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Health Committee - Minutes of EvidenceHC 1583-II
Taken before the Health Committee
on Tuesday 8 November 2011
Mr Stephen Dorrell (Chair)
Dr Daniel Poulter
Mr Virendra Sharma
Dr Sarah Wollaston
Examination of Witnesses
Witnesses: Jo Webber, Deputy Policy Director, NHS Confederation, Peter Hay, President of the Association of Directors of Adult Social Services (ADASS) and Strategic Director Adults and Communities, Birmingham City Council, and Councillor David Rogers OBE, Local Government Association (LGA), gave evidence.
Q118 Chair: Good morning. Welcome to the Committee. Thank you for coming, and, in David Rogers’ case, coming back yet again. Could I ask you, briefly, to introduce yourselves and tell us where you come from, please?
Councillor David Rogers: I am Councillor David Rogers. I chair the Community Wellbeing Board of the Local Government Association.
Jo Webber: I am Jo Webber, Deputy Policy Director at the NHS Confederation.
Peter Hay: I am Peter Hay, Strategic Director for Adults and Communities at Birmingham City Council and President of ADASS.
Q119 Chair: Thank you very much. I would like to begin this morning, if I may, with a question about quality in the delivery of social care services which was prompted by a piece of evidence we received a couple of weeks ago from Bruce Moore, who is the chief executive of Hanover Housing. I want to read you a quote from the evidence he gave us and ask you to react to it. He said to us:
"The standards at the moment are very low…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."
If the base proposition is true, I suppose the conclusion is true as well. But do you think the base proposition is true?
Peter Hay: We would argue very strongly that there is a need to ensure that good quality care is paramount. That is key to reform and to encouraging people, in whatever way they choose, to pay for it as well as to build the case for reform. CQC’s data, which are only about the minimum standard-they do not give you now any detail about the stretch beyond that-are clear that 70% of residential care meets those minimum requirements, and 80% of home care. That does not mean that 30% are in the gap. It means 30% are somewhere between that and their failure regimes. The trouble with our care system is that it is too diverse. There are some fantastic examples, and there has been some great work done in changing residential care-in particular, the My Home Life initiative. Equally, there are examples of considerable failure, and we have seen some of those very tangibly this year. We have to be clear and assure the bottom line, particularly around dignity and safety, as well as build great quality from there. But I do not agree that it is the worst in Europe.
Councillor David Rogers: I do not have a great deal to add to that, Chairman. Obviously, there is a range of opinions and there is a range of levels of quality. The CQC facts speak for themselves, as Peter has said. In some ways, we ought to look beyond exercises which measure it in that way and look at what might be described as "softer measures"-how people feel about the care they are getting and whether they are or are not treated with dignity in whatever setting they find themselves. That is why the Commission that has recently been set up to examine those issues is a step in the right direction and could well come up with some ways of seeking to ensure that is better in the future.
Q120 Chair: Whether the starting point is, as the Hanover Housing man said, that these standards are the worst in Europe, or whether the starting point is that there is too much variation and there are too many examples of service failure, the conclusion from either proposition is that things are not as they ought to be in terms of the quality of care delivered to people who use these services. That, presumably, is not in dispute.
Councillor David Rogers: No.
Peter Hay: No.
Q121 Chair: It is not that people are not interested. It is not that people will low quality of service delivery. What is the key issue in your mind that has gone wrong to allow that to happen and how should it be addressed?
Jo Webber: There were a range of things going on. One element of that is society’s view of elderly people and how they should be treated. Another is that a lot of residential homes are small "islands of care" and it is very easy, within a small island of care, to get adrift of standards and quality. That is one of the reasons why we have, along with the LGA and Age UK, set up our Commission to look at dignity in care. We want to know what it is that stops the best care becoming something which is adopted by everybody across the system. That is why we are doing the work now. What we want to come up with is not another example of explaining what is wrong with the system but some tangible methods by which we could encourage spread across those individual care homes.
Q122 Chair: I will bring in Rosie in a second, but this is an ongoing service. People are being cared for day by day.
Jo Webber: Yes.
Q123 Chair: Commissioners in the social care world are signing cheques to people to deliver care that you have acknowledged, in too many cases, does not meet the standards required of it. It is not a question of structures and "Sometime in the future we will have a structure that works better." How do we ensure the cheques are not signed if people are not happy that the service delivered meets the required standards?
Peter Hay: One of the key issues here is that social care is in urgent need of reform. It needs a single coherent framework against which we set out what is important and how that is delivered. If you stick with residential care, there has been a debate about whether residential care is necessary or not. Once you begin to move to the point that it is unnecessary, you leave it alone, and the dangers of that are clear. We need a coherent framework of the values that are important, particularly about dignity, safety and quality and how those are promoted. That comes through to some of the tensions to which you have alluded. You will hear from providers that commissioners should not play a role in contract monitoring and quality assessment.
Q124 Chair: Do you mean they should simply send the money unconditionally?
Peter Hay: I did not say that, but you can. It needs that kind of counterpoint. You are absolutely right. The key issues are ensuring the involvement of both the commissioner and, increasingly, people who hold those budgets themselves in determining and assuring the level of quality so that there is constant vigilance about value for money and the quality being delivered to the standards that people expect.
Councillor David Rogers: To expand on that for a moment, if I may, it is not only the commissioning that local authorities do or the personal budgets that are being deployed in the way that has been described. There is also the growing number-tens of thousands or hundreds of thousands-of people who are making individual purchasing decisions based, sometimes, on information that could be better. Their feedback is also important to drive quality.
Chair: Thank you.
Q125 Rosie Cooper: I was almost about to be sarcastic and say, "Let me give you a clue." Money is driving this down. Might I ask Peter and David how much your authority-Birmingham-pays per week for residential care?
Peter Hay: For older people it is £450 a week.
Councillor David Rogers: I do not have those responsibilities in the local authority.
Q126 Rosie Cooper: But do you know how much you pay?
Councillor David Rogers: It is a not dissimilar figure, but the fundamental point, which I think you are driving at, is that the current system is underfunded and has been for many years. The demand is growing and, therefore, that gap is growing. That is a case the Local Government Association, and indeed others, have been making for a long time.
Q127 Rosie Cooper: I do not know if you have done a tour of residential homes. Last year, I spent a number of months visiting them, and a more depressing and horrible experience I have never had in my life. When you get into the detailed reasons for it, the local authority is driving costs down to a figure which is below cost to the providers who, therefore, try to recoup that money from selffunders. The whole thing is so tight that there is no room for manoeuvre. Then we sit and wonder why standards are being driven down to what can be said to be probably one of the worst in Europe. I do not know what Europe is like-and better minds than mine can say whether that is true or not-but one thing is for sure: the CQC were here in front of us and said that standards were at the absolute minimum, and still we have homes failing. You acknowledge that you are paying what is a minimum and what is possibly below cost. How can you sit there and be surprised or tell us that you think this is okay and people are getting quality? They are not.
Councillor David Rogers: I have already said there are the measures the CQC looks at, but there are also other measures. The best homes are firmly embedded in their local communities. You were hinting at this, Jo-that where there is contact and they are seen as part of a wider community, it is likely that the level of care delivered to individuals is better than where they are isolated. I have also said that the system as a whole is underfunded.
Q128 Rosie Cooper: Absolutely. What do you say to an old person, for example, in Liverpool where the homes are getting £420 a week, which is below a level at which providers would say they could provide a good service? What do you say to the people of Liverpool in this system?
Peter Hay: What is clear is that local authorities pay a rate they agree with their providers in that area.
Q129 Rosie Cooper: No. They tell their providers.
Peter Hay: Not all local authorities tell their providers. In Birmingham we are doing an exercise called "open book" and trying to work in a consensual manner on the costs and paying for that. We are not interested in "doing one over" on the providers. It is a shared responsibility. We are working in that "open book" way to agree a fee rate. It is not only about the fee because, clearly, occupancy rates are also important in this business and we need to understand both dynamics. I am not interested in buying poor quality care. Providers choose to enter those agreements and I want to do so on an amicable footing, a footing which recognises the proper role of residential care. I do not recognise your description of residential care as universally depressing. I can take you to care homes with a majority of councilfunded placements that are far from overwhelmingly depressing.
Q130 Dr Poulter: I have two points. Jo Webber said that we have islands of care in residential care. There may be some better examples in Birmingham, but that is certainly the view expressed. We then have the slightly utopian view that we need to have local residential homes embedded in the local community. That does happen in some places, but it certainly is not going to happen in deprived urban areas at the moment. What I am trying to drive at is: should there be a much stronger onus on local authorities to monitor the contracts that they are putting in place and ensuring that the standard of residential care is better? Certainly, it appears that local authorities may commission services-give the money-but is there the monitoring in place to make sure, at local level, which Councillor Rogers said he wants to see, that that is happening? If it is not happening, should it happen?
Peter Hay: We would want to take one slight step back. If you are in the business of providing care, it is your business to assure yourself about the front line and the quality of it. That emphasis has been lost in recent years. This is still an industry that, occasionally, says it is the responsibility of the regulator and not the provider to project quality. Reflecting, particularly, on recent events, the fact that the eye was not on the ball of quality, from the people whose business it is, has been a serious shortcoming in the system.
Fundamentally, if you choose to enter this business, we need to find ways in which the quality measures are transparent and you are working with that; then, clearly, the council, together with those who are buying their own care, have a role in that further quality assurance and checking and reporting on that, and, increasingly, in how that is communicated to those considering care, so that they are making informed decisions and can see what is happening to the quality standards being achieved.
Q131 Dr Poulter: Do councils do that at the moment across the country? Do they monitor the standard of care that is provided? Obviously, it is desirable, as Councillor Rogers has said, to make sure that the care homes are embedded in the local community where possible-and it may not be possible in some parts. Do they do that effectively at the moment?
Peter Hay: There are some areas for improvement, but essentially-
Q132 Dr Poulter: Can you explain how you do it in Birmingham? When you have given the money to the provider, how do you intervene if there is failing care? How do you monitor care in Birmingham?
Peter Hay: We monitor the contract and quality, and that ranges depending on what our judgment of quality is. For some of the providers who are struggling, we have quite intensive periods of intervention and assistance, designed to help them recover their business and quality standards.
Q133 Dr Poulter: In what sort of ways?
Peter Hay: That includes putting people on site to work through what is going on, to suggest areas for improvement and agree an action plan, through to, if we are satisfied with the level of care and quality, more infrequent reviewtype meetings and all the rest of it. Clearly, what we then also have is constant review of intelligence, particularly from front-line staff but also from people themselves, in order to adjust where we think people are. The final dynamic, of course, is that this is not only contracting. There has been a growing oversight of care through the viewpoint of safeguarding vulnerable adults. Sometimes that merges into quality as well because, increasingly, safeguarding is one of the tools being used. It covers a range of things from harm through to quality.
Q134 Dr Poulter: Certainly, it sounds as if you are monitoring contracts, but are you satisfied that this is a standard practice among local authorities?
Chair: Can I add to that? Where does the information come from that allows you to do what you have just been describing?
Peter Hay: The first point of good information is engaging your staff in perpetual use of it. Clearly, we are obliged, by law, to review care packages, so a review should also be intelligence and insight into how that person’s care is being received. Obviously, you also have intelligence coming from safeguarding referrals. You have intelligence from carers and relatives as well as from residents themselves. Pulling all that together gives you an overview of the care provider in your area.
Q135 Dr Poulter: But the point is that it took the Care Quality Commission to go in, from a national perspective, and flag up abuses at a local level. What I am trying to drive at is, what you people are doing on the ground to deal with these abuses and poor care. You are paying for the contracts and you are commissioning them.
Peter Hay: The vast majority of safeguarding issues are dealt with by the local authority at the local authority level. They are not discovered-
Q136 Dr Poulter: If the CQC has to go in and flag up abuses, clearly local authorities are not dealing with local safeguarding issues.
Peter Hay: No. If you look at where referrals come from, in relation to safeguarding they come from individuals and care staff and they go to the local authority. Some are spotted, but CQC is a minor player in the detection of safeguarding incidents.
