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UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE
To be published as HC 317-ii
House of COMMONS
TAKEN BEFORE the
Tuesday 26 JUNE 2012
dr peter melton and geoff lake
GEOFF ALLTIMES CBE and ANDREW COZENS CBE
Evidence heard in Public Questions 73 - 171
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Taken before the Health Committee
on Tuesday 26 June 2012
Mr Stephen Dorrell (Chair)
Dr Daniel Poulter
Mr Virendra Sharma
Dr Sarah Wollaston
Examination of Witnesses
Witnesses: Dr Peter Melton, Accountable Officer, North East Lincolnshire Care Trust Plus, and Geoff Lake, Adult Social Care Strategic Advisor, North East Lincolnshire Care Trust Plus, gave evidence.
Q73 Chair: Good morning, if you can hear me down there. I apologise that a busy Committee timetable in the House has got us into a room that is a little larger than we really need, but if we speak up and address ourselves as a public meeting I am sure we can survive.
Thank you very much for coming to join us this morning. We are looking forward to talking to you about the situation in northeast Lincolnshire. As you know, the Committee has published a report on Social Care-and indeed a number of other reports-in which we have talked about the importance of integrated services. Word has reached London that you do it quite well in northeast Lincolnshire, so we would like to find out a little more about how you do it. Perhaps you could briefly introduce yourselves and the roles that you have played in northeast Lincolnshire.
Dr Melton: I am Dr Peter Melton. I am a GP who practises in Immingham and I am now the designate accountable officer of North East Lincolnshire CCG and Care Trust.
Geoff Lake: I am Geoff Lake. I am Adult Social Care Strategic Advisor to the clinical commissioning group and was previously Director of Integrated Commissioning in the Care Trust Plus.
Q74 Chair: It would be useful to the Committee to hear you describe, to start with, and obviously reasonably briefly, how it works and, in particular, what the structure that I believe you have around a Care Trust Plus means in practice. The Minister of State has referred to it as "an experiment that didn’t get out of the laboratory", which I think was his phrase. Do you think that is right? How does it work in your locality? Let us start there.
Dr Melton: We established the Care Trust Plus in 2007. It was against a journey-a background-of the desire for continual integration. Even back in 19981999 we were established as a locality commissioning pilot that had governance arrangements that involved the chair of adult social care and the executive officer responsible for social care on those commissioning pilot arrangements. We didn’t go forward in establishing the organisation until 2007 in the light of commissioning a patientled NHS. There were some negative reasons for doing that but also some positive ones. One of the pressures that we were put under was to go on to a larger footprint in terms of a larger PCT serving the population of northern Lincolnshire, which did not feel like a correct geographical fit. It made us think again about how we could maintain a locallyfocused organisation serving the population of northeast Lincolnshire, which is a very discrete and tight geographical community.
It was going along that path, and working with the local authority, that we came up with the concept in 2007 of this arrangement called a Care Trust Plus. The principle was that the respective organisations, in terms of the local authority and NHS, had within them different levers to be able to address the needs of the population in different ways. From the health point of view, we felt that when people became unwell or were at their point of most need they required a joinedup solution. Sometimes they needed excellent medical clinical care but often they had care requirements as well, and people would end up in hospital-which I saw as a practising GP-not necessarily because of the clinical care they were receiving but because they were not accessing the appropriate care requirements. There was a question, from a health perspective, as to how to bring those together in a much more responsive and flexible way so that when people become ill, scared or frightened in the middle of the night, the system responds to them, and they are not resorting to having to call 999 and ending up sometimes in the most inappropriate care sector. So it was a decision to move adult social care into the NHS.
Along with that, the "Plus" was to move the elements that should relate to health and wellbeing into the local authority on the assumption that the local authority had most of the levers to actually improve people’s health and wellbeing. There were two elements to that. One was transferring public health into the local authority, so our public health function went in, again in 2007, ahead of the new reform agenda, and also children’s commissioning and provision. The rationale was that most children’s prime focus of need relates to health and wellbeing as opposed to illness. The idea was to take a much more integrated approach to the needs of young people and their family, addressing their health needs but also housing, education and issues around crime and prevention so that we could take a much more joinedup view.
With regard to the point you made about the Minister referring to care trusts being an interesting experiment that never quite got out of the lab, in terms of the policy and regulatory framework within which we have been operating, there probably hasn’t been the incentives for local organisations to consider the care trust option. A lot of the policy and regulation has been about planned care, elective care and convenient care, often at the expense of those people who need complex joinedup solutions. I think we are at a tipping point. When I network and talk to my clinical colleagues who are starting to establish clinical commissioning groups, they fundamentally believe that integrated care is one of the things they really need to focus on. In terms of the new organisational arrangements and the new type of leadership within those organisations who are very embedded in their own communities and feel very passionate about some of the most deprived within their community-where there has not been the enthusiasm for organisational change to this point-we now have the opportunity, with a new type of leadership, to start to reenergise it as a potential model.
Q75 Chair: Can I ask you to make clear to the Committee the extent to which the Care Trust Plus model allows you to look across the different parts of the system and move resources freely between the traditional functions, for example, social housing and community health or primary health, or indeed social care and social housing, within a single budget?
Dr Melton: We tend to look at the budgets as integrated, pooled budgets and sometimes it is genuinely seamless in the way that we utilise them. There is an agreement. The Care Trust Plus arrangements are underpinned by a legal agreement between the NHS and the local authority with a threeyear strategic plan. We have an annual business plan that describes the outcomes that we are looking to achieve on a yearbyyear basis and, within that, we try to agree some of the outcomes that we want to achieve.
I know the Committee has previously taken evidence from Torbay, and some of the outcomes we have are very similar to theirs. Again reflecting on when I was talking earlier about the principles that, as a GP, I can try and provide the best care as a clinician but if the care arrangements are not in place then sometimes people will end up in hospital, in terms of our emergency admission rate against our ONS cluster we are the lowest. If we actually implement our QIPP plans this year, as we are envisaging, we should be the 14th lowest out of the 154 PCTs in the country. Outside the south-east, we will be the lowest. The way we have done that is very much by working in an integrated way, both in terms of clinical community, even some things around the commissioning approach for the care home sector, and aligning change in the quality incentives for the care home sector-the contracts associated with that-to GP contracts and also community care contracts to provide support for the care home sector. Linked to that-when you talk specifically about housing-are some of the schemes relating to extra care housing. We have put additional NHS funding into Warm Front to try and improve the environment in which people are living.
Geoff, are you looking to come in on some specifics?
Geoff Lake: On that particular question about "Do you move money around?" the answer is "Yes; can do and will do", but it is always associated with a significant redesign of service. Clearly, the first concept for us is ensuring that we understand how much money is being spent by whoever within that kind of systemic model of care. Having mapped that, we then think about the service redesign, starting from the point of the total resource being spent rather than who the money belongs to. Where we have implemented major service redesign, those opportunities have been taken. They do not extend into housing to the extent that one might have wished them to, particularly social housing, but they are now beginning to extend into extra care housing because of its relationship to other parts of the service redesign. So, yes, we do, but always associated methodically with service redesign, and then very strong outcomes frameworks in terms of all the parties to those revenue streams that go into that single pool being associated with common purpose and common outcomes so that everybody, in a sense, gets a gain from that.
