly if we are looking at Health and Wellbeing Boards run by the toptier authority-but, obviously, housing is not the responsibility of the toptier authority-some direction from Government in a more specific way to direct local authorities into the importance of housing in a more integrated social care system?
Bruce Moore: I want to say yes-
Q108 Dr Poulter: You can say "yes".
Chair: Be careful what you wish for.
Bruce Moore: -but what you wish for and the reality you can see transpiring are different. You can see housing representatives on Health and Wellbeing Boards, but it is about the will locally to make sure there is good housing. To expect that health and social care will always think about the housing agenda is not realistic in terms of mandating that. It is about tackling some of the worst perverse incentives that exist in the system and articulating the benefits of working in that way rather than mandating the structures and putting people on boards.
Q109 Dr Poulter: I did not mean necessarily to mandate the structures, but do you think there needs to be a central Government driver, for there to be a local plan, for example, to deal with-
Heléna Herklots: Could I come in and say "definitely"? I can say yes on this one, Bruce. We rely so much on good leadership, do we not, on making a lot of these things work? You do need that but, particularly when you are trying to get a change through, you need some structure and some financial drivers as well. Housing is so critical to this stuff working that we need to do more than we have done in the past. We have spent 20 years trying to improve the housing circumstances of older people. We have made some progress, but older people still live in the worst housing conditions in the country. It is critical to public health, to health and social care and it is a building block. We have to find a practical way. That has to include looking at the new bodies that are coming through and saying housing needs to be part of that. It is a key player.
Jeremy Hughes: One thing that would certainly help, and probably is not within the way the system works but could easily be done, is to make the proposed forthcoming social care White Paper a cosponsored item with DCLG. If it is only the property of the Department of Health it will not solve the issue.
Q110 Valerie Vaz: You talk about local authority housing, but there is also the other side, of people in their own homes. How are you going to get local authorities to visit people in their own homes?
Heléna Herklots: That is the critical part, because it is about how you can help people get the adaptations they need and get the insulation they need so they are not cold in winter, for example. All of those things are so critical to the health of the population that you need that local authority strategy as to how housing fits into this whole area.
Q111 Valerie Vaz: There is the philosophical argument about the state interfering, which some people do not like, and the personalisation, holding your budgets and not interfering-the state holding back. How does that all fit in together? It cannot.
Bruce Moore: There is a real struggle at the moment in terms of home improvement agencies. They are fantastic agencies in equipping older owner-occupiers to get their properties fit, suitable, adapted and all those things. They have been withering because, in effect, as budgets are squeezed, they are seen as discretionary spend and they have been lost. The consequence of the loss of the home improvements agencies-the loss of that advocacy and the case management that helps people find their way through the system to do those adaptations-means that people spend longer in the hospital bed or whatever else, costing the system much more. Those are the services which are currently being lost or ratcheted back to the bare minimum. They give people the confidence that they should do this thing and that they will be helped through the system rather than, "It is all out there if you can find it." It is great that it is all out there and you will find it if it is, but even if it is there you need that help to unlock that potential.
Jeremy Hughes: There is also a role for the private sector and a big opportunity. You cannot go into B&Q at the moment and see products that are marked as "dementia friendly," but surely that would be helpful. If people wanted to be able to buy something that would help them support a family member with dementia, they should be able to do that. There is a business opportunity, a market opportunity, for the private sector as well.
Chair: I want to protect one o’clock, so now we will turn to David Tredinnick.
Q112 David Tredinnick: I have a couple of quick questions about economic regulation and failure regimes. Mr Moore, what form of economic regulation is Hanover subject to at the moment, please?
Bruce Moore: We are regulated by the Tenant Services Authority-it was the Housing Corporation-and that is looking at the viability, our financial projections and our business plans. That is because there is public money invested in us.
Q113 David Tredinnick: Is there one particular organisation that takes a view of your financial viability?
Bruce Moore: The Tenant Services Authority at the moment is the regulator. That is going to pass to the Homes and Communities Agency, but that looks at our financial standing. That is looking after the public investment that has been made in housing.
Q114 David Tredinnick: That is fine. More generally, what economic regulatory system does the panel think will increase public confidence?
Heléna Herklots: It is a system that does not only step in when there is failure but that can try and prevent it. The Southern Cross example is one that is uppermost in lots of people’s minds. We had lots of people contacting us, worried about their relatives in care homes across the country, and not only Southern Cross ones. The system will find a way of assessing financial viability, and also whether the housing model is one that could be looked at in terms of whether that can apply into the care sector as well, understanding, for example, if you need to close a care home. The University of Birmingham has said you need six months at least to do it well. That should be part of the financial viability assessment of providers.
Q115 David Tredinnick: Do you agree with UNISON’s call for the Government to rethink the private sector’s role in the provision of health services following the Southern Cross problem?
Bruce Moore: The Southern Cross problem was exceptional because of its bizarre business model and also because of its scale. Most care homes are run by one or maybe two entrepreneurs, and there are many, many providers. The Tenant Services Authority only looks at the larger housing associations because the small housing associations are too small to be on their radar. The scale of the risk is so much smaller. It is about finding a mechanism whereby you are assessing not only the quality of the service but also if there is a viability behind it in terms of its charging, its financing, and where it is funded from. If you can see it is being squeezed, you will either squeeze the quality of the care that is provided, which is the worst thing, or you will go bust. There has to be a mechanism whereby poor operators are taken out of the system and replaced. It is part of that regulatory overview, saying that if you are not making enough money something is going to go wrong.
Q116 David Tredinnick: What sort of failure regime would guarantee continuity of service if we have a problem in the future?
Chair: Coupled with that, David, is there any evidence in the Southern Cross case yet as to the scale at which individuals’ care was disrupted? There was a lot of concern but was there evidence of interrupted care?
Heléna Herklots: I have not seen the evidence. What it did, from our perspective, was raise huge concerns, not only with older people but with relatives. It did not matter what care home provider they were with. Part of the impact of Southern Cross was not only the uncertainty for the people who lived in those homes but also what it did to people’s views of how we care for people in this country. People who were thinking about helping their parents move into a care home were suddenly feeling even worse than before.
Q117 Chair: Ironically, if the result of Southern Cross was that care was not interrupted, then what we need to do is institutionalise what happened rather than change what happened.
Heléna Herklots: Exactly.
Jeremy Hughes: One of the key elements, in answer to the question, is to increase the amount of attention commissioners give to the financial viability of the people who are providing the services. That is more where we need attention than assuming that setting up something like Monitor, or extending Monitor across social care, will be the answer. Historically, commissioners have not been as attentive as they should be to the financial viability of the providers.
Chair: Thank you very much. I failed by three minutes, but thank you very much for your evidence.
 Note by witness: the correct figure is £681 million.