Q137 Dr Poulter: The minor player has to go in and flag up the major abuses on a national scale. Do you not believe there should be a stronger role? Is that not a failure of those mechanisms and safeguards, which you are saying you have put in place, because they have not worked? It requires the CQC, which you call a minor player, to go in and flag up those abuses.
Peter Hay: I am sorry, no. I thought I disagreed with the fundamental premise. CQC does not find the majority of abuse in care homes. It comes and is reported in other ways.
Q138 Dr Poulter: But the CQC has to flag up in a very practical and public way what goes on. We have seen how the CQC deals with that. What are the mechanisms for care homes that you have, as local authorities, across the board to pick up on this? You have not addressed the question.
Peter Hay: CQC gives you a different perspective. CQC goes in and examines the care home in relation to the whole range of standards. That can sometimes throw a different light on how a care home is providing quality. Sometimes it can confirm the view of councils in those kinds of things. Only very rarely does it find particular incidents of safeguarding. CQC is a part of that intelligence system that allows you to take a view about the quality of care being delivered in your area.
Q139 Dr Poulter: I have one more question. I am failing to follow the logic here. We have had a lot of evidence already that flags up great concerns about care. We had the quote the Chairman gave at the beginning which said that, in this country, the standards were very low and it is probably one of the worst in Europe. You disagree with that, but that was a view expressed to the Committee. We have also heard that the CQC goes in and has flagged up standards of not just very low care, but basic dignity not being presented. My concern is that local authorities are commissioning services but are not necessarily making sure that those services-and it is very clear from what the CQC have done-are of a sufficient standard. How can things be done better by local authorities to monitor contracts and to make sure that you provide that duty of care to adult social care and elderly people that you need to in a better way? There is good evidence that has not been happening.
Peter Hay: That is about the sort of mechanisms. Some councils have used quality premiums to pay for enhanced quality. It is about the risk monitoring of providers and the work you do with providers to boost their standards. It is also the work you do in a more developmental sense. In Birmingham, for example, we have a Care Development Agency, which is about the training of all staff and supporting their development to raise standards. This is, historically, an undertrained work force. It is all those kinds of things that push together to drive up standards.
Q140 Barbara Keeley: It is my experience, locally, that the standards are too diverse and clearly, as with NHS care, they can fall below minimum standards. My own experience was going to a carers’ dropin, asking them and having them sit and recite at you which homes are any good and which are hopeless. They are the people who experience these things.
You talked about islands of care in residential care and the value of being embedded in the local community. I want to raise with you the question of ownership, because we have had the issue of Southern Cross this year, and homes being sold for their property values-a casinotype mentality of passing them round the place. Can you comment on how you can develop those values with an ownership that is changing? In my local authority we had seven Southern Cross care homes, and that is a significant proportion of the ownership. It has changed now and gone from Southern Cross to a range of other providers. I fail to see, unless we can get a grasp on this ownership issue, how one can guarantee continuity of staff, care and commitment to the values that must be important in terms of being an owner. If you are buying and selling a home only because of an appreciation in its value as bricks and mortar, it says a lot about where we have come to. Could you say what impact you think the ownership issue has had on the issue we are discussing?
Peter Hay: From the ADASS point of view, we are very clear that the focus of the business should be on the standards of quality, safety and dignity. It was very clear that, in relation to the provider that failed in Southern Cross, its focus was not always upon those issues. It was distracted or, if you like, more minded to look at the propertytype issues. We want to consider the response to that. It needs a detailed and considered review of what would make a difference in relation to that. One of our starting points in this, however, is that we think providers should be prepared to be transparent in relation to quality and governance and how those things are put together. In particular, people are suggesting there is a difference between-and this is coming across from providers-those focused on the longterm investment into models of business and those looking for shortterm returns. We think that transparency would allow people to choose what is important to them. Sometimes different things are important to different people, and there is nothing fundamentally wrong with the property model being used by Southern Cross. Other people use that all the time as part of business costs. The focus of the business and its transparency about its standards are key to the future.
Q141 Barbara Keeley: Following on from what you said, it seems to me that, having been involved-as other MPs have been-in talking to Southern Cross about what they are doing, there is very little control at the local authority level. That goes back to the point, just made, about what happened. Southern Cross was deciding who the new owners would be. A number of times, during discussions about that, I thought that that was not right. Here we are with many thousands of people-35,000 or whatever it is-across the country whose daytoday living and future living is being decided on the basis of, "Do I want to own these bricks and mortar?" If you are having a review of that, it is very welcome. However, where we have been with this handover from Southern Cross happening right now is an issue that you need to keep a handle on.
Peter Hay: Yes. Since the mid1980s we have made a decision, as a society, that there is a role for the independent and private sector in the care of older people. That has grown and changed as a business to see the emergence of big providers of the scale we now have. That means they make decisions on a business footing. That is not the role of local authorities. There is no role for local authorities in determining whose businesses they are. Our role absolutely-and it is a role in which we are not as strong as we could be-is about informing people and helping them make informed choices in relation to what they choose to take up.
Q142 Barbara Keeley: Where does the role sit, then? If you think it does not sit with local authorities, where does it sit? Is it with Ministers?
Peter Hay: There is a particular role for councils in determining whom they commission from. That is absolutely there to be determined, if you like. Part of that is also, as I have said, helping customers understand what they are buying, how they are buying it and whom they are buying it from.
Q143 Chair: Do you think there should be a "fit and proper person" test for the operator of a care home? We operate a "fit and proper person" test before you can buy a newspaper title. Should you operate the same principle for somebody who operates a care home?
Peter Hay: There are currently those kinds of tests in relation to the management of the home, and there were provisions in relation to the registered provider issue. Clearly, as I said, one of the difficulties is how you determine financial viability as being the particular issue, and how you would spot that. That is much more difficult than a particular type of test.
Chair: It was a slightly unfair kind of "curler". I am anxious to move on. I will go to Valerie and then David, who has been waiting very patiently.
Q144 Valerie Vaz: We have other questions on Southern Cross for the other group. That model failed, so why do you think that is acceptable? It may have happened in the 1980s, but the whole economic situation has changed now. Is it not right that we should revisit that model? We are talking about "customers" when actually, we are talking about elderly people.
Peter Hay: I do not think it was acceptable that the model failed, but the responsibility of that is absolutely the responsibility of Southern Cross. If you look at the history of Southern Cross, people removed equity and value from that business on the back of other decisions. It was not an unprofitable business. They also did not have a focus on the needs of older people or people with a learning disability. The driver of the business was property and return. That created a model which, inherently, crashed and burnt. It is about the failure of that provider. We need to learn lessons from that as to what needs to be in place to spot and deal with that. Behind how that happened, it is much more complex. As I say, on the surface, that was not being detected. It is important that we have a full review.
From the point of view of local authorities, we have met our responsibilities in full and responded with reassurance and a calm transfer. The predictions of doom and gloom and older people dying in the car parks never happened. We have worked to commission the transfer of Southern Cross in a very safe, smooth way. It is absolutely imperative that we now reflect on what we have learnt from it and how we can move forward.
Q145 David Tredinnick: I now want to look at the integration of health and social care services. The first question is: what health and social care services need to be integrated, and to what end? What other local services need to be included, please?
Councillor David Rogers: Our view, in the LGA, is that this is ultimately about the wellbeing of individuals. They are going to have, as individuals, a variety of needs and a range of services that can help to meet those needs. We take a broad view of that issue. You were hinting in your question that it is not only about aspects of health care and aspects of social care. It is about all the other things that happen in a particular area or a particular community that support people’s lives, whether that is community safety, leisure, housing, transport or lifelong learning opportunities-everything that enhances somebody’s life. That is why we see a very clear role for leadership in this at the local authority level, and why we welcome the proposals for Health and Wellbeing Boards, for instance, in the Health and Social Care Bill. We see that as being the vehicle-the mechanism-for commissioning decisions or influencing commissioning decisions in the future that will help to achieve that.
Jo Webber: The issue with integration is particularly about people with multiple longterm conditions, which is a lot of the very elderly or the elderly-frail. Integration comes in many forms. It can involve integrating services within a pathway of care for an individual patient. It can be about integrating the commissioning. One of the key problems with the word "integration" now is that it is used to mean all sorts of different things to different people. If you look at personalisation and personal budgets, that is the ultimate integration of budgets, particularly where that is a personal health as well as a social care budget. The people for whom you could see the most gain are the frail elderly with a multiplicity of conditions. There, you need to have a package of care which is based on the functionality and independence of that individual and not a particular disease they may have, because they will have several of those.
Q146 David Tredinnick: Before we go to Peter Hay, if a patient, their family or provider thinks a particular route of medical treatment is appropriate, do you think that is something physicians should listen to in this area of choice the Bill is addressing?
Jo Webber: I am not quite sure of your question.
Q147 David Tredinnick: You touched on the issue of choice and I am trying to expand on that. If a patient wants to pursue a particular line of medical treatment, is that something that close attention should be given to in these reforms?
Jo Webber: Absolutely, yes. This is always going to be a balance between choice and integration. The two are not mutually exclusive. If you are looking at a pathway of care, an individual and their carers may have a series of choices to make within that pathway. The key thing, from their point of view, is that patients do not recognise the slightly artificial differences between organisations that we use in everyday parlance. For them, the most important thing is to understand what is happening to them, where they can make choices and where they can input into their own care package across a range of things that helps to support them to be independent.
Q148 David Tredinnick: That is very helpful. Finally, Peter Hay, do you have a perspective on this?
Peter Hay: Yes. The work we have been doing is to try and move social care away from being just a set of specialist services for people of the highest possible need: to think not only of that but also work around enablement, restoration and rehabilitation of people with needs back into their homes and communities with fewer services than needed before and, indeed, an increasing offer with universal services, prevention and information. You have to think of the different types of integration needed across those three areas. That fits absolutely into Councillor Rogers’ point about the strategy and the local Health and Wellbeing Board’s role in that. Linked to that strategy, we clearly support the integration of resources with the outcomes you are trying to achieve and want to try and explore that further.
Q149 David Tredinnick: I know a lot of other Members of the Committee want to come in on this, but you would see patient choice as an important aspect of that, would you?
Peter Hay: Absolutely.
Q150 Barbara Keeley: I am interested in what evidence there is about the integration of health and social care advancing or receding. The interesting thing is that this has been a policy driver for years and yet we only find very few examples where it is working as well as it might. Given what you said about longterm conditions, I know, for instance, that the abolition of my local PCT has ceased active case management, which is an area of integration. So I have seen, locally, things affected by that. Are the changes that are happening, particularly the abolition of PCTs-the churn in the NHS-affecting things? Is this integration moving forward, staying still or receding?
Jo Webber: We have evidence of different things happening in different places, as you would expect. We did some surveying work with ADASS last year about what helped local systems to integrate. We surveyed PCT chief executives and directors of adult social services. It was about having shared visions, common directions locally, good relationships and a shared culture.
Q151 Barbara Keeley: But that is all going now. You are talking about something where half the picture is vanishing. PCTs are being abolished and people are moving.
Jo Webber: The issue is that, in a period of instability, it is always more difficult and challenging to keep those integrated services going.
Q152 Barbara Keeley: Would you say challenging or impossible?
Jo Webber: It is challenging, not impossible, because it does depend on the relationships. Not everybody is leaving from every area in the country that was there before. There are still some local teams who are committed to continuing with the integration, but it is challenging when you are moving things around and people are thinking about where their longterm career prospects are. That is a distraction from the day job of how you develop integrated structures and integrated services. It makes it more challenging. It is not impossible. In some areas of the country, the financial constraints, in particular, make it something people are looking at earlier on because they recognise there are efficiencies to be made.
Councillor David Rogers: Can I add to that? Jo, quite rightly, has said there is mixed evidence on what is happening in the current situation. Coming back to my earlier point, the way we view integration is based on the individual, starting with the service user or patient. There is enormous potential for Health and Wellbeing Boards in the future because they will include locally elected representatives and GP representatives, both of whom are close or should be close to those individuals. Therefore, they will have, in my view, the necessary thoughts in their mind-the way they go about their business-in setting the priorities and ultimately doing the commissioning to drive that process forward in the interests of the service user or patient.