Q76 Chair: Andrew and Barbara want to come in, but can I have one final go? As a service user in northeast Lincolnshire, do you think I notice a difference between the service that is delivered in your community and the service that is delivered in the majority of the rest of the country in terms of the coordination, first of all, of information around the system about my condition and my needs and, secondly, of service provided to me by these different agencies? Do you think it is different?
Dr Melton: As a GP, my practice straddles three local authority boundaries. My practice is located within northeast Lincolnshire, but I have a significant proportion of patients who reside in Lincolnshire and north Lincolnshire as well. So in terms of experience as a GP, but also the feedback I get from patients, carers and family, it is very difficult to respond in a joinedup way to some of those complex needs. As a practical example, we have adult social care, mental health and community nursing colocated within our building. On a monthly basis we have multidisciplinary team meetings that bring everybody together for some of the most complex patients who reside within northeast Lincolnshire and we are able to come up with a joinedup response to address and meet those needs. It is much more difficult and challenging to be able to do that for populations in my neighbouring local authority areas. In terms of my team-in particular, the community matrons-they find it so much easier to coordinate care packages for people because they can bring the whole team together. Being in one building helps but we are moving much more towards common IT solutions so that we are sharing records, and we are working towards that.
There are obviously issues and challenges associated with IT. Sometimes you get too much information and you cannot cut through to what is actually important and relevant. As a consequence, you can lose some of the information that you need to act upon. The principle is joinedup teams, services and solutions. It is also joinedup infrastructure behind them, some of which is IT solutions but some of which is the way in which we commission and the financial incentives that move through the system to incentivise people to work together. Those enablers behind the scenes make a difference to people.
Q77 Andrew George: Dr Melton, earlier you mentioned that you were aligning GP contracts with care home contracts. I have a twopart question on the back of that. First, how does that work practically now, given that one of the concerns about the interface between health and social care is that of cost shunting, moving from a freeatthepointofdelivery Health Service to a chargedforatthepointofdelivery social care service? Secondly, looking forward under the Health and Social Care Act where contracts for GPs are going to be let from York, how are you going to align in those circumstances? Won’t that result in a more disintegrated arrangement than the one you are able to achieve now?
Dr Melton: With regard to the contracts, all our practices are on a local PMS contract. We had variations in contract, in terms of financial value and on quality outcomes associated with that, because they were inherited over a period of time. About two or three years ago, we went through a PMS review which moved everybody on to the same contract with the same contractual values and clinical quality outcome measures. 15% of GP practice income is at risk associated with those quality measures-the quality provision that goes on what they do within the practice, with the partnership responsibility and with health and wellbeing. Also, we have an ongoing committee, which includes the LMC, to renegotiate that contract on an annual basis. It gives us the flexibility to align incentives to a much more integrated solution so we can do that with care homes and with the hospital as well as our mental health provider and our community care provider.
There are risks, as you say, in moving the contract to the NHS Commissioning Board, which is one of our key incentives for changing the behaviour of practices. I think there is a real challenge for the reform agenda because, for CCGs to be successful, there needs to be a clear alignment of business between the constituent member practices and the business of the CCG. There is a lot of talk about managing conflicts of interest, but I think there needs to be a reconciliation of conflicts. We need to be clear and transparent that conflicts do exist and we need to be able to demonstrate that, in terms of using the public purse, money is not being used in an inappropriate way. But there is no underestimating the fact that the contractual lever for practices is a big incentive.
One of the things that I have been challenging our practices to try and come up with is this. Along with the councillor members, we are in the process of establishing a provider network for GPs that will start to manage some of those conflicts. I am saying to them, "Come forward with recommendations for money that currently exists within the PMS contract: how we might be able to hold that locally and how you might recommend to the commissioner, be it the local CCG or the NHS Commissioning Board, in terms of assurance, that we could use that money more effectively, some of which will be supporting the care of the people who are the most vulnerable that require joinedup solutions." We are working through that at the moment. One of the challenges could be about who should hold that resource. One of the thoughts being developed at the moment is: should that be held by the CCG or the members or should it be held, potentially, by the local authority? Could it be something that actually sits under the Health and Wellbeing Board so the Health and Wellbeing Board is holding the local premium to start to try and incentivise practices to tackle those challenging issues?
Q78 Chair: Have you had any discussion with the Commissioning Board or the emerging Commissioning Board about that concept?
Dr Melton: It is one of the things we are trying to work through locally. The emerging Commissioning Board and the medical director are working on a primary care strategy, which will design some tiers in terms of what primary care should be doing. It includes the core requirement-the mandatory "must do"-but, on top of that, will start to give flexibility for some local solutions that would make sense in Grimsby, Scunthorpe, Hull or East Riding because some of those local arrangements will be different. The Commissioning Board, under the local medical director, is trying to support that type of approach.
Q79 Barbara Keeley: My question is about contracts too, Dr Melton. You said something about specifying quality standards in your contracts with care homes, but the question is really about care home fees. Clearly, the fee could be being paid by the NHS, by the local authority or by a person themselves as a selffunder. What we hear about quite substantially is that the squeeze on quality has come from local authorities not increasing-or even cutting-their fees. You have even talked about your practice straddling three local authorities, so presumably you will be dealing with a number of situations there. How can you ensure quality when the local authority element of fees is the one that is being hit the most, if you like, by budget cuts and so on? Is that not happening in your area?
Dr Melton: Geoff is itching to come in to reassure you.
Geoff Lake: Go back two and a half years in northeast Lincolnshire. The care home sector was extremely poor and had only about 40% of its longterm care home market rated as good or excellent. With the demise of the star system through CQC, that had gone up to 92%. Why? There are a number of things.
One is that we sustained fee increases as a deliberate strategy. Secondly, because we were integrated, it was so much easier to incentivise the quality agenda. There is a distinct quality scheme in northeast Lincolnshire that is an integrated scheme with a number of domains that covers health and respect, and dignity and safeguarding, which is funded by the NHS and by adult social care. That is paid out on the basis of regular appraisal of performance.
We have sustained our resource into the longterm care home sector, even though our placement rate has dropped over the last three years by 35% and is now about 6% to 8% below the national average. We have sustained all the resource in there to segment that market to better reflect, increasingly, the complex care needs that market has to provide for. If you are placed by the public sector in northeast Lincolnshire, you probably have about 18 months to live in a longterm care home, and it is really important that the quality is sustained. So we are raising our fee levels at the moment by reducing our placements and keeping all the resource in and, in addition to that, we have the quality scheme which is ratcheting up consistently in terms of its demands on people. We have taken a very "shaping the market" approach to longterm care homes, including the integration of the continuing NHS healthcare receivers of funding in that system. It is a single market with a fee structure that reflects both quality and complexity.
Q80 Barbara Keeley: Is it higher than surrounding local authorities? What, typically, would you be paying?
Geoff Lake: I do not think, necessarily, it is higher than surrounding local authorities but its emphasis is very different. We are in a market that is overprovided. To some extent, we have the commissioning levers to emphasise the quality in a market that is already too large, and to deal with that part of the market that we wish to deal with. It is never quite apples and apples.