Q153 Dr Wollaston: Following on from that point, I am wondering to what extent you think the proposed Health and Social Care Bill will support integrated commissioning. You have mentioned that you are very positive about the role of Health and Wellbeing Boards, but what other things, such as changes to Payment by Results, need to be put in place? What further measures do we need to support the drive towards further integration? What aspects of the Bill are holding it back?
Councillor David Rogers: I do not claim to be an expert on Payment by Results, although I realise it does have significant impact on the system as a whole. I do not want to prejudge what you might say, Jo, but you probably know more about that specific issue than I do. As I have already said, the proposed new structures after this period of turbulence, which is understandable for the time being, do have enormous potential to drive integration. That, in my view, will be good for the individuals who, at the moment, are somewhat mystified about what health care is, what social care is and, indeed, what the other ranges of services are that might help to support their independence. The potential is there. There is a turbulent period at the moment, but we have a good deal of, in my case, positive anticipation of what is going to be possible in the future.
Jo Webber: The issue is how you bundle and unbundle elements of Payment by Results to develop something that gives you, for some patients, what will need to look like a capitated budget so that you can have a year of care. That enables you to work with partners locally on the preventive end of care as much as on dealing with some of the crisis situations that might come up. The whole point of personalised care packages is that they must be able to help you better support people in their own environment to live to their potential. There are ways of using Payment by Results, if that can be bundled up in a way that makes sense when there are very functional things that you may need to be dealing with, rather than, as I said before, a series of individual diseases all going on at the same time.
Q154 Dr Wollaston: At the moment we are incentivising hospitalbased care. Your feeling would be, if we incentivised the whole pathway of care, that that would give more flexibility to genuinely put the money back to the primary care end.
Jo Webber: Absolutely. Then you can move money around the pathway and there is an incentive for you to look at preventive and early interventions of care rather than waiting until there is a crisis before the patient gets care.
Q155 Dr Wollaston: Do you see it as the role of Monitor to drive this, or the NHS Commissioning Board?
Jo Webber: It is the role of the commissioners within the system to drive this. This is where areas like Health and Wellbeing Boards can come in. You can develop, locally, a pathway of care which may vary from area to area but works with the grain of the local community and the place where that patient is living.
Q156 Dr Wollaston: Do you feel hopeful that that is going to happen, that we are going to see capitationbased Payment by Results and whole pathway care?
Jo Webber: I would hope so. Payment by Results works on an episodic basis with scheduled care very well, but we need to get much more subtle about Payment by Results when it comes to dealing with people with a range of longterm conditions.
Q157 Dr Wollaston: Is there anything else you would like to add that you think would improve the system to drive better integration?
Jo Webber: Going back to the previous conversation, stability is always good for driving integration, although I know that is not within the gift of the Health Select Committee. Developing local relationships and ensuring you have a system which people have information about and can navigate their way through is going to be very important, as is bringing in other players locally, particularly housing and leisure facilities. To keep people independent, well and active you need to have that pathway included-other providers that, traditionally, you might not have thought of as delivering health and social care.
Q158 Chair: If you are going to have the kind of flexibility within the budget between health and social care, and in particular social housing, is that possible, do you think, without a single integrated budget?
Jo Webber: You have to align the budgets. I am not sure whether you need a single integrated budget, but you certainly have to align them and make it easier to pool budgets-at the moment, is not as easy as it could be-to ensure you can pool that money.
Q159 Chair: Can I put the question another way? Do you agree it would be simpler if you were operating a single budget, and that aligning separate budgets is, necessarily, more complicated?
Jo Webber: There are some fundamental issues about what is chargeable and what is not. It would require a lot of thought before you completely integrated health and social care budgets.
Q160 Chair: From the point of view of the commissioner, the result, if those issues could be addressed, would be a simpler commissioning process.
Jo Webber: It would. However-
Chair: Says he, leading the witness.
Jo Webber: The other thing to remember is that things are going to be commissioned at many different levels within the new health care system. Some elements are going to be commissioned at National Commissioning Board level and some at local level. Integrating the whole of that would be quite difficult.
Q161 David Tredinnick: One part of the puzzle that has not been mentioned is the public health officer, this new role that is recreating something that was around in the 1970s. How important do you think that role is?
Peter Hay: It comes to the crux of the issue. Jo referred to the work we did together-in an integrated way-on the conditions for integration. Clearly, over the last year, a number of those factors we identified-such as financial complexity and organisation stability-have got worse, not better. One of the key features of the new world is how you can, through the Health and Wellbeing Board, embed the joining together of the budgets-which is only the start of the work, from my own experience, and even though it finishes with it, it takes a lot of hard work to get there-as a way of doing business. Although all the evidence suggests it is relationships, trust and things like that which build integration, we have not embedded it into the way we work and the governance systems of the place. That is fundamental.
Secondly, once you have your aligned budget, you need to do some fairly difficult and longterm work-not a takeover, but creating a new way-on taking the best of commissioning from both and using the best skills in both and blending them. For example, we have entirely different approaches to working with markets. Finding ways of working that out is absolutely key. Public health plays a really important role in setting the strategic direction and priorities for all of that so you know, very clearly, where you are aiming. The great hope for public health is to set that "light" as to what it is we are trying to achieve here and how we might be able to achieve it. Then you have your mechanics of joint commissioning and integration towards that strategic end.
Councillor David Rogers: Directors of Public Health have enormous knowledge and experience of population health as opposed to individuals. That is what they would be bringing, in the advice that they are able to offer, to the new structures. From my point of view, that would be extremely valuable and at least as valuable as that offered by Peter’s colleagues as Directors of Social Care and indeed Directors of Children’s Services.
Jo Webber: They also have a wealth of understanding from the evidence base for a lot of health interventions. That can be very helpful when you are looking at how you move towards early intervention.
Q162 Chair: Evidence base or lack of it.
Jo Webber: Yes.
Q163 Andrew George: I want to move on to Dilnot, but may I permit myself-for being well behaved earlier by not interrupting-to build a bridge from the earlier discussion on quality into Dilnot by this route? How sustainable do you believe the system is, looking into the future, if it is built on the back of the lowestpaid workers in the country? These workers are being asked to do work which most of us here would not be prepared to do-that is, to clean up after immobile, demented and incontinent older people-working shifts and still getting minimum pay. Is it sustainable, for this system, to continue on that basis, particularly where you are talking about quality? Staffing complements are often hardly capable of keeping pace with the pressures on them.
Councillor David Rogers: You have brought us back, as you say, to earlier elements of this discussion, and I know you then want to move on to Dilnot specifically. Fundamentally, this is about the way society values older people. In my view, that value, currently, is not at the level it should be, and all the other things we have been talking about flow from that. That is why I mentioned the Commission on dignity in care earlier. It is those dignitytype issues, which, again, you have alluded to in your question, that lie at the heart of so much of this. It is incumbent-not on those of us who are involved in current roles within the system, but much wider than that-on society as a whole to reassess the value of older people. That is not only but particularly because we have a growing proportion of older people within the population, and particularly in less urban than more urban areas. But it does play inversely. That is the context in which we are looking at all of this.
As far as Dilnot is concerned, we see this as an element of the jigsaw that needs to be put into place in order to bring about reform. We not only have Andrew Dilnot’s report, but the Law Commission’s report. Certainly, we have elements of political consensus that a way forward needs to be found. Obviously, that needs to be tested.
Q164 Andrew George: That is right. I will come back into it because the two questions-Dilnot and the one I was asking about, building on the back of the poorest paid-are about future sustainability of the care system. Knowing that the elephant in the room is that the care system is built on the back of the lowest paid we are asking to do some of the hardest work, I want to get an understanding from the three of you about whether you feel that is sustainable. Are the foundations going to crumble?
Peter Hay: The sustainability of social care has always been at question. If you go right back to the Wanless reviews, there were gaps between, if you like, the demand for care and the resources available. Dilnot himself reveals a further gap. The gap has never been disputed. The gap exists. Where social care has responded is by trying constantly to change the way it does what it does. Why we are developing systems around prevention and enablement at the moment is to try and respond to the further reduction and increasing nature of that gap due to the effects of the comprehensive spending review on local government. What we try and do is avert the collapse of social care by constantly trying to reexamine what we do in the absence of the reform and resources that we have clearly asked for for some time.
We would also want to suggest that it is time to rethink where we are on work force. Social care as an employer, in the period to 2010, grew by 7%, and I am sure you would be interested in the job growth going on in there. In particular, personal assistants-people employed directly by citizens with money-are the second biggest group of employees. There are now more people employed in personal assistant roles than there are working in social care and councils, suggesting there is something important about relationships rather than technical skills going on. We fully understand that, but there are real opportunities, in relation to considering this as a work force issue, to change some of those dynamics you have alluded to.
Andrew George: I will get in trouble with the Chairman if I do not move quickly and firmly into the area of Dilnot.
Chair: I have a very liberal view of these issues.
Q165 Andrew George: The Chairman and I respect each other, which is wonderful. Looking at Dilnot in the round, is this going to take us to the sunlit uplands? Is this going to be the sustainable future of care for the next, say, 25 years? There seems to be broad support, with a few exceptions. Do you all believe that Dilnot pretty much has the balance right and that what we need to do is move on and implement it as quickly as possible?
Councillor David Rogers: The questions that he was tasked with answering have been answered, but that is not the whole picture. The key point there is that we do not know what the Government’s response is going to be in terms of future funding-whether that is in an incremental way or in some more major way is, as yet, unclear. We are as interested in the answer to that as, no doubt, you are. The fact that the current system remains at risk, despite all the things that Peter and his colleagues are doing, illustrates the need for reform as starkly as anything else.
Q166 Andrew George: Mr Hay, your organisation felt that it did not deal with the growing funding gap. Is that right?
Peter Hay: Andrew Dilnot’s brief was to deal with the issue of people selling their homes and how they pay for care. He dealt with that brief admirably and in a way in which ADASS has welcomed. It does not, however, fit against dealing with the whole of social care. If we are going to come to that question, we need to address it, particularly from the domain of quality. At the heart of Andrew’s proposals are issues associated with trying to encourage people to use a range of financial products to save for their old age. They will not do so unless we are clear about guaranteeing a quality and a peace of mind that incentivises and builds on that. We do not invest in things on the basis of how broken they are.
Q167 Andrew George: In what way would you tweak it?
Peter Hay: The honest answer, at the moment, is that we do not know. We have not seen or been involved in discussions about what the resource commitments are towards social care. ADASS has been consistently clear that adult social care needs both reform and resources. As with pensions, when those things became clear it was possible to engage in a conversation about the short, medium and longterm priorities and to put those against the available resources. We would like, through the process of engagement and towards a White Paper, to begin those discussions. If you put the resource envelope against those, there is a range of things you could do to achieve all the objectives of both quality and, indeed, looking at how you might recompense people who currently sell their homes. You can achieve all those things, but we do not know, at the moment, what the Government’s intention is in relation to the financing.
Councillor David Rogers: The need for simplicity is one of the issues he tried to address. His cap proposals, an aspect of that, mean that people have a clearer understanding of what they need to do to plan for the future. One of the important reasons why people do not plan at the moment is that they do not know what they are planning for. Anything that brings greater certainty to that is a welcome aspect of the proposals. But all these things need to be done, not cherrypicking one or two of them.
Jo Webber: I would absolutely agree that the issue here is the Government’s response to the Dilnot Commission. I know, from a Health Service point of view, that we cannot delay this and take us back for several years before we come to a conclusion about how we take it forward. Unscheduled demand is still going up at a rate of about 4% per annum. We know that delayed discharges are going up. We know there is pressure on the system. We have to come to the crux of the issue-what is going to be personal responsibility in terms of funding, and what is going to be guaranteed through whatever scheme comes up to the Government? Being in a period of uncertainty is not helpful, at the moment. We need to know that something is going to happen reasonably soon, so the pressure on other parts of the system can be mitigated.
Q168 Barbara Keeley: People keep saying we need to have the debate on social care to move the question forward, yet it does not happen. As I understand it, the social care work force is bigger than the work force in the NHS, with more than 6 million carers. Then there are all the people receiving care. And yet here in the House-where we get 100,000 people pressing us to have a debate on the price of fuel-despite all the need, it seems so hard to get a debate going. Dilnot said that people do not think about it, do not plan for it and do not want to. How on earth are we going to get this going? We are not going to make a decision about billions of pounds unless there is a pressure. Is that not part of the problem that you have been tussling with for years? I certainly found, on talking to people locally in my constituency, that there is little understanding of this. People understand that the council spend money on bin collection but not that they spend it on social care, and yet that is the biggest budget. What can we do about that?
Jo Webber: Part of the issue is that people do not understand the divide between health and social care, so they do not understand the divide between what they will and will not have to pay for.
Q169 Barbara Keeley: Why do they not understand it? Why can we not move it on? We are not going to progress with this unless people do start to understand it.
Chair: Do you understand it?
Peter Hay: No, not always. I have been clear that it is a very complex system with legislation scattered all over the place. It is an extremely complex system to understand. We are very clear that, in ADASS, we would like to see a simple, clear and modern system which is understandable. That includes at the point of entry to the system, which can include dementia or mental breakdown. We have an opportunity to raise the standard.
My counter to your position is that it is too late to understand the system when you become a carer or when you become demented. The tragedy of today’s world is that that is the point at which people start to understand it. Yes, we want a debate, but I am not sure we will get public support for this because it is so difficult to understand, as it currently is. We have an opportunity to place this differently.
Q170 Barbara Keeley: I think this is important. I understand that people who are demented, or their carers, are too tired or confused to engage in the debate, but they will have family members and friends. Here we have millions of people caught up in a system that is not working terribly well, that is causing great stress and pressure to people and has a work force larger than the NHS, and yet we cannot seem to get a debate going about it.
Councillor David Rogers: I share your frustration, and have done for a considerable period of time, that, despite the significance of the issues for individuals, for families and for professionals in various ways, it does not seem to get the public political attention that it should. We are all striving to achieve that in different ways because it is so important.
Q171 Rosie Cooper: One of the basic premises of Dilnot is that we should quantify unmet need. We have been told that one local authority has estimated that one-fifth of its existing selffunders would now qualify for free care. That would cost them something like £100 million. To what degree do you think the Dilnot proposals have taken into account regional variations in implementation costs? Also, what might the total cost be for England as a whole?
Chair: Can I ask you to couple that with this question? If we spend all the money-in answer to Rosie’s question-will that leverage in any private money? One of the key principles of Dilnot is that, if we put £1.7 billion of public money on the table, there is private money that is a new source of revenue for the system. Is that correct?
Councillor David Rogers: Chairman, that was what I meant when I talked earlier about bringing greater certainty. The cap proposals within his report do bring that certainty to give people a target, if you like, that they are aware of. In itself, that will help to bring a higher profile to the system as a whole. There will be a greater understanding of where that level of personal responsibility lies and that the catastrophic costs-if something goes very seriously wrong-either for a younger person or, indeed, an older person, will be met by the state. But it is not easy and, as the questioner has said, there will be regional variations in meeting the costs. I do not think those have been fully explored yet, but we need to be aware that that is the case. That is part of the ongoing debate between the report of the Commission and the Government’s response to it.
Peter Hay: The costs and how they fall is clearly something that can be modelled. They tend to fall over the longer term, but clearly they also do vary geographically. They are also difficult to model without being clear about what some of the policy context is for this. In particular, I would come back to the use of eligibility. There is a contrast between Dilnot’s recommendation about "substantial and critical levels of eligibility" and the work of the Law Commission, which suggests we need to redefine what we mean by eligibility.
To put it at its simplest, the challenge is this. There is an assumption in Dilnot that people will get to qualify at the £35,000 cap and beyond. We need to incentivise people not to get to £35,000. We need an enabling culture. It is in their interests because they keep the money, and it is in our interests-changing this demand constantly away from the top end of specialist services and doing something at these lower levels. That is where finance products come in. Can we find "win, win, wins" which help us to achieve that enabling public climate rather than an entitlement climate-to achieve savings to the individuals and a saving to the public purse? I do not think we are there yet. Clearly, the insurance industry is looking for greater certainty before making its move. We would say it is not only insurance, but a whole range of financial products, that people choose in relation to this. If they can have a range of financial products, we might be able to find things that work in that more enabling way.
Q172 Rosie Cooper: In chatting to various organisations, including insurers, they do not believe this is a market of real benefit to them or that they would get involved in now. If Dilnot is implemented, by the figures of that one local authority-a 20% increase in the number of people who would qualify for free care-how would you manage that?
Councillor David Rogers: I would rather look at a wider evidence base than one local authority-and you would understand that-but there could be unmet need in the system. The very fact that eligibility criteria are being tightened in the current system illustrates that some needs are not being met. That is also part of the case for reform. Whether the figures you are quoting are representative and would be real increases, and how those would then be met, is all part of the debate we need to have between his report and any future system.
Q173 Rosie Cooper: They are all the critical ones.
Councillor David Rogers: They are, yes.
Q174 Rosie Cooper: There are huge numbers of people with moderate needs that are not being met at all.
Councillor David Rogers: Yes. Of course, what happens at the moment-and you started off by referring to selffunders-is that there is a period of time when some people meet their own costs, they run out of money and then they become the responsibility of local authorities. It is a very complex system, both for the individuals concerned and for those who, in their professional life, have to try and manage the process.
Q175 Rosie Cooper: If that situation exists, they become the responsibility of us all, and the local authority by default, if you like, and we have to find a solution. We cannot keep driving down costs and expecting quality to go up. I know we talk a good game, and I am tired of listening to the good game, but the reality out there is not necessarily the goodgame talk.
Peter Hay: What we have is a responsibility to reform this system. Behind your question sits an assumption that this would be backloaded for those who have paid for their own care. That would have to be part of the discussions about implementation when we are clear about what the resource envelope is. Also, there is an important decision about how the state gets involved in people acquiring or consuming their resource up to the cap, and the rules for those that have already done that would need to be set with it. That is a context and a debate that can be had when we are clear about what we are trying to achieve and the financial envelope we are trying to achieve it in. To add to the costs at the moment without that debate does not take us forward, so I would like to model that carefully.
Q176 Barbara Keeley: Can I ask an extra question on what you have said? There is paying for your care up to £35,000 or there is your family, effectively, paying for it by providing it. That seems to have been ignored.
Peter Hay: Absolutely.
Q177 Barbara Keeley: Do you agree that Dilnot should not have ignored that? There is going to be no incentive, in some ways, for a family to provide months and years of care.
Peter Hay: That is why I also referred to the tension with the Law Commission. The Law Commission are very clear. They use eligibility because we understand it, but the Law Commission virtually say, "For goodness’ sake, do not put into the new law the current eligibility because it militates against carers." Those who do the most for their families and each other, sometimes at enormous stretch and strain, tend to get the least. We have to find a way of building this system from another capacity. What is now clear is that there will never be a point where we close the gap financially. How we close this gap is about working with the contributions that people make-the contribution of carers and the contributions of communities. It is all of that we need, not just money. We absolutely have to enhance that in some way. One of our concerns is that you do not get this rush to the cap. You are trying to come the other way, are you not? How do we do that when we have never achieved a public policy framework that puts the priority on prevention because the drains always come from the top end?
Q178 Rosie Cooper: A thought has just entered my head. If you are selffunding then you pay, often, more than the local authority is paying. Therefore, you are usually paying more than cost to subsidise those who are coming in at a reduced local authority rate. If you hit that £35,000, or whatever that cap is, more quickly, then your safety net starts to disappear pretty quickly.
Peter Hay: Yes. We have assumed, however, that, clearly, in reaching the £35,000 new rules would have to be set for the consumption of that resource. It would change the entire funding mechanism because of the dual payment system you referred to. Again, those are all assumptions and a debate is needed about how they are taken forward.
Chair: I am conscious of time. Valerie wants to ask a few questions on FACS-fair access to care services-and Sarah also on personalisation.
Valerie Vaz: Yes, I do, but I thought Rosie was going to lead on them.
Q179 Rosie Cooper: Yes, very quickly. I have a question for Councillor Rogers. It is essentially the continuation of the point that social care should not exist solely as a welfare net for those with the severest need or limited means. If vast numbers of councils are only providing that service at that level, surely we are saying that social care is now a welfare net.
Councillor David Rogers: I do not think so. As I have referred to in several answers already this morning, we do not see social care with that very tight definition, which is the one that you are using. We see the services that local authorities provide, across a whole range of different areas, as being part of the care and support that individuals have within their communities to keep them as independent as possible, to keep them living in their homes where that is possible, and all the rest of it. So it is also about information and advice. That has been referred to several times this morning. I would not disagree that there is still room for improvement in many areas, but significant strides have been made in recent years to provide better information and advice for everybody, including those who are paying for it themselves. It is also important to realise that the context in which we are looking at this is one of striving towards integration. I know we touched on that earlier, but I do think that is the right way forward.
Q180 Rosie Cooper: Could you give me an example of anything other than advice that you provide to people with less than substantial or critical needs?
Councillor David Rogers: There are all the universal services that are available to everybody. We have touched on them already this morning, but I can repeat them. It is things like leisure services, being able to be active. That includes activities in people’s own homes or in care homes. There are services of that nature. It includes transport services, libraries and cultural activities.
Q181 Rosie Cooper: But everybody gets those.
Councillor David Rogers: Yes. That is what I am trying-
Peter Hay: Can I specifically help, as it may connect with the coming questions on FACS? As I said, we are keen to invest in a different way of doing social care, prevention, universal services, enablement and substantial care. In Birmingham this year, we are putting £4 million into telehealth care. Telehealth care is not assessed using eligibility criteria. It is assessed by your ability to make use of it. The enablement service operates at moderate, substantial and critical and, clearly, we turn to people at those levels. We have invested a lot of money in falls prevention. The eligibility for that is whether you have had a fall, not whether you meet FACS criteria. We are putting work into mental wellbeing for older people. Again, it is the depression you feel in old age, not FACS criteria. Also, we are doing work for people with a stroke, using conductive education. Again, that is determined by the stroke and by the evidence that, working together, it prevents things happening in the system. We may be able to retrieve that.
That is all about trying to invest in this different model of prevention, enablement and substantial care. Quite clearly, in FACS, in the period to 2009, when resources were increasing, the number of older people being served was falling. In Birmingham, because of our demography around young people with disabilities, we were keeping up with that, but the number of older people being served was falling at greater rate than the national average. We have been trying to reverse that trend because, clearly, the FACS criteria are not working properly in a different approach, as Jo referred to, to older people in particular with longterm conditions, and to how we deal with this in a different way to avoid crisisled responses to old age.
I hope that gives you some examples of money being spent from the social care envelope. I am taking £50 million out of the budget but I am spending more on prevention now than I did in 2009 by a considerable factor.
Q182 Valerie Vaz: Before I go on to FACS, how are you measuring the outcomes for that?
Peter Hay: They are very different things. The conductive education is a full universitybacked research programme with The Stroke Association. The falls prevention is more from local measurement, to track that through and to show the benefits. There is <?oasys [pc10p0] ?>the telehealth care thing we built, and the whole system demonstrators that are about to be published, so there are different ways. What we are trying to do-this links to the cryptic remark earlier-is to produce evidence from our practice because there is no evidence on prevention at the moment. What we are trying to do, with the explicit consent of the council-and it is not the only one doing it-is to invest in different ways of producing it and to build the evidence case. If it does not work, we will not repeat it.
Q183 Valerie Vaz: Coming on to FACS, I would like to hear from all of you what your view is on it and whether it is working. Added to that, could you give us your remarks on the portability of it? We have had evidence from people who are assessed in different ways by different authorities. How do we stop that?
Councillor David Rogers: That is certainly a possibility under the current system. As part of a package of reform, we have consistently supported an assessment that would be portable and therefore would mean the same thing wherever it was carried out. How the needs then identified might be met could vary, depending on local circumstances-the nature of the place in which the person lived. Clearly, certain types of services are more readily available in urban areas and they are perhaps not so easy to provide in very remote rural areas. There are all sorts of other comparisons you could draw. The portability of the assessment is something that we would fully support. I hope that answers the second part of your question.
Q184 Valerie Vaz: Yes. Does it still work? Do you think there should be a new role for it now?