Q81 Rosie Cooper: I have a very quick question. Forgive me, but my hearing is not very good so I am lipreading as best I can. You said that you were increasing the amount you pay for a care home place. How much are you actually paying per week?
Geoff Lake: It depends on the circumstances of the individual. Continuing NHS healthcare would be in a fee range. Enhanced care beds for people with dementia would be something like £580 a week, but those have some variances to them in relation to either quality or the needs of that individual.
Q82 Rosie Cooper: So a care home does not have a price. It is the patient and their needs that dictate the amount of money you will pay?
Geoff Lake: There is a framework within which we operate, but there is flexibility in that framework.
Q83 Rosie Cooper: But if you are a resident going in-and I have seen it-individual homes charge different things?
Geoff Lake: Yes.
Q84 Rosie Cooper: For example, good care homes can cost approaching £1,000 in various parts of the country. In places like Liverpool, which are underfunded, you are talking about £500. You are telling me that you are the bee’s knees. You have really good care, really good quality, and you are doing it for £580. Is that what you are saying to me?
Geoff Lake: I am not saying we are the bee’s knees. I am saying that we have a distinct strategy which has a premium on quality. We have sought, in a difficult period, to retain all the resources within the longterm care home sector and we are making fewer and fewer placements, but we are using those resources to try and pay better and achieve better quality. But no way would I claim to be the bee’s knees.
Q85 Rosie Cooper: That is the point I am getting to, I suppose. In each part of this system I hear people talk a good game and everyone tells me that it is getting better and better. But your increasing quality may be somebody else’s very basic standard or may be absolutely superb compared with somewhere else. I hear a lot of words but I am not sure I see a great difference on the ground.
Geoff Lake: The only things, in a sense, I can point to are a pretty rigorous quality appraisal of-
Q86 Rosie Cooper: CQC standards are the minimum.
Geoff Lake: I quite agree.
Q87 Rosie Cooper: I think I have lip-read that you said that which is good is up to about 90%. Yet, if you had the CQC here, they would tell you their standards are minimal. There is nothing to write home about. It is better than being on the floor.
Geoff Lake: Let me put it into an historical perspective. When the CQC star rating was in place, we went from 44% good and excellent to 92% good and excellent. I totally agree with you that that regime has now significantly changed and it is about minimum standards. What we are attempting to do now is use the quality scheme, which we have been road testing for a couple of years, as the benchmark beyond which we will then commission.
Q88 Rosie Cooper: That is to benchmark it against other things in your area, but how does that benchmark compare to the best in the country? Where are you in that framework?
Geoff Lake: It is difficult to answer that because quality schemes are not in place everywhere in the country. This has been developed, though, based on research and analysis elsewhere, first, of those that did exist and, secondly, working with professionals to make judgments about what was the right standard.
Rosie Cooper: More words. Thank you.
Q89 Dr Wollaston: Dr Melton, I was very interested to hear you say that your practice straddles three local authority areas. Obviously in northeast Lincolnshire you are noticing the difference by shifting more funding to social care. But the accusation is often made that if you shift the funding to social care there is less for the secondary care sector. Some people might argue that your patients from northeast Lincolnshire have the best of both worlds because they can still access the same secondary care as those in your practice from other areas, if you see what I mean, but are benefiting from an improved standard of social care. What would happen if all the practices made the same cost shifting into social care? Would the secondary care sector service deteriorate? That is an accusation that one sometimes hears.
Dr Melton: I am not 100% sure I have the question right, but I will give you an answer. If I haven’t answered the question, come back at me.
Q90 Dr Wollaston: Are they getting the best of both worlds, if you see what I mean? Are they benefiting from the hospital sector relative to other patients in your practice who are not from northeast Lincolnshire?
Dr Melton: No, I don’t think so. In terms of going forward, one of the things that all my providers are asking for is to take a more integrated commissioning approach and define some of the quality outcomes, whether it is the quality outcomes expected within the care home sector, for primary care or within the secondary care sector. They are saying, "Start to take a different approach that describes some of those outcomes and then let us get together to work towards what that means within the care home sector, within community, within primary care and within the hospital", and starting to think about how-particularly in secondary care, which starts to work in a different way-to become much more specialist, focusing on the case management of the most difficult patients who are a higher risk, either clinically or financially, but also supporting the system which would be supporting me in my personal professional development-me as a provider of service and how I start to improve the quality of service-as well as going out and supporting the care home sector and the community care sector to help them develop things.
Locally, within north Lincolnshire, we have three district general hospitals serving small populations. There are risks as to their viability, but I think there is an opportunity. If we can work with the hospitals to start to provide a different model of service that is much more integrated and is providing support to all the sectors, they have a product that my neighbouring local authorities may well want to buy. Hopefully, this approach makes sure that I have a sustainable hospital care sector that is viable going forward and can start to promote what it is beyond its natural boundaries. I see it as a way of trying to maintain those services but, as I say, I am not quite sure if I have answered your question-particularly from looking at your face.
Q91 Dr Wollaston: Are you hopeful that the other three local authority areas are going to move towards a similar, much more integrated model?
Dr Melton: We would love to have my neighbouring local authorities transfer their adult social care budget to us, but it is not something that we have been able to achieve.
Q92 Chair: What you said in reply to Sarah’s question about the acute sector suggested that you are going to work with your acute providers to improve their service so that they can take market share from their neighbouring acute providers; in other words, exporting the problem of rightsizing the acute sector to somebody else. Did I hear that right?
Dr Melton: There are clearly tensions in the system. If we are establishing local CCGs working on behalf of local populations, we cannot underestimate the fact that I have a statutory duty to try and maintain-to get the best possible outcomes for my population-albeit understanding that there is going to be a wider responsibility for the geography of greater Lincolnshire, north Lincolnshire and the Humberside area as well. So there is an inherent tension in there. But if we want locallyresponsive organisations, fundamentally I have to make sure, on behalf of my population, that I am trying to get the best services I can, recognising the fact that I am part of a much wider system and will have to try and reconcile some of those tensions.
Q93 Mr Sharma: We have heard quite a lot about integration. What degree of integration is there between NHS and local authority management and how has that been achieved?
Dr Melton: Do you mean the change in the value base?
Q94 Mr Sharma: No. There is integration?
Dr Melton: Yes.
Q95 Mr Sharma: How do you think you have achieved that integration between the NHS and the local authority?
Dr Melton: It starts at the top in terms of leadership. In terms of any joint venture, there needs to be strong cosponsorship for any initiative and if it does not start at the top of the respective-
Q96 Mr Sharma: Has it taken place? Has it started?
Dr Melton: Yes.
Geoff Lake: Can I try and answer some of that? There are arrangements between the Care Trust Plus and the local authority to share a number of the infrastructure supports. HR, estates and a number of other functions are shared. Care Trust Plus buys those from the local authority on an agreement, so we share those particular functions. We have within the Care Trust Plus a series of posts-not management posts-which have the ability to influence and work with the local authority, let us say, on the health and wellbeing agenda as well as in the Care Trust Plus. The integration, horizontally, of functions across the local authority and across the Care Trust Plus has taken place since 2007. It works the other way in terms of public health and children’s services as well. Is that what you are after?
Q97 Mr Sharma: Yes. I am trying to work out an easy way to put this, but you have worked both with the local authority and the NHS on different healthrelated matters. Are there other services in the local authorities which are as important as health, such as housing? Have you worked with or integrated those services in the whole system, the package?
Geoff Lake: Yes. There are a number of areas that we are working with. For instance, extra care housing is led and influenced by the Care Trust Plus on behalf of the local authority, fitting into the wider strategic housing function of the local authority. It is a very clear example of where we have tried to place the leadership of something in a particular place because it best fits there to be able to do so. Work to do with health visiting and children’s centres, for instance, has gone the other way. The local authority is leading that but supported by the Care Trust Plus. We constantly try to have this relationship where one is influencing the other. Working with the academies on the development of a new workforce-health and social care integrated workforce-is another area where we are working with the local authority, with its education leadership role. So, yes, we try and seize those opportunities within the strategic plan that the two organisations have.
Q98 David Tredinnick: I want to ask about the funding arrangements, but, before I do, I would pick you up on something you said earlier. You said that you were working with three small district hospitals. I wonder if this, in itself, poses fundamental problems because there are three of them, they are small and, presumably, they are dispersed.
Dr Melton: Our local acute trust, which is Northern Lincolnshire and Goole, has hospital sites at Grimsby, Scunthorpe and Goole. We have a programme of work, at the moment, on sustainable quality services and what we can do in terms of providing services for those populations. That links back to this inherent tension that, locally, we were leading the sustainable services review on behalf of the wider population and sometimes we were being challenged by our own population, both in terms of the public and our clinicians, saying, "Actually, you are compromising here because you have to be thinking about what is right for northeast Lincolnshire as opposed to thinking about the particular". So there are some fundamental tensions within the system, but that is being worked through at the moment, as I say, both in terms of financial values and also as to some of the quality. I have been going to the local authority and briefing councillors and I think we need to be describing what it means in terms of quality and patient experience. If we have to change services significantly, it needs to be clearly demonstrated that there are going to be improved quality outcomes associated with that.
Q99 David Tredinnick: Turning to funding arrangements, what problems are posed by the differences between the NHS as a universal, comprehensive and free taxfunded service and social care as a meanstested service with user charges, and how are those problems overcome?
Dr Melton: To give the scale, our NHS budget locally is of the order of £250 million. Our own commissioning savings target year on year is about £3 million. In terms of adult social care, our total commissioning budget is £50 million and our savings requirement year on year is £5 million. So the scale of the savings requirement on those two budgets is massive in terms of disparity.
At the moment, and going forward for the next two to three years-Geoff would say four years-we believe that we have robust savings plans in place that mean we will be able to meet those cost pressures. One of the ways, we believe, that we are able to do that is through integration and shared working. It has meant, at times, that some of the issues you are alluding to, such as cost shunting and how we manage the boundaries between NHS responsibility, adult social care responsibility, personal responsibility and family responsibility, are not clear in terms of how we have reconciled them. Going forward, given the scale of the challenge that we are going to face, both in northeast Lincolnshire and the country as a whole, there needs to be a clear debate on the role of the public sector in terms of helping people. We talk about adult social care and criteria, but in terms of access to NHS services we have a low priority procedure list that is not routinely funded under the NHS. That is reviewed on an annual basis, and if people request funding, they have to make an exceptional case for why they are getting funding. So I think it is a big challenge for all of us going forward as to the role of the public sector, both in terms of NHS and local authority.
One of our plans is investing and developing communities because, often, communities working on behalf of some of the most vulnerable in our society are an untapped resource. One of the things we are working on with adult social care and the local authority is how we can start to shift some of our joint resources into sustainable communities to help individuals and families manage their own health and wellbeing. So there is a challenge: what is it that the public sector is doing, how do we support communities in terms of the third sector-what they might be doing-and also, fundamentally, what is going to be a requirement of individuals and families as part of those cost pressures? I don’t think that is an answer that we can come up with. It is something that needs a much wider discussion.
Q100 David Tredinnick: You have kind of answered part of my next and last question but I am going to ask it anyway. With integrated commissioning and budgeting, how do you deal with responsibilities at the boundary of health and social care such as continuing healthcare?
Geoff Lake: Am I allowed to come back on the last question before answering that?
Q101 David Tredinnick: Yes, through you, Chairman.
Geoff Lake: That is one of the most difficult things to tackle. If we go back to some of the earlier discussion, the really effective means of using the money is to take a wholesystem view of the service, pool all the resources and then use the money very flexibly to meet the model of service that you want, regardless of the revenue stream. Once you do that, you are into some real difficulty about how that money share impacts upon the distribution of social care and healthcare provision within that entity. We do not have any magic answers to that. To some degree, we fudge that slightly and deal with it as clearly as we can where it is possible, that is, in very complex social care cases. But the more you pool the resource, the more you focus on outcome and the more you face that problem of what is free and what is payable. The concept which we are struggling with, and addressing at the moment, is this: once you try and integrate personal health budgets, individual budgets and direct payments, how do you do those as a real, genuine wraparound for an individual to use as they wish while, at the same time, that is funded from two streams of money, one NHS and free?
Q102 David Tredinnick: I am sorry to interrupt you, but, listening to you, it strikes me that there must be huge economies of scale out there to have one funding system.
Geoff Lake: Absolutely.
Q103 David Tredinnick: The great challenge is whether you drop one system or the other, or how you deal with it. You would like to elaborate on what I said, as you are nodding. It is always good to see someone nodding when you have asked a question. It is very reassuring, I can assure you.
Geoff Lake: I have long argued the case. There should be one single funding stream.
Q104 David Tredinnick: Can you elaborate on that? What is your model then? What goes in your new model, please?
Geoff Lake: Can you clarify what you mean by, "What goes"?
David Tredinnick: No. I have asked you to clarify your answer. You said, "Yes, I would prefer to see one funding stream".
Geoff Lake: Yes.
David Tredinnick: How is that going to be created out of the two funding streams? What goes to create your new model?
Chair: There are five funding streams at the moment.
David Tredinnick: Thank you, Chairman. The Chairman said five funding streams.
Geoff Lake: Yes.
Q105 David Tredinnick: How do you tidy it up? You must have a vision because you have been talking about it.
Geoff Lake: I am trying to find the right words. I think the CCGs of the future offer an opportunity for taking the delegated responsibility for adult social care funds that you can equate with what I would call those people who are complex and very vulnerable and who require intermediate services. So the CCG could be a vehicle whereby it is utilised for a single funding stream to target particular groups of people, whom we must all be concerned about, as we move forward in pretty difficult circumstances, leaving, through Health and Wellbeing Boards, the ability to take a pooled responsibility for those funds that are associated with prevention and wellbeing. I think you can tidy up the allocation of resources that would allow you to do that. That would provide much greater freedom to look at the service model that you want and the outcomes that money should deliver for you on a wholesystem kind of approach. It is what we have tried do with a number of the service redesigns that we are attempting at the moment: creating a single stream of funding while acknowledging that, in a sense, they are different funding streams, but trying to get the accountability, not as to how each pound is spent but about how those outcomes are delivered and "Are they being delivered?" If those outcomes satisfy the respective funders, then, in my view, you have taken a major step forward.
David Tredinnick: Thank you for that. I think Dr Melton wants to come in.
Q106 Chair: I am interested that you pick on the CCG as the owner of the combined fund rather than the Health and Wellbeing Board.