Councillor David Rogers: That is an element of the reform we would like to see, and we have said that consistently, both when social care reform was being considered by the previous Government and, still, with the current Government.
Jo Webber: I would agree. We would also support the portability of assessment. Obviously, the way in which that assessment is carried through to services that somebody receives is going to be different depending on their own circumstances. People need certainty about the fact that they are not going to be assessed in one way in one place, and needing something completely different somewhere else-that their needs carry with them. That does not mean to say, obviously, that needs cannot change over time. Of course, they can. But that initial ability to port your current assessment across is very important.
Peter Hay: FACS is a way of rationing care. It does not necessarily mean that is the best use of resources. That is the tension we have had. It has served as a lever for the rationing, but clearly, as I have indicated, there are other ways of trying to find a more effective use of resources. For many reasons, we are clear that FACS is reaching the end of its life. But I should be very clear that it is, of course, in legal terms, the only way in which councils can control their budgets. One of the reasons it is so significant is that the law is very clear. If you are going to alter your allocation, you have to do so through the prism of FACS, so I should put that caveat in very carefully. I know that very well.
Q185 Valerie Vaz: There is a wide definition.
Peter Hay: Absolutely.
Q186 Valerie Vaz: I was wondering if it is probably better to have something like NICE guidelines-I am using NICE in the general term-where all local authorities have the same criteria. The point about FACS is that there is a lot of uncertainty. Every local authority defines the different categories in different ways. Also, on the portability issue, if you are taking it to another local authority, are they obliged to apply the same criteria? Are they obliged to help the person have that same package all the way through?
Councillor David Rogers: Peter has pointed out that that is the legal basis for this work at the moment. I agree with that, obviously, but I have also said that I recognise-it is similar, again, to Peter’s remarks-that it is perhaps not the most useful or mostlikelytosurvive mechanism for the future. Therefore, we need a standard system by which people are assessed and their needs are recognised as being the same wherever they might be. How those needs are met-and I need to stress that second half of it-will depend on them and their communities.
Peter Hay: What we are looking for is tools that get you the best outcomes and the best use of public money rather than just this rationing device. That is linked to the points Councillor Rogers has made very ably about a great local strategy and how you are meeting that need. Things that help with that, rather than restrict this box, as we have been doing with needs and means, would be very helpful.
On portability, we should be clear that there are also differences between workers, as there are between councillors, as you hear from people who use the services. The guarantee people have is that they have a support plan which lasts till the next review. They never have a guarantee of the same thing for life. We need to find a very simple way, through portability, that says, "That was your plan for the next year till your next review. You can plan a move, accordingly, within that period," and we need to trigger it towards that next review. We are making a mountain out of a molehill, if I may say so, on portability. We need to find a way through that guarantees that. It is significant for those people it affects, but I don’t think it is the way we need constantly to come back to this sole issue in reform.
Q187 Barbara Keeley: Can I take us back to the role of information in social care, as we have touched on a couple of points? As with the need for a debate, there is probably a need for a revolution in the information that is provided because that can really enable the choice and control we want to see people having. Could you comment on what progress you are seeing in that information revolution for social care?
Peter Hay: We have seen considerable progress in recent years, but we would say this is still in the nursery. It has an enormously long way to go to create the kind of informed consumers at the end of this that we were referring to. It starts with the recognition afforded to those people who selffund and councils realising that they have a role in helping people use their own money. It is also about the role of information and prevention-helping people make decisions much earlier-as well as information in relation to market choices and the buying of care. We are seeing some developments in there and a lot of activity going on, but we should all be clear that it has a really long way to go and it is a very serious kind of development. It must be trusted and accurate information too in order to build that credibility. It is something we would like to accelerate the development of.
Councillor David Rogers: To add to that, an aspect of it is identifying carers because, as you will know, I am sure, there are many who do not consider themselves to be in that role, whereas an outside observer would clearly see that was a role they were playing. It is about retirement planning, and planning not only for a specific date but for the needs that might arise. It is things like lifetime homes and accessibility standards within buildings. As has already been said, improvements have been made but there is still a way to go on that.
Chair: We do have to have an absolute deadline of twelve o’clock, so, Sarah, can we quickly cover personalisation?
Q188 Dr Wollaston: Can I move on to the whole subject of personalised budgets and personalisation in general? How do you respond to the charge that personalisation can undermine services for certain vulnerable groups? I am thinking, particularly in my area, of the John Parkes Unit which provides for severely handicapped children. Parents of those children are now being expected to move towards personalisation, but feel the trouble is that no private provider is going to want to take on the risk of providing the high costs. They feel that personalisation is undermining the service and would like to see block contracts. Equally, there are groups, such as those living in rural areas, who might feel disadvantaged. How would you respond to that? Is it appropriate for everybody?
Peter Hay: Clearly, the situation you referred to links to special educational needs and different related initiatives. My experience, and that of, I suppose, my colleagues with me, is in relation to the use of personalised care in adult social care need. What we have seen is the ability of people to use it; it is less about the device. It is about helping you to get the support you need in accordance with your support plan, to lever in resources from your network and those around you, and from the care market-the things that best support you to do that. We are seeing better outcomes and some efficiency. We are certainly seeing a very big movement away from the use of block contracts as people make choices accordingly. The key point in this is people getting the support they need in a way that they need it.
Q189 Dr Wollaston: Do you feel there is a case that sometimes the services are not provided because they are quite high risk to provide?
Peter Hay: We only release a personal budget when we are satisfied that the support plan in place is appropriate for the use of that budget. You absolutely have to be sure about the support plan and its adequacy before you release the money.
Councillor David Rogers: There is also a role for local authorities to encourage market development in a whole range of services. I am a councillor in East Sussex and something that council is doing-with a range of very small providers, starting with personal assistants, whom we mentioned earlier, but going up through the whole range-is encouraging more job creation and employment opportunities within that market, and therefore more choice for those who will have the budgets to deploy.
Q190 Dr Wollaston: Do you think there might be a problem in the future with some unscrupulous personal assistants undermining the system or not providing adequate care for vulnerable groups who are not in a position to let people know that that is happening?
Peter Hay: We heard a lot of those concerns when we started to introduce this. Personal budgets are now being used by one third of people using adult care, and it is very hard to think of large numbers of those kinds of instances. It is partly because it absolutely comes down to being very clear, before handing over the money, about how this plan meets the support needs, and it is also about informed people being on top of the quality and value for money they are getting. There are, of course, as there are in any system, risks and dangers but we have not seen that as a feature.
Q191 Dr Wollaston: Overall, it has been a great success in your experience.
Councillor David Rogers: Another way of answering the question you put is that trading standards within local authorities around the country have for a while been using systems involving a quality, reliability and trust procedure in relation to people like plumbers or electricians. That principle is being extended now into the sort of market development Valerie was referring to. East Sussex is doing that. There may well be other examples of that around the country.
Q192 Valerie Vaz: I have two quick questions. What happens when their personal budget money runs out?
Peter Hay: You said, "What happens when the personal budget money runs out?"
Q193 Valerie Vaz: Yes. If they get a personal budget, what happens if it runs out? Let us say they have used it on all sorts of things.
Peter Hay: The money is linked to a support plan. You cannot simply have it in a pot that gets used. Again, that has not happened that I am aware of.
Q194 Valerie Vaz: They take control of it.
Peter Hay: Yes, absolutely. You put the necessary checks in place upfront.
Q195 Valerie Vaz: We have had written evidence from Professor Ann McDonald who says that personal budgets do not work. She says it is developed around rhetoric rather than from a strong research base that assesses outcomes for all user groups. What would you say to that?
Peter Hay: I would ask to show some other piece of evidence, not least the ADASS work done recently surveying 58 councils. If you look at that, the work of the National Audit Office and all those kinds of things, they point to the satisfaction of people with the use of these tools. We have some way to go. If we were to flag up the successes, it has been successful in helping us devise a different model for planning social care, thinking about preventing and enabling in particular. We are showing some-
Q196 Valerie Vaz: Do you think she is wrong?
Peter Hay: We are showing some very good outcomes in particular groups. Taking people with disabilities out of day services and into day opportunities and using personal budgets has been a major success. It is more difficult as you talk about older people with severe dementia-of course it is much more difficult-and particularly if all you are offering is a transfer of money using direct payments and all the complexity that comes with it. We still have some way to go with further development, but it is absolutely right to broaden the menu from the old fixed menu of provision to the support needed.
Q197 Valerie Vaz: I am conscious of the time. Thank you. What do the others think?
Jo Webber: Obviously, we are interested in the development of integrated personal health and care budgets. There has been some work done, particularly in mental health, as to how those work. The evidence we have is that they are welcomed by people using services. The challenge is the change in culture. Social services themselves would say it has been something they have had to live through-that change in relationship and the power dynamic between the professional and the user or their carers. That is something we are very early on the road of in health. This is a very longterm agenda. I do not think you are ever going to have anything other than a mixed economy for the foreseeable future, particularly around older frail people with carers the same age as them who may find personal budgets quite challenging, given everything else they are doing. That does not mean to say, in the long term, we might not get to a place where those integrated budgets could be the norm.
Councillor David Rogers: I do not want to repeat what has already been said. The evidence I have seen shows that people feel more empowered and more in control of their lives when they have a personal budget. To my mind, that is a good thing. But it does provide a challenge for professionals and, indeed, less professional staff-lower levels, I mean, not entirely unprofessional-who have been used to working in other ways in the past. It is more challenging for them than it is for those who use the personal budget.
Chair: We have gone beyond our deadline, but Virendra has one very quick question.
Q198 Mr Sharma: Before becoming a Member of Parliament I had some experience, over 10 years, of working in the social care field. I found that there was always a difficulty when the families who were the carers saw that income coming through as supplementing their own income, rather than using it. Do you not see that there still will be a conflict within the families when the income will be used for different purposes, rather than in the house?
Peter Hay: It is not income. It is a resource to build on the support you already have and to add to that support in accordance with suitable advice.
Q199 Mr Sharma: But the families see it as income.
Peter Hay: It is about the integrity of that support planning process, not cash on the table.
Chair: It is a familiar dilemma. Thank you very much. You have answered a wide range of questions very fully. Thank you very much indeed.
Examination of Witnesses
Witnesses: Mark Lobban, Director of Strategic Commissioning, Families and Social Care, Kent County Council, Helen Buckingham, Director of Whole System Commissioning and Deputy Chief Executive, NHS Kent and Medway, Sheila Bremner, Chief Executive, North Essex NHS PCT Cluster, and Jenny Owen CBE, Deputy Chief Executive & Executive Director for Adult Social Services, Essex County Council, gave evidence.
Q200 Chair: Good morning. I am sorry for keeping you waiting. You were probably in that session and heard that we covered quite a wide range of questions. Could I ask you to introduce yourselves and tell us where each of you comes from, please?
Mark Lobban: Good morning. I am Mark Lobban, Director of Strategic Commissioning for Kent County Council. I have been in post for only the past two months. For 12 years prior to that, I was the Assistant Director of Hertfordshire County Council. I am responsible for commissioning.
Helen Buckingham: I am Helen Buckingham. I am the director of Whole System Commissioning and Deputy Chief Executive of the Kent and Medway cluster of PCTs. I have been in the Medway system for nearly three years, but have been working across Kent only since April so, like Mark, I am a fresh pair of eyes on what is happening in Kent.
Sheila Bremner: Hello. I am Sheila Bremner. I am the Chief Executive of the cluster of primary care trusts in North Essex.
Jenny Owen: I am Jenny Owen.
Chair: Hello, again.
Jenny Owen: Hello, again. I am the Deputy Chief Executive and the Director for Adult Social Services for Essex County Council. I have been there for seven years.
Chair: Thank you very much. Andrew, do you want to lead straight off-first of all on Dilnot-as you need to go?
Q201 Andrew George: Yes, and my apologies for having to leave. You were all here earlier and heard the question-and therefore I will throw it at you-as to whether you believe Dilnot is the sunlit uplands. Does it provide the way forward and it is just a question of implementing it, or are you concerned, particularly in areas like yours, that it is going to mean that the public purse is going to be brought into play for a large number of people who are currently selffunders?
Mark Lobban: That is absolutely true for Kent. Obviously, it is a concern in the southeast. If you look at the demographics and the income in the southeast, it absolutely is the case.