Dr Melton: This is a very difficult question. How do you reconcile those?
Chair: All important questions are.
Dr Melton: Fundamentally, it links us back to democratic legitimacy and the framework within which we create that integrated pool. As to some of the tensions that we have talked about within the system, if I, as the accountable officer, have a delegated budget from the local authority, one of the things that we probably did not mention was the fact that, as part of the legal agreement, we have reserved matters that reside within the local authority. The local authority, as part of those reserved matters, can start to describe-on behalf of the population and the mandate that it has from its population-the flexibilities against which we can use that adult social care budget. In the same way, when I am talking about our low priority procedure list, we have to operate that within the national guidance as to how we can use NHS resources. We need to be operating, in terms of creating that single integrated budget, some clarity as to the rules, both from local government and the national Government, about how we can use those. I have to be frank-and Geoff has already alluded to it-that, with some of those rules, there are always boundary issues as to how you can apply them in the best way.
You particularly mentioned continuing healthcare. We have been doing some work on trying to look at our most complex people within our community. Are they complex because they have both complex health needs and complex adult social care needs or are they discrete communities? When you start looking at their needs-within the NHS, those people we would risk-stratify as being complex and, when we look at adult social care, those whose needs are complex-only 20% of them are the same cohort we are both dealing with. Sometimes that means people who have complex adult social care needs end up in the NHS sector. Sometimes people with healthcare needs end up in the adult social care sector not having their clinical needs met and then, eventually, coming back into the hospital. As part of continuing healthcare-total packages of healthcare-we are the 16th highest in terms of total number in the 154 PCTs. When you look at our cost per case, we are about the eighth lowest. It actually means that, with a joinedup solution and working together, you can provide the most appropriate care for people.
Q107 David Tredinnick: I get the impression that you are feeling your way in the dark and you are pioneers-brilliant-doing lots of new things. But shouldn’t one of the outcomes be a national standard or framework where there are easy interfaces that can be taken and matched that have already been developed?
Dr Melton: Yes, and I have read the Committee’s last report about synergising the outcomes frameworks for public health, adult social care and health. Clearly, we need to be synergising those and bringing them together.
Q108 Rosie Cooper: I have a number of questions I was going to ask and you have partially answered them, but there is a main question I want to come to. I just want to make sure I have heard you right and I understand. Dr Melton, you talked about tensions in the system being worked through. My initial question there is: By whom? Who is working through them? Jointly, I would say to you that I have been involved in local government and in the Health Service for 30 years and we have always talked about the ideal of integrating budgets and the care trusts and all of that. The question I was going to ask was: Who would decide on what is delivered and what are the priorities? From what I heard you say, Mr Lake thinks that the CCG should be that body, ergo you are getting the Health Service billions plus the appropriate part of the budget from local government-have I understood and heard that correctly?-so you become ever more powerful.
Dr Melton: One of the reasons why I would hope that we have been successful locally is that it has been genuine partnership and not a question of becoming "ever more powerful." In terms of the partnership arrangements, particularly as to public health, health and wellbeing, the local NHS has transferred resource into the local authority to carry out those duties on our behalf.
Q109 Rosie Cooper: But you will make the decisions. The CCG would make the decisions.
Dr Melton: The CCG and also-particularly, I would say-frontline staff. Again, I will give some practical examples. When I talked about our multidisciplinary team meetings, it is the whole team coming together to decide, through delegated budgets, what is most appropriate. One of the similarities between social work and general practice is that, often, we are better at risk management and better at demand management, whereas sometimes the specialist services are more risk averse and struggle with that.
As to containing costs within adult social care, we have talked about continuing healthcare. Longterm residential care placements, in terms of complex care and home care packages, are very expensive. For people who still have ended up in hospital, the risk is that they will be discharged home to recurrent ongoing costs. As to making sure that people had the best package of care recurrently going forward, we were having an issue recently about delayed transfers of care. In terms of clinician and social work working together, within the space of about two or three weeks we had reduced that delay of transfers of care by a half. It is about the-
Q110 Rosie Cooper: The matter I am trying to get to is that the CCG will be the body, if you like, that has the money and, therefore, will decide the priorities and split of that money. Is that what I am to understand?
Geoff Lake: This goes right back to the beginning and something we did not say very clearly. Part of the governance is based on accountability remaining within the CCG for children and-what used to be, but change is occurring at the moment-public health. The accountability remains there just as the accountability remains in the local authority for adult social care. What underpins that accountability is a very clear agreement about what the threeyear strategic plan is that the local authority wishes to see delivered through the resources it is transferring. We sign off between us in the governance system, including with members, exactly what the business plans are on an annual basis. So there is a form of governance that brings the rigour to it of ensuring that what is required is being done.
Q111 Rosie Cooper: I may not share that view. The question I was originally intending to ask is this. Care trusts have generally been between a PCT and a unitary authority. My area has Lancashire County Council. West Lancashire, which I represent, is within Lancashire but there is a crossboundary flow of patients, for example, from Sefton, which you would probably call the Greater Merseyside area. So it is crossboundary. How would you say that model, and the examples you have given, would operate in a situation like that?
Dr Melton: With difficulty. One of the nice things within northeast Lincolnshire is that we are coterminous with the unitary authority. It makes it much easier to enter into those partnership arrangements. There is no getting away from it. One of the challenges for the system is: what are the transferable lessons, from what we are doing locally, and to what degree are they transferable? Across the country as a whole, we have a definite group of individuals who are our most vulnerable and would need joinedup solutions to be able to address those needs. That is common. How you might address that would be different, depending on the organisational arrangements, because it is not only the local authority arrangements but also the CCG arrangements and how they might work out. I would not want to try and describe what would make most sense for the northwest because some of it is related to the current organisational arrangements and some of it has to come back down to the leadership, the cosponsorship and the enthusiasm for championing and driving integration. It may be that within a particular area, for example, a CCG-and I have talked about boundary issues within my own patch-might want to lead on behalf of other areas because of experience or enthusiasm. For me, personally-
Q112 Rosie Cooper: But crossboundary is not really where the Health and Social Care Bill is, nor where the future is, is it? Crossing boundaries is not really acceptable.
Dr Melton: No. I am trying to say that any solutions to support local integration of services would be different for different communities. I alluded to it earlier on, in terms of the arrangements that we had as a locality commissioning pilot before "The new NHS: modern, dependable" came out. A lot of the arrangements that we had in place in northeast Lincolnshire were adopted in "The new NHS: modern, dependable" and became the footprint for primary care trusts. They weren’t transferable across the country, which I think sometimes was where PCTs didn’t work out. It is a bit like what Geoff was saying. We are not here saying we are the bee’s knees and everybody should be-
Q113 Rosie Cooper: No. I am just trying to explore where the difficulty is. Can I ask you one final question? In your integrated model, the one you have and you are happily talking about, have the GPs given up any powers? Have they given up any authority?
Dr Melton: In terms of the membership model, we have a social work practitioner practice that is a full member of the council of members, and indeed has more votes than any other practice because the votes are proportionate to the delegated commissioning budget. For example, I am the biggest practice in our area and the social work pilot has two and a half times more votes than I do. That is unique because I do not think there are any other areas in the country, in terms of the constitution of CCGs, where they have had other practices other than general practices as part of the council of members. In terms of our governing body, we have two elected members on the governing body along with the director of adult social services.
Q114 Rosie Cooper: I have a very final question. Without all the businessspeak and palaver that goes with it, some real English: can you describe a real change that you have made-a real change?
Geoff Lake: At the front end of the healthcare, community health and adult social care system: a single point of access for both; an integrated staff group that includes professional social work, professional nursing, other members of staff, advice officers, and care navigators; a single point of referral; a triage system behind the telephone system that is totally integrated between health and social care in order to ensure that, if there is a necessity for an individual to pass through that system, they are getting to the right point of a care system first time round and as quickly as possible. That is taking all the demand management-a single phone call. It now has general practice. It runs 24/7. It now has out-of-hours in it as a single point of access.
Q115 Rosie Cooper: Forgive me, that sounds like another almost Liverpool Direct business model. I am talking about a real difference on the ground. Where is the real difference?
Geoff Lake: The real difference on the ground is that has saved-
Q116 Rosie Cooper: It has saved you money. What difference has it made to people?
Geoff Lake: It has saved a number of people from being admitted to hospital inappropriately. It has saved a number of people being admitted to longterm care inappropriately. It has saved a number of people being sucked into the system and allocated lots of resources when that was not the solution-they needed a community solution-and so on and so forth. It responds more speedily to people and gets them to the right point more quickly.
Q117 Barbara Keeley: I want to ask a very quick question about the context. Obviously there are some very admirable aspects to the way you are integrating budgets but I do not have a feel for the context in terms of the local authority. Elsewhere, local authorities have had budget cuts of amounts like £50 million or £100 million in my region. Given that adult social care is 40% of their budget, obviously that is a shock, and we know what is happening with the NHS budgets nationally. Has your local authority had budget cuts and what level were they? Have you sustained the adult social care budget within the overall budget envelope? Is it stable, has it increased, decreased or what has happened? I just do not have a feel for it. It is okay to talk about pooling money but if that is a shrinking pool as far as the local authority is concerned, that has issues in itself, hasn’t it?
Geoff Lake: The local authority was, I think, the fifth hardest hit of all local authorities. It lost, over the period of the savings plan, something like £25.7 million of its revenue. Adult social care, over a threeyear period, is saving £15.2 million from a budget of £50 million.
Q118 Barbara Keeley: Is saving or cutting?
Geoff Lake: It has had to make efficiencies-cash reductions-of £15.2 million. So we are seeing a significant budget cut within a local authority that has also been quite severely hit.
Q119 Chris Skidmore: Mr Lake, you touched earlier on issues of personalisation and personal budgets. I was interested to know what proportion of service users in the Care Trust Plus are on personal budgets, obviously with the intention to move to near enough 100% by 2015. I wonder how far you are down that road. Also, in terms of the care trust, how many were on direct payments as well? I do not know if there is any information you could give about that.
Geoff Lake: Yes. About 43.5% of our service user base utilise direct payments or individual budgets in line with the national definition that is used to count those. The proportion of people receiving direct payments is-it is better to deal with numbers-about 600 or 650 people, on direct payments specifically. We are currently working to try and align personal health budgets and individual budgets and direct payments, particularly as to continuing NHS healthcare and complex dementia needs, including the carer element of the direct payment. So we are taking an incremental approach to the development of individual budgets.
Q120 Chris Skidmore: In terms of the personal health budget, you are not part of the pilots, are you?
Geoff Lake: Yes.
Q121 Chris Skidmore: You are. In terms of putting the mechanics together, could you talk through exactly how a personal health budget locks into whether it is a direct payment or whether it is a personal budget and how the local authority fits in here-if it is a personal budget-whether the local authority is leading the menu of choices or whether that is led by the Care Trust Plus? I am fascinated to see, if you are a service user-when we went down to Torbay, their rationale, and I am sure it is very similar to yours, was that it is always about Mrs Smith, so if you have Mrs Smith with her personal healthcare budget, maybe because she is diabetic or has early onset dementia and there is an identifiable care pathway developing-how you wrap around a care plan and a budget to go with that care plan. How does the NHS allocate resources and how does the local authority?
Geoff Lake: The early stage is of trying to put all of that together rather than have them as separate things. At the moment, those have been separate streams of funding and separate allocation of individual budgets or personal health budgets. We are working around a small group of people with severe dementia and their carers at the moment to bring together into one single budget-so drawing off the NHS and drawing off adult social care-a wraparound resource of money that represents their total needs, that is, represents health needs and adult social care needs, working alongside what is used in adult social care, applying the resource allocation model to healthcare and building that up from unit costs, and then building the unit cost up into the personal health budget itself. We use a complex case manager to be the navigator with the individual as to what the outcomes framework is intended to be for the use of those resources.
Q122 Chris Skidmore: You have the Care Trust Plus at the moment, which obviously allows, effectively, the PCT element to siphon the money off. But when CCGs are firmly established in April 2013, how will the case be made to the CCG that this money needs to be allocated? Will the case manager present the case to the CCG at the senate forum or whatever?
Geoff Lake: It is a very interesting question because one of the tensions around personalisation-personal budgets and personal health budgets-is that much of the money you really want to draw off is locked away in service contracts with big organisations. What you have to do, effectively, is find the levers for pulling that money out of those kinds of static service contracts and then reallocating it in terms of a personal budget to somebody. It is a radical change in the system and, at the moment, all our negotiations and discussions are about how we draw off that big service budget in order to turn it into cash.
Q123 Chris Skidmore: I imagine that a lot of the service budget is wrapped up with local authority contracts.
Geoff Lake: Some local authority contracts, some health contracts. You can take day services as a good example where you might have a contract for the provision of a day service. If you are going to be allocating personal budgets, you cannot spend that money twice. That person may not decide to go there, so you have to find ways of getting the cash out of that system and making it available for people to use as they would want to. That is one of the reconciliation issues that we face at the moment.
Q124 Chris Skidmore: Do you have any solution at the moment?
Geoff Lake: Yes. We are negotiating the reallocation of that resource back to commissioners in a retraction programme that enables organisations to reposition themselves in future to offer services to people with personal budgets rather than have servicebased contracts.
Q125 Chris Skidmore: That will be led by Payment by Results, will it?
Geoff Lake: You can do that in mental health services, using Payment by Results, particularly as to functional mental health. It is much harder to do that in traditional adult social care service contracts.
Q126 Chris Skidmore: Why is that?
Geoff Lake: It is because the PbR methodology is not one that has been used. It is a health system much more than an adult social care system. It is not easily replicable.
Q127 Dr Wollaston: Earlier, you touched on the section 75 flexibilities, saying that you thought there needed to be more clarity. Could you maybe let the Committee know what you think you would like to see spelt out very clearly in order to make these arrangements easier? You have said yourself how difficult it is to get other areas to come on board even though it is clearly delivering best results for patients.
Geoff Lake: The constraints of section 75 are that, in our view, it is focused so much on money and the mechanics of money rather than on the outcomes that resource is trying to achieve. If I were to put it bluntly, I would argue that, in a sense, it needs to be service driven-section 75-rather than financially driven.
Q128 Dr Wollaston: In other words, "This is what you want to achieve. You sort out how you are going to do it"?