Q202 Andrew George: In Essex, you have large numbers of selffunders, I think.
Jenny Owen: Yes. The first thing-and the most important thing-about Dilnot is that it will help people to understand what they will and will not pay for. It will set something much more clearly, which you were talking about earlier and which is absolutely apparent, that people do not plan, cannot plan and do not understand what they are going to have to pay. It will address that. It will address a cap and then the public purse will kick in. It will, therefore, cost an authority like mine more money.
What I do not know is how the Government will respond to Dilnot and how it will change a resource allocation to a place like Essex. All I can do is calculate-if, according to Dilnot, the cap comes in at that amount-how long people tend to live beyond the point at which they need that care. All that modelling I can do. What I do not know is what would be the expectation about how we would meet that within existing resources. The big issue is that it will make it more transparent and show what people pay. It will not bring, necessarily, extra money into the system. The range of questions you were asking earlier make it fairly apparent why we need extra money in the system.
Q203 Andrew George: Yes. Do you believe, in the current system, that people entirely understand that they are still meeting the hotel costs, in a residential setting? Obviously, under Dilnot those are not covered-they are not in the equation-and, therefore, people may be under the false impression that the cap will apply and, beyond that, there is no other cost.
Jenny Owen: That is right. I do not think that that is clear yet. Until the Government decides whether it is going to adopt it or not, I do not think that programme of information will get out. At the moment, people are not clear what they would have to pay for, how much that would mean and, therefore, when they would reach that cap. To give you an example, people living in residential care in Essex at the moment tend not to live more than two years. How many people will therefore go over the cap? That is why you have to do the modelling.
Mark Lobban: I am hoping, as well, that it may even be a catalyst. If you think how we have had developments in housing, particularly extra care housing where you have support on site, there has not been that massive change that has been required over the years from residential to extra care. There has been great progress made in some areas, but I am hoping, with Dilnot, when you begin to look at hotel costs, that people will start to demand different models of care where they can invest in property. We might see more alternatives to residential care and have a big leap forward with extra care housing.
Q204 Andrew George: Other than seeking clarity about the Government’s response and how much they are going to put into the system going forward, do you not see any need, yourselves, within your own areas-in Kent and Essex-for any other amendments to the recommendations by Dilnot? You are relatively content.
Jenny Owen: I thought it took us a long way forward, so I would welcome them being introduced. I do not think it puts extra money in the system-that is my main beef.
Q205 Chair: Do you agree with-I think it was-Peter Hay, who said in the previous session that he felt that if there was a proper discussion, and we addressed some of the questions that Dilnot addresses and some of the quality questions, the result would be an environment where it would be more realistic to get people to plan their own affairs to meet future requirements for themselves through financial products, rather than waiting till the bill landed? Do you agree with that view?
Jenny Owen: I do agree with that view. We did a lot of work across the social care sector prior to this Government when the previous Government was looking at a White Paper. I thought then it was starting to open up a debate about how a system could be sustainable: what should the public purse pay for; what should the private purse pay for; what could individuals pay for? Obviously, we are in this rare moment in time when there are a lot of older people who have their money tied up in their property. It is not going to be a "for ever" situation but, at this point, we have a situation where large numbers of older people do have property, that is where their money is and they are not planning. I think Dilnot will take us forward into that debate, which stopped and needs to start again.
Q206 Chair: Thank you very much. Can we move on to the subject that you are obviously, as two teams of two, particularly well qualified to talk to us about: the extent to which the process of integration between health and social care is being developed in your localities. Do you think it is successful? What has helped it recently? What has hindered it? What stands in the way? If we could start with understanding where each of you are coming from on the integration agenda, that is the issue we would like to focus on.
Mark Lobban: As you know, I have been in post for two months now, so I have spent a considerable amount of time visiting various establishments in Kent and talking to lots of people. I have noticed an incredible wealth of innovation within Kent. One of the issues we have is that we have not consistently rolled it out across quite a large geographical area. So we do have these examples of innovation. Another issue is that we would need to look at how we join up a strategic overview of this, particularly working with health. What I have witnessed is lots of very good personal relationships across health and social care and, where you have these very good personal relationships, innovation has flourished. What we now need to do is to step back and look at how we can have a consistent approach across the county.
Helen Buckingham: I would support what Mark is saying from my perspective, coming in across the cluster. I see some very good examples of integrated working in Kent. I have seen examples of that, in my past, as well as in other places. What I do not see in Kent right now is a structured and strategic approach to delivering better outcomes through integration. What I do see is a great deal of commitment from the new leaders in our system-I include the clinical commissioning group leaders in that-to working differently. Recognising integration of health and social care, both at the provider level around the individual patient or person who uses the services, and at the strategic commissioning level, is one of the absolute key things we have to get right to tackle the challenges we face in the future.
There is a lot of opportunity for us to do things better and a lot of willingness to do that. Where we are now is putting the structures in place around that. The discussions that Mark and I have had since coming into post, and which we have had with our colleagues, are very clear. We will get the outcomes we want to achieve only if we have the right will and the right relationships-and that means building a lot of personal relationships-and also the right governance processes around those that enable us to take decisions and put them into practice.
Q207 Chair: Integrated services means changing the way care is delivered in some very fundamental ways, does it not?
Helen Buckingham: Yes.
Q208 Chair: Do you think that good relationships, even if they mature into good relationships between institutions, are able to do the heavy lifting required to achieve integrated services rather than cooperating services?
Helen Buckingham: Not on their own. That is why we need the structures for them as well. Good relationships are a prerequisite because some of these discussions are difficult and you need to have the relationship to sustain you through the difficult conversations and the difficult implementations that we all have. They are necessary, but not sufficient in themselves.
Q209 Chair: What more is required? I am sorry, but we will come to Essex in a second. If we have something that is necessary but not what is sufficient, what more is required?
Helen Buckingham: We are putting in place a structure-and Mark might want to talk about it as well-which enables us to bring the people who make decisions in the new environment as well as in the old environment together in the right place. We are basing that on the outcomes framework for health and social care. We are focusing, all the time, on getting better outcomes for people, in this context Kent and Medway-Kent for today’s context-and doing that in a way that makes the best use of our resources. We cannot ignore, and we have not ignored today, the financial challenge around us. Our challenge-our duty-is to get the best value by, if you like, dividing outcome by cost, and the best way of using our resources mutually, again thinking about it from the point of view of the individual service user and the organisation. Organisations exist only to serve service users. They do need to exist to serve service users because we need sustainable services, but we have to focus on having organisations that can deliver personalised care. That is a big cultural shift for the organisations as well. We need the structures in place that enable us to keep having those conversations, to shift our minds as leaders and to support and empower the people on the ground who deliver all these services and think about the individuals they serve to do the jobs that they want to do.
Mark Lobban: As I said earlier, there are real examples of innovation. The plans we have at the moment for integration are exciting. The willingness to integrate services so that there are single points of access and building teams around GPs is absolutely fantastic. The challenge is how we make this consistent and roll it out across the county. I have worked in commissioning for 20 years now and this is probably the most difficult time during that period because it is down to governance. If we are very clear about governance and who is making the decisions then, for people in my position, it is very easy to commission services. Why is it so difficult? An example in Kent is that we have eight clinical commissioning groups-obviously, with Medway as well, which is unitary, there are nine clinical commissioning groups. Of course, we are also embracing localism and moving towards 12 locality boards for local government. Today my decision making-where I get my decisions-is absolutely from cabinet; tomorrow, increasingly, through 12 locality boards, working with a PCT cluster board at the moment that cannot really take decisions-and quite rightly so-without discussing and seeking agreement from eight or nine clinical commissioning groups. It is very difficult then to roll out some really good practice across such a wide area.
Q210 Chair: Can we hear how you do things differently?
Sheila Bremner: There are some similarities, obviously, in terms of the progress that has been made in Kent. You touched on some of these issues in the earlier session. There is an issue as to the definition of "integration". Are we talking about integrated commissioning or integrated provision? In Essex, we have examples of both. There is a very clear intention about the integration agenda, and the agenda has been around for a long time, but how much progress are we making? We have something in the order of 18 or 20 different examples of integration across Essex, but I would agree with Helen that the approach to it has been ad hoc and evolutionary rather than strategic and organised. That is perhaps the bit linking to the second part of your question about what more is needed-the bit that is missing.
There is evidence, across a number of the examples of integration, that they are delivering the benefits we intended them to, in terms of patient experience, outcomes and financial benefits to the system. Going forward, perhaps the reforms offer us a number of new opportunities, through the Health and Wellbeing Board, to be very clear about the strategic intent in terms of integration. What we need, in addition to that, is very clear leadership and ownership of the responsibility for commissioning integrated services across a particular client group, for example.
There is also a cultural issue, which perhaps links back to the first point about relationships, although I think it is a bit more than that, and links to the personalisation agenda as well in terms of expecting to be able to commission-either at an individual personal level or at an organisational level-care which is joined up and not fragmented. Jenny, I do not know whether you would add to that.
Jenny Owen: I agree with Sheila. What I can do, which perhaps you cannot from Kent, is give an historical perspective, having been there seven years with at least three NHS changes in that time. I have to say that it does not help. You asked earlier on, "Is it impossible?" It is, almost. When I came to Essex in 2004 we had 11 PCTs all wanting to make their own arrangements because they were accountable bodies. One of those was a care trust in the centre of Essex, so we could do some comparisons. It was quite useful to be able to monitor the outcomes that they were able to achieve for older people versus the other areas. The outcomes were good-financial control was not quite as good, but the outcomes were good. But then that changed down to five PCTs, and five PCTs that were commissioning bodies. The care trust was a provider organisation and did not survive the change into the commissioning PCTs. We are now down to two clusters with seven GP clinical commissioning groups-potentially seven, as it has not quite landed yet, but about seven-also going down to a lot more local arrangements around locality boards.
What does not help is changing the system. You can get good integrated working but it almost always gets unstitched. It does not survive. Coterminosity would be brilliant. In places as big as Essex and Kent, you have to be realistic that that is not likely, but boundaries are important, as is, if you have to work across boundaries, being able to get some principles about what can be consistent. When we started working seven years ago on trying to get a single assessment-I do not know if any of you remember the importance of single assessment across health and social care; I know the Chair does-it was difficult in Essex because we had 11 PCTs. I needed, for the county, one assessment system, but the 11 PCTs wanted different assessment systems. I could not work on one IT system to do that.
Q211 Chair: You still have 11 separate IT systems, do you-probably more now?
Jenny Owen: We do not have 11 different IT systems, but certainly we have different IT systems that do not talk to each other very well. We are now buying a system that we think will help to integrate the data about people, which will give us costofcare packages across both health and social care. If that works, it will be wonderful.
I wanted to give that perspective because, over the years, there have been substantial attempts to do one definition of integration, either joint commissioning or aligning our budgets, or, in the case of the care trust, seconding the staff in and doing the whole thing. We are all opportunistic. We look for opportunities to develop integrated working and we have, as Sheila said, a significant number of parts of our services that are working in an integrated way. But it has never had that requirement for governance in the way that children’s work absolutely did. It absolutely buckled down-"You must do it like this." In the adults world we have never had a "must have" governance framework for joint commissioning. That is why the Health and Wellbeing Board will help us move that forward in terms of governance.
Helen Buckingham: Could I add one more point on that from my past experience as well, relating to the Health and Wellbeing Board? Mark said that he worked in Hertfordshire. I have also worked in Hertfordshire in the past, when we had eight PCTs. One of our biggest challenges was not integration between health and social care-everybody got that. What they struggled with was pooling budgets and working in different geographic areas: why should one part of Hertfordshire put money into a pot that would be spent in another part of Hertfordshire? What we are trying to do now, as we build the new structures in Kent, is start right from the beginning with conversations with the emerging clinical commissioning groups and the Health and Wellbeing Board about that tension, which is always going to be there, as to the local priorities and the greater good. Simply putting the problem on the table does not solve it, but if you do not put it on the table, you are never going to solve the problem.
Chair: Rosie has a view about Health and Wellbeing Boards she would like to explore.
Q212 Rosie Cooper: Jenny, you talked about Health and Wellbeing Boards but they do not have decisionmaking powers. Sheila, I think you talked about strategic intent. Mark described a chaotic proliferation of potential decisionmaking bodies, which is reflected in most of your comments. How do you see that helping you and how does that impact on your ability to have an integrated care agenda from April that really starts to motor and to make a difference to the people who depend on you?
Jenny Owen: I am going to give it a good shot. It is better than things we have had in the past. I have been around long enough to remember joint planning arrangements and joint frameworks and so on. We have been operating in shadow form for about a year but we have not been able to bring on the clinical commissioning groups because they did not exist. They had not formed their boundaries. We now have the representatives of the clinical commissioning groups on the Health and Wellbeing Board and we have had a development day. Basically, you are right. We do not have a statutory power to enforce. What we do have, though, is an opportunity for that body, which is an executive body of the council, and is going to make decisions for the council, to build partnerships and the understanding, based on a good assessment of the need of our communities in Essex, of why we would have these joint strategic priorities-
Q213 Rosie Cooper: Could I ask you a question?
Jenny Owen: I want to finish the sentence. It is in that agreement about the priorities that we will find a way forward.
Q214 Rosie Cooper: You talked about having seven commissioning groups.
Jenny Owen: About that many.
Q215 Rosie Cooper: How many of them were represented at that development day?
Jenny Owen: Four or five. It was five, because two have not settled yet.
Helen Buckingham: Obviously, we are going through a similar process in Kent and all our CCGs are engaged in that process.
Q216 Rosie Cooper: They were all there.
Helen Buckingham: They were all there. They are all at a different stage of development but they were all there at the table.
Mark Lobban: The point I was making was that the transition is very difficult, so it is seeking that clarity. I am very happy that we will have 12 locality boards because Kent is a huge area. I am very happy that we have the number of clinical commissioning groups we do. It would be great if they were coterminous, but we have to deal with that. The problem I have, of course, is the transition. At the moment, it is the distinction between when you go to cabinet and when you go to locality boards and we are thinking hard about what can be devolved to the locality boards. Of course, we work very closely with the cluster board and their relationship is developing with the clinical commissioning groups. That is the environment we are in at the moment.
Q217 Rosie Cooper: When you say "what can be devolved to the locality board," can you explain to me what you mean?
Mark Lobban: Yes. This is the localism agenda. My decision making, at the moment, goes via our countywide cabinet. The cabinet will decide what powers it wishes to devolve. Kent has set up 12 locality boards, with district and borough council members-I think there are five in place at the moment-and the decision needs to be made. It is a bit like the fire service, where you have a countywide-
Q218 Rosie Cooper: Do they have the powers yet?
Mark Lobban: No, they do not but, of course, we actively work with them.
Q219 Dr Poulter: I have a couple of questions. Helen made the point that, at the moment, although there may be some good examples of where things work individually on the ground in some areas, there is nothing overall that is strategic or structured in place, and there is a hope that the Health and Wellbeing Boards would be useful in helping to provide some structure in that respect. In terms of getting integration of services, it is not only about structures, necessarily, is it? It is also about how the services are reconfigured in an effective way on the ground. Would you say that the primary driver for service reconfiguration is often a financial driver and that, if we want to get proper integration, there needs to be a financial driver that assists with integration because relying on loose relationships has not necessarily been good enough in the past and will not necessarily be good enough in the future?
Helen Buckingham: That is an interesting one, and a very interesting one as we see GPs taking over the leadership role. We cannot park the financial issues. They are very real. There is a real risk of changes being proposed which people assume are financially driven when the drive is about better outcomes. Thinking about some of the work we are doing in Kent at the moment, we have done work in our hospitals, so far in West Kent and spreading out across the whole patch, looking at what happens when somebody is in hospital. Is every day of their care in hospital an active day of care? No, it is not. Why would that surprise us? We know it is not. Why is it not an active day of care? A lot of it is about waiting for the next bit of the system to work again. Why would that surprise us? Seeing the response of the clinicians to that work has been fascinating. They want to fix that because it is the right thing for the patient. It is the right thing to get the people who use services in the right place to get the best outcomes for their care. It will have a financial benefit because of the number of days which, in a sense, are being wasted, and that will help the whole system, but the driver is about better care and outcomes for the individual. There is a real challenge for the clinical and managerial partnership, as we move forward, in linking outcomes and value for money in a much stronger way than we have done in the past.
Q220 Dr Poulter: You mentioned "value for money" there, which is the issue. The concern is, if we talk about, for example, preventing people inappropriately being admitted to hospital and the costs of that, say, for the longer stays associated with dementia, there is a human issue and there is a financial issue. It is very expensive and people are presenting in crisis because they are not necessarily properly supported in the community. Having structures in place is one thing, but, at the moment, you have separate budgets. Would you say that making those budgets work better together, or integrating those budgets, would be a very effective way of making integration happen in reality?
Helen Buckingham: This is a personal view-and others may want to comment-but we always have to couple the governance arrangements, whether that is pooled budgets or whatever else, with the cultural and relationship shift. One on its own will not deliver the change that we need. We can put whatever structures we like in place. I have worked in places which have had good joint commissioning with good outcomes and places that have had weaker, shall I say, joint commissioning and we have not had the good outcomes. The structure has been there but that has not been enough to deliver the change. In other places, the relationships have been there, but that has not been enough to deliver the change. It is bringing the two together that gets the change we need. It is about making sure the person on the ground-who is, in a sense, pulling the person who uses services through the system-feels they are able to do that and can challenge when the system is not working so that they are empowered at the individual level as well as us, as leaders, challenging each other about the way our organisations work together.
Sheila Bremner: If you are clear that there are some aims in common and there are pots of money associated with delivering those aims, it makes a lot of sense to put them together. It also makes a lot of sense to put the leadership for the delivery of those objectives and the safeguarding of the money together in one place as well. I think it makes a lot of sense. With all of these things, I do not think it is an "either/or"-one works and one does not. As Helen said, there are examples-I have worked with pooled budgets-where they have worked well and not quite so well. I do not think it is necessarily the structural change. There is the leadership issue, the cultural issue and so on. But I can see that it makes sense to say, "Okay, let us put the money in one place and be clear about what the outcomes are."
Q221 Dr Poulter: On that particular point, there are, as I say, areas where there is good leadership and good relationships between health and social care, but there is great variability. It is patchy even within different local authority areas. In bringing the budgets together, would that be an effective way of reducing the variability and having it as a crude mechanism to help support this integration we have been talking about? I am not suggesting necessarily a complete budget fusion, but would some way of doing that be a good facilitative measure?
Sheila Bremner: It could help. In view of the variability, it will help and be much more successful in some places than in others. It is a bit like asking whether we need to have organisational change to integrate services at the provider level. You need to put people into the same organisation and have them managed in the same place. Sometimes you do and it helps; other times not. As well as putting the money together in one place, what might help is clarity about leadership and responsibility for delivering an integration agenda. At the moment, it can be spread across a number of organisations and relies on, in some respects, the good relationships, the goodwill and the intention that we have talked about. Being clear about the leadership and the ownership of the responsibility for delivering agendas is as important as putting the money together in one place.
Helen Buckingham: So are the measures of success, how we hold each other to account for what we deliver, and how we know whether we are succeeding or not, as the case may be.
Jenny Owen: I will pick up on that point. There are three points I wanted to make that pose difficulties with pooling budgets-not aligning necessarily, but pooling them-and bringing them together in that way. The first is that you have to work out who is bearing the cost and where the benefit comes. We know that, often, where you make joint commissioning decisions-and I will give you the examples of reablement, hospital at home and virtual wards-they absolutely help demand management and the NHS. They cost social care. That has to be understood-your point, that you know what you are measuring-so you are measuring those outcomes, what you are putting in and where you get the benefit. To be able to get agreement about where that benefit share is requires quite a sophisticated level of partnership working.
Q222 Chair: If there is a pooled budget, there probably is not a need for a benefit share, is there?
Jenny Owen: It depends on who is putting what proportion of the budget into the pool.
Q223 Chair: If the pooled budget is for the services for a particular group of people and you invest in preventative early-stage activity, the same budget receives the benefit of those individuals not needing-
Jenny Owen: The point I was making was that it might not meet all the social care needs. You might need to still pick up those points from the budget. That is why you have to be clear what you are putting in, what outcomes it would achieve and who is putting the proportion in-where the benefit comes from. That was the point I wanted to make.
Helen Buckingham: If we move to a pooled budget arrangement-and I have worked with pooled budgets and they can add real value-I am still accountable to the taxpayers of Kent for agreeing that a pooled budget arrangement is the best way to spend the money they are giving me to get outcomes for them. I have to be clear that there is a benefit to that pooled budget arrangement for health services as well as to the individuals who receive it.
Jenny Owen: The second point I wanted to make, to go back, was that when you move down to the level of significant numbers of people having personal budgets, as in the cash personal budgets, you then have less money to pay with in your commissioning budgets. There is going to be a different alignment between the amount the strategic commissioner has for commissioning for the numbers of people if a third of it has already gone on personal budgets. That is clear.
The third area is that we are just now getting to the point of clinical commissioning groups having budgets and setting budgets to meet the needs of their population. There are very different levels of discussion from, at one end of the spectrum, the quite sophisticated "What can we jointly commission?" to "I do not really understand how you are going to work social care." It is that different. I am not quite sure that the clinical commissioning groups will be ready to think about pooling budgets for a while.
Q224 Dr Wollaston: Can we move on from that to talking further about personalisation and the negative impact it is having? Helen, could you comment on whether you are going to find it more difficult in the future to commission services if some of the money has already been taken out and handed to people in the form of personal budgets?
Helen Buckingham: I think it is more difficult. That does not make it wrong. It is more challenging and it is challenging to the whole system. It is challenging to us, as commissioners, and it is challenging to providers. The response to some of the discussion you had in the first session-I think it was a question you raised-about the issue of very highcost care and the risk to suppliers was quite interesting. As a provider, you can work with-and I would expect our providers to work with-people as individuals to make sure that they are delivering a package of care that is appropriate to their needs as a person, not a onesizefitsall approach. You can do that without necessarily holding a personal health budget. The more people who do hold personal health budgets, the more difficult it is, as Jenny and Sheila say, to commission strategically by waving big pots of money around and, also, the more important it is for us to be strategic leaders of the system and to develop our markets in a more sophisticated way to enable providers to respond to that different challenge.
So, yes, I do think it is more difficult but, if we are going to focus on the right outcomes for the individual and we are going to use resources in a better way, that is the way we have to go. The exciting conversations we need to be having with people who use our services is how those who are in receipt of direct payments or personal budgets from social care and, in the future, personal health budgets, at a personal level, link those two. We are a pilot area for personal health budgets and that is one of the conversations we are starting to have.
Q225 Dr Wollaston: It strikes me it is going to be incredibly complex. Is your role going to be guiding other suppliers as to what kinds of facilities they might want to look at providing and guiding your clients in how to use them?
Helen Buckingham: There will be different roles at different levels. There will be, if you like, tactical roles, which are at that level with suppliers and providers. But I hope, and this is a bit of the ambiguity at the moment, that somebody, somewhere in the new systems-and the Health and Wellbeing Boards should be well placed to do this-will also have that strategic oversight of what this means for the whole match of supply and need, in our case across Kent and Medway: what is happening to the population in Kent, so that we know what is happening to our populations of older people and young people; and what that is likely to mean in terms of the types of services and market we are going to need to have in the future.
Q226 Chair: Even if we got into a world where personal health budgets constituted, let us say, 20% of your budgets-and we are light years away from that, at the moment-it would still give you 80% of the budget. You are not without a few tools if you have 80% of the spend in your hands.
Jenny Owen: If you think about the social care spend, we have lots of experience of this because it puts people in the same sort of position as selffunders. They have the money to spend but they still need the things to buy. The only point I was making-and it was not a negative one about personalised budgets at all-was simply that pooled budgets might not be the only thing we need to think about. That was the point I was making.
Q227 Valerie Vaz: I asked the witnesses we had earlier about Professor Ann McDonald’s view on personalisation. I would like to gauge what you all think about it.