Geoff Lake: Yes. Clearly, you have to operate within the constraints of available resources and you have to deliver the outcomes that are required, but with much more clarity about what you are trying to do and what the outcomes are that you are trying to achieve with this resource that satisfy the stakeholders in that resource.
Q129 Dr Wollaston: There is genuine flexibility that they can make it work?
Geoff Lake: Yes.
Q130 Dr Wollaston: Could I draw you further on why it is that you cannot get your neighbouring areas to come on board? What are the barriers? What would need to happen? Is it all about leadership or is it across the board?
Dr Melton: It is about focus and priority for our neighbouring local authority areas. The population that I am talking about are quite small numbers. When we have had conversations before with the local authority, they will start to say, "Yes, that is interesting", but it is not a key priority area for them so it tends to drift off the agenda. To be frank, given the scale of things that we have to do, sometimes it gets in the sort of "too difficult" box to try and do anything about it.
Q131 Dr Wollaston: But if they are getting significantly worse outcomes, as you have described, why do you think they don’t see it as a priority for them to match your outcomes? I think it is a very important point. Why isn’t it happening?
Dr Melton: You are probably right. There is a leadership requirement to try and articulate that. It is one of the conversations that I have been having with my neighbouring CCGs because they-particularly East Lindsey, which goes down to Louth, from our point of view-or the GPs there, are saying, "We would much prefer this sort of model. We are seeing people ending up in the local Grimsby hospital because we don’t have the same arrangements for community support and adult social care support. We would like to try and come up with a solution that would bring the same sort of benefits to our population." So it may be that it is not us who are starting to describe that because it is for a relatively small population. It is for our neighbouring CCGs to maybe champion that cause.
Q132 Dr Wollaston: Do you feel hopeful that the new arrangements under the Act may make this easier? I know many commentators are saying that the Act will make this harder. Are you saying that in some areas it will make it easier?
Dr Melton: A lot of this comes down to enthusiasm and belief in terms of whether it really does bring benefits for the population. I genuinely believe-and when I network and talk to my GP colleagues who are either taking on accountable officer or chair roles they also really believe-that integration is key.
The other thing that they are passionate about getting involved with is the Health and Wellbeing Board. They see people on a daytoday basis who are being medicalised, who are turning up in their GP surgery looking for help when, often, the help is about education, chances of employment, safe environment and warm housing. As community leaders who are embedded in their communities, there is a real desire and willingness to rise to the challenge of, "Yes, we want to develop high quality services for patients when they need them" but also "How do we bring them in a joinedup way, particularly working with adult social care?" The other element-and I think there is a real passion and desire that is growing-is how they work with the local authority to support their community leadership role.
Chair: Gentlemen, I think you have seen, from the bubbling of questions, that I have had a difficult job getting colleagues in and I have not been able to accommodate them all. We have been very interested in what you have had to say but we also have two further witnesses sitting behind you, so we would like, if we may, to move on. Thank you very much for coming.
Examination of Witnesses
Witnesses: Geoff Alltimes CBE, Chair, Local Government Health Transition Task Group, and Andrew Cozens CBE, Associate, Local Government Association, gave evidence.
Q133 Chair: Gentlemen, welcome-I think in both cases-back to the Committee. Could I ask you, very briefly, to remind us who you are and where you come from?
Andrew Cozens: I am Andrew Cozens. These days I am an Associate of the Local Government Association, offering strategic advice on adult social care.
Geoff Alltimes: I am Geoff Alltimes. I am also an Associate member of the LGA here this morning, but, as you will know, I was previously here as part of the Future Forum initiative. It may be that some of the questions are in that territory. I am happy to answer those but I may not be able to answer them from the point of view of the LGA.
Q134 Chair: Thank you very much. You will be aware that in our report on Social Care we stressed the importance of joinedup services-integrating services-looking for crosssystem reform. Both of you have been authors of reports that have said the same thing. Where do you think we are getting to and what is the key to moving forward faster?
Geoff Alltimes: What is important from my point of view, and it probably does pick up the Future Forum previous experience, is that the recommendations that were made from the Future Forum have been, in both instances-both phases-accepted by the Government pretty well in full, with exceptions in some places. Also important is that we are in a phase where, in the role I have at the LGA, which is chairing a task group of all the chief executives and directors in local authorities that are part of the Department of Health’s health reform machine-we have been engaged for the last six months in trying to influence the policy elements of those-we are now into much more of the implementation. I am encouraged by those discussions in the sense of the commitment to the intent of taking forward those recommendations and moving on integration, but I think it is probably fair to say that that is in the making.
The NHS side of the business is going through very significant change at the moment and that means, as we know from all the reports in relation to integration and as you were reflecting with the earlier witnesses, they depend on the relationships that individuals have locally. We are in a position where there is quite a bit of change going on at the moment, but I would be more optimistic than not-from the task group I chair-about the way in which those things are gradually coming together. However, as you will know, your report was looking to the Health and Wellbeing Board having more of a direct commissioning function and that is not there. The test for us is the commitment to the Health and Wellbeing Board, of which I am a strong advocate. I believe, as a result of the recommendations that we made in that first Future Forum report, that the Government agreed to strengthen the Health and Wellbeing Boards. So that has gone some way, but the test will be when we get to the very next phase, which is this autumn, with Health and Wellbeing Boards needing to align their financial and service plans for the 20132014 year. That will need to happen this autumn and that will be the test.
Q135 Chair: There is one bit of terminology. In your Future Forum report you referred to the Health and Wellbeing Board as being "the crucible" of integration and there are other documents that have come out since that refer to it as "a crucible." I wonder whether we are being sensitive about this or whether you think there is significance in that change.
Geoff Alltimes: I have to say that I have given that no thought whatsoever. On the crucible point, one of the things that we were keen to have a section on in that integration report-the second Future Forum report-was essentially the financial circumstances, which probably are the most difficult ever and which we referred to as "the burning platform." That is where I think the heat of the crucible must come from and that is why CCGs are going to be as interested as local government in how we can use integration to achieve joint commissioning, in itself, to achieve better outcomes for patients and residents, but also transactional efficiency savings and a transformation in avoiding hospital admissions.
Andrew Cozens: Setting aside the Salem witch trial connotations, one of the issues is the weight given to the local priorities and local service design issues within the Health and Wellbeing Board as against the other pressures subregionally, nationally and the other expectations on players sitting round the table, and, in addition, the extent to which the focus is on health and social care integration or, more generally, on the integration of a range of local services and the place of the Health Service within that wider picture. Issues about housing, where people live and the communities in which they live, are of equal significance to people in terms of improving outcomes, I would argue.
Q136 Rosie Cooper: Before I ask the question, may I go back to Health and Wellbeing Boards and the description you give of the budgets in the autumn? Can you describe what you really mean? Whose money is it, where does it come from and who has the power to do what with it? Who is going to make the decisions?
Geoff Alltimes: I mean simply that you would expect the Health and Wellbeing Board to look very specifically at the local authority’s plans in relation to the adult social care budget, including the issues about the context of overall reduction in local government and the children’s social care budget, but also, as Andrew was picking up, those wider determinants-what is being planned in relation to housing and leisure and so on. Obviously that is the local authority money where there is much more freedom to determine how to spend that.