Mark Lobban: I am also a member of the National Market Development Forum and we often have discussions about personalisation. We quite quickly find out that someone is talking about it from the perspective of, say, someone with a learning disability, while someone else is talking about it from the perspective of an older person. That is an important distinction.
If I focus on older people, for instance, one of the issues we have, particularly if we are looking at providing home care or domiciliary care, is that sometimes there is a very narrow description of personalisation that is limited to this beauty contest, if you like, between providers. From work that I have done in the past, when we ask older people what they want, it is not necessarily to choose the provider that comes through their door. They want to make sure that they are from a trusted source; they want to know the name of the person that comes into their house; they want to be able to get up when they want to and go to bed when they want to; and they want be treated with dignity and respect in their own home.
The issue about personalisation needs to be much more sophisticated. I was interested in your point earlier about block contracts. The days of block contracts have gone, but I still absolutely think that there is something about how we work with providers that have volume. For instance, in Kent, no one provider has any more than 10% of the market share in domiciliary care, but there is potentially a different relationship with someone that has 600 or 700 users than a provider that has tens of users. What I need to do, as a commissioner, is to be saying to these providers, "How do you provide flexible responsive services, because you have the volume?" One of the ways we could develop that is through technology, creating a marketplace where people can, Amazonstyle, rate the performance of providers.
Our role, as a local authority, is to give people good advice and information so they can make informed choices. Yes, you can take a direct payment. You can take the money and arrange your own care for a personal assistant. What does that mean? You get complete control over the resource but what happens when that person is sick or goes on holiday? What backup do you have? Alternatively, we can take this money and broker the relationship between you and, maybe, what we might call a key strategic partner because they have this volume. They can hold on to that resource and work with the individual as to how they have care delivered flexibly. The only way they can do that is if they have sufficient volume. So there is still, for older people and personalisation, the relationship between volume and being able to deliver services flexibly. It is much more modern than your block contracts.
Q228 Valerie Vaz: Yes, but I am getting this picture of Aunty Mabel, aged 75, sitting on a computer buying her care and she is sick and ill. How is she managing that?
Mark Lobban: This is the point. I do not think older people necessarily wish to choose. Aunty Mabel does not necessarily want to choose her provider. Something that annoys me, and it happens in all local authorities, is that markets have often become fragmented. It is not down to the choice of the individual receiving care, but the way in which we purchase care. It is the misinterpretation of what "personalisation" is. For instance, social workers in some local authorities may be selecting various providers. How much is that down to the choice of the individual or a misinterpretation of what personalisation is? At the moment, I do not think older people are choosing their domiciliary providers because they do not want to, but social workers and people arranging services are. There is a way in which, if you sit down and talk to individuals, you can say, "This is the quality of the service. This is the service that this particular provider offers. They provide care to some of your neighbours and they do provide a flexible service. That is one of your options. Another option is you could take the direct payment."
Q229 Valerie Vaz: Who is doing the talking? Is it someone at the local authority?
Mark Lobban: Absolutely. This comes back to who is assessing need and who is working with the individual to work out what options are available.
Q230 Valerie Vaz: So you still need people to do that.
Mark Lobban: I think, also, if you have this approach where you look at what personalisation truly is-and we are looking at flexible services-it is about the local authority also letting go a bit. We need to trust their providers, and there is something about trusted assessors. Providers that have earned the trust and can demonstrate the quality they provide should be given more flexibility to work with the individual to adjust packages of care. Still, today, we have too many examples where it is "time and task" and a provider has to phone social services so that a package can be reduced. Then there is a delay in someone coming out and reassessing and, at that time, the person does not even need that level of care. We have to have a new relationship with the individual but also the organisations that are providing that care.
Q231 Rosie Cooper: Could you describe how you would monitor that-how you would gain assurance?
Mark Lobban: I need to be clear. We need a healthy marketplace because it is not only about us commissioning care on behalf of social services, but about the private market as well. We need to embrace the diverse market. When it comes to the issues that I have mentioned about providing care flexibly, if you have key strategic partners, for instance, that is when you can sit providers round the table and say, "What are you doing to provide care flexibly?" I have 100 commissioning staff at the moment and we monitor care. We go to care homes and monitor care home provision. It would not be any different than we do now. Also, there are other things we need to look at. We need to look at the wider community and at peer monitoring, if you like, of good friends and neighbours. How do we incentivise people in the community also to pop in and be the good neighbour and perform a monitoring role? There are lots of things we can do around that.
Helen Buckingham: I would like to come back on the 80:20 business-20% of budgets for personally held budgets and 80% outside that. If we get it right, that 20% in personal health budgets could have a profound impact on a large proportion of the other 80%. Except for the most specialist services, most of what we spend our money on is pretty normal runofthemill, happens every day, acute care and community care. The more we can support people to take responsibility and be supported in taking responsibility for their own care around their longterm conditions, so this is the frail elderly people, those with dementia, children with disabilities-I do not mean abandon them to make all their decisions themselves; I do mean support them in their own care-the greater impact we will have on less desirable use of that expensive acute sector. Getting personalisation right is critical to every bit of the system, not only the services used directly by somebody with a personal budget.
Q232 Dr Wollaston: What happens if patients decide, genuinely, that they would rather give that money to their partner to be their carer and not use outside services at all? Would they have the flexibility to do that?
Helen Buckingham: It is the same dilemma that the local authorities have gone through with direct payments, is it not? We need the right governance arrangements that ensure that our money is used is in a way that delivers better outcomes for the individual, and that includes experience, but in a way that protects them as well. There are safeguarding issues to take into account and there are-it depends on the needs of the individual-quality, experience and qualifications issues to take into account. I would hesitate to rule anything out, as I never say "never", but there would be a lot of things you would have to look at carefully before you say yes, you would do that.
Q233 Dr Wollaston: So possibly yes, but there is a general rule-
Helen Buckingham: You need a framework.
Q234 Chair: There is a tension here, is there not, that underlies this whole personalisation agenda, which I do not think has surfaced as much as it needs to? The further you go down the road, whether or not it is social care-it is true in health care as well, but stick with social care for a second-of believing that each individual’s care can be identified precisely and then converted into a sum of money, the further you get to a position where you are looking at an individual and saying, "You fall into square X71 of this matrix," and you are back to where we started. Before we had the Community Care Act 1993, this was all done through the social security system. How do you square off these two conflicting pressures?
Jenny Owen: I agree. It takes you to an entitlement that is more like a benefits system: if you have that type of need, you have that type of requirement to meet that need. The advantages of that, of course, are that you do not have to put so much of the infrastructure resources into the assessment type-
Q235 Chair: It is worth reminding ourselves why we moved away from it. We thought the costs were running away from us.
Jenny Owen: The costs were running away and it became the responsibility of the local authority, and then we had FACS, that gatekeeper. But now what we have is all the questions you were asking about portability and whether you can have a consistent system. That is the tension that you are describing.
As to personal budgets-and I wanted to answer your question, if that is okay-in Essex we have about 11,500 people on personal budgets. That is about 80% of those people eligible for personal budgets. Only about 20% of those take the cash. The others are on the managed service. When you look across, it is not untypical that a large proportion of people are still on a personal budget but it is a managed service, commissioned for them.
When we started on the journey of going into personal budgets, we commissioned a threeyear evaluation to look at the experience of people as they went on to the system. We have had our second report and, basically, the messages are that people are really satisfied with the outcomes. It gives them a lot more flexibility and the ability to have a service that is responsive to them, which is a lot of what the complaints are about, particularly with older people looking for home care. Often the complaint is around not being able to get that from a managed service. They needed more very skilled people to help them with the support planning and the confidence about how quickly you could get through the system to know what your allocation was. There were messages in there about how we needed to improve the way we supported people through this, but people were saying that they were significantly more content with the outcomes, and that they saw that as better. In a way, that, for me, is the crux of it.
We also put some resource into somebody working around personal budgets- personalisation-for people with dementia. What she concluded in her work was that, for people with dementia, personalisation is absolutely critical because it has to be very personal around the needs of that person and the progression of their disease. It absolutely can be the most important way of organising the care and support for someone. What tended to happen was that people who were working in the social care system-the social workers and the assessors-were not confident of doing it. They felt there was too much of a risk and, often, they did not see it as an opportunity or an option. Much of the work that we did was to try to show how it was working with examples of where it had been very positive. The Alzheimer’s Society is about to publish a report very much along these lines. It is not right for everyone but it is right for quite a few people. There are ways in which you need to support people through the process.
Chair: Very good.
Q236 Dr Wollaston: Do most people-that 80%-opt to have it managed by yourselves because they do not want to be employers, themselves, directly?
Jenny Owen: There is a whole range of reasons. In my experience-and this was a point you made earlier-when people are in crisis and needing care and support, it is not the best time to say, "Do you want a personal budget?" You need to be able to stabilise the situation, to work with the family and to think about the future arrangements. Then, when you have something in place that manages that particular crisis or difficulty, over time, you can start to talk about what is a better range of options for that person.
Q237 Dr Wollaston: So they gradually move on.
Jenny Owen: Yes. The worst possible time to give people a whole load of responsibility is when they are in the middle of a crisis. That is why reablement, doing something and then coming to a view about what service is needed, and how and when it should it be provided, is best. It is much better to do it after you have had a period of reablement.
Q238 Rosie Cooper: Would the managed care be done by the local authority or a voluntary agency?
Jenny Owen: It could be either. It is a commissioned service. It could be commissioned from the voluntary sector, the independent sector or the local authority. In the local authority in Essex we do not provide many direct services. But we have a very strong organisation of disabled people, the Essex Coalition of Disabled People, and we have contracts with them to do support planning and brokerage. What we find is that many, many more people who have their support arrangements through the coalition go for the cash payments. It is about confidence.
Q239 Rosie Cooper: May I quickly ask you a couple of questions about a situation where people with moderate care and support needs in Kent receive local authority funding, but people in Essex do not, and how, when we have almost a consistency of criteria, we get to that?
Mark Lobban: We do have moderate criteria. Obviously, as I say, I have been there two months and I have moved from Hertfordshire, where the criteria were substantial and critical. Does it make a difference? I am not sure if it does. It comes back to some of the earlier conversation about "depending on how much you invest in preventative services". When I say "preventative services," I mean services put in place to prevent people meeting the criteria and that threshold. I agree with one of the earlier panel members that social care is much wider now than just the services we provide and the criteria. We have the greatest incentive to provide other services to stop people meeting our criteria because it is far more expensive when they do hit that threshold than before.
Q240 Rosie Cooper: Is your definition, or your criteria, the same across-
Mark Lobban: Ours is moderate.
Jenny Owen: The FACS criteria are set by the politicians who look at the amount of money they want to spend on eligible needs and make that decision.
Q241 Rosie Cooper: You are talking about local politicians-councillors.
Jenny Owen: Local politicians-councillors in Kent and councillors in Essex-made those decisions based on what they had in their budget at that particular time.
Q242 Chair: Then you classify the service users into the categories where they can be funded.
Jenny Owen: As you know, it is a gatekeeping exercise and there is an attempt at objectivity. It is jolly difficult. I always found it jolly difficult as a social worker. However, as to Mark’s point about the correlation of total spend on people in a community and their FACS criteria, if you did a study of that, you would find it is not necessarily a strong correlation. For example-I do not know if you remember, and I am afraid I cannot remember the name-the authority that went to critical only a couple of years ago showed that they still spent a significant amount of money, but on people who did not have to go through the FACS criteria. They spent a lot of money in the community and on voluntary organisation spend. We have a range of services in Essex, as they will have in Kent, that support people who do not have to go through the eligibility criteria, and there is a significant spend on those.
Q243 Rosie Cooper: Do you track the people who have not qualified for support from your local authority? In other words, is this real?
Jenny Owen: We do not track.
Q244 Chair: What I think you are agreeing with is what Peter Hays said-I wanted to bring in this quote, which was not cited earlier. Julie Jones from SCIE told us previously that the fair access to the care system is "coming to the end of its useful time." I noticed Peter used almost exactly the same words. Is that, essentially, what you are saying?
Jenny Owen: It is, absolutely. It was a way of gate keeping resource and it is not particularly helpful.
Chair: That answers the question. We have run out of time. Thank you very much indeed for coming and sharing your experience with us.