On the other side would be the money that the CCGs will be responsible for, as it were, the local bit of what was the PCT budget in the past. This new CCG would obviously then have the decisionmaking power in relation to that budget. The problem is that a fair bit of it is circumscribed by the present tariff arrangements and we need more flexibility on the health side to enable them to look differently at how that bit of the money is spent.
Thirdly, we must not forget that the NHS Commissioning Board will be responsible for some of those specialist areas of commissioning. We would need to make sure that there was a senior representative of the Commissioning Board ensuring there was integration with what that plan was.
Q137 Rosie Cooper: I get that there is a pooling of information-
Geoff Alltimes: Yes.
Rosie Cooper: -and a pooling of discussion at the Health and Wellbeing Board. What happens then? What if the Health and Wellbeing Board does not agree with decisions the council has made or the CCG? What, other than talking, can actively happen, other than people going back to their respective organisations and letting them know?
Geoff Alltimes: That is the key question because there isn’t the ability for one side to control the other. I believe it will be necessary for the organisations to look at how they are deciding to spend money. There will be the joint commissioning commitments that already exist and CCGs, in their authorisation process, will be asked to look at where they stand on that and where they stand in the future in relation to joint commissioning. But I think both will be under an imperative to achieve better outcomes and efficiency savings from what they are doing. There will not be a lever to resolve that. It is going to have to be worked out locally. My experience is-and the examples we have heard-that is possible to do, and I have a fair degree of optimism in relation to it. But it is important that we do all we can to ensure that the context in which that happens pushes it in that direction.
Q138 Rosie Cooper: Indeed, I hear you and I love the optimism. I suppose my real problem is what happens if you are a patient and/or a social care user in an area where that optimism is not the path that is taken. You have nowhere to go.
Geoff Alltimes: You would then expect, wouldn’t you, that HealthWatch would be part of the wider setting there and you would expect local authorities, the CCGs and, come to that, the NHS Commissioning Board representatives to be answerable and accountable to their local communities for what they are doing.
Q139 Rosie Cooper: Local communities, okay, but I am just not understanding. You are now saying that local HealthWatch could in fact be a referee?
Geoff Alltimes: I wouldn’t go as far as "referee" but they would definitely be part of the holding of the Health and Wellbeing Board to account.
Q140 Rosie Cooper: I think that local councillors will be held to account by their electorate, and Health and Wellbeing Boards will have half their membership not accountable to anyone other than GPs or whoever sent them there. So I don’t think that accountability is uniform. The local people may have the ability to sack one half of it, but it would not be able to deal with the clinicians and/or the representative of the CCG or whoever is there. I don’t see that as being real accountability in any way, shape or form. This new streamlined "getting rid of bureaucracy", "Let us get rid of managers and save money", now we have HealthWatch who is acting as a referee over a Health and Wellbeing Board, which is-or could possibly be-a talking shop at which only certain members would be held accountable, I don’t think is a fantastic model, in my head, for making a difference. It is great for talking and for moving it on, probably slowly, but not for making big differences.
Andrew Cozens: The framework is set by the joint strategy that all players round the table, including HealthWatch-because they sit round the table as well-are party to. That will be a published document with specific local outcomes that I think all parties will be held to account to. The minimal position is that people are cocommissioning, sitting round the table together and then going away and doing things separately. But there is quite a lot of, as Geoff said, inherited infrastructure as well as inherited services that are put together jointly. There is a range of things that can be done within the framework of the Health and Wellbeing Board, assigning lead commissioning roles, specific jointlyappointed commissioners with delegated budgets, purposecreated vehicles and other things that you can do within that framework. Ultimately, the strategy and the outcomes that flow from it are the way that people will be able to judge the success of the Health and Wellbeing Board.
Rosie Cooper: God help you if you need it and it isn’t a success. That is my problem.
Q141 Chair: Can I refer us back to the evidence that was being given by the previous witnesses? We asked them where responsibility rests for carrying forward this integration process. One of them said, very clearly, the CCG rather than the Health and Wellbeing Board, which I thought was quite striking. How do you react to that?
Andrew Cozens: I think there is a duty on all parties to promote integration.
Q142 Chair: I understand there is a statutory duty, but what I am more interested in is who is actually going to do it.
Geoff Alltimes: Andrew referred to the models for aligning commissioning or going for joint commissioning. It is going to depend on what those parties agree in relation to what model they go for. I would certainly expect there to be a level of joint commissioning. I hope that there will be some places where they will go with the Committee’s model, a lead commissioner, in relation to older people’s services. My own experience of trying to achieve this sort of integration locally in my previous role in Hammersmith & Fulham-where I was the joint chief executive of the PCT at the same time-makes me believe that it is possible for people to see the benefits of both the joint commissioning and then using that as a lever to achieve what is the bottom line of what we are all about, which is the integrated provision. That is what is necessary. Whichever way you cut the accountabilities, you have to be able to persuade and influence people to work together. We have to try and make sure that the system encourages people to do that to the greatest extent. But I accept the point that there isn’t a way of guaranteeing that other than building in the mechanisms Andrew was referring to, that is, making sure that joint outcomes are referred to in the published strategy that enable the local community and the other partners to hold each other to account.
Andrew Cozens: I would argue that the local authority holds the rein in terms of the specific responsibilities for the place that they have and the fact that these are statutory committees of the local authority-these Health and Wellbeing Boards. CCGs seem to me to carry the primary responsibility for bringing health to the party these days.
Q143 Chair: But, as Mr Alltimes said, the key is to properly deliver services that are restructured to meet the needs placed upon them. Sometimes the tendency here is to make it sound as though all that is necessary is for them to meet, discuss and have a coordinating session, whereas what is required in very many areas is a complete rethinking of the way care is delivered. It is the carrying through of that that is the real challenge, isn’t it?
Geoff Alltimes: Indeed. Obviously you would have looked at many examples, as we did in the Future Forum, of places where there was considerable work invested in trying to rethink the "pathway" that a patient might be travelling on and where they could get different help-where we could avoid hospital admissions. You will know from your own references that in my neck of the woods, inner northwest London, we were looking at a Torbay model of care coordinators, wrapping social care staff and community health staff around GP practices, and we were also part of that very largescale integrated care pilot that brought together a number of GP practices, authorities, acute trusts, community trusts and mental health trusts as well as the GP-CCGs. It is that sort of change that we need to have. We are in the early stages of that integrated care pilot, as you will know-and I think you have referred to it being in the BMJ article-but it does show figures, like colleagues were talking about earlier, of a 6% reduction in hospital admissions. That means a reduction in people-mostly older people-going into hospital when they do not need to. So there is a quality issue as well as a saving issue that we are trying to address there. But they are complex changes, and my argument would be that we are only going to achieve them by quite a lot of people being prepared to behave differently in order to make that happen.
Q144 Andrew George: Mr Alltimes, given your earlier responses, I wonder if you have been given adequate opportunity by the Committee to extol the benefits of the work that you did on the Future Forum looking at integration and whether there are still aspects of the report that you produced which you do not think have been appreciated as much as perhaps they could have been, and indeed taken on board by the Government and used to advise the Health and Social Care Act as it went forward?
Geoff Alltimes: Thank you. I still hold to the key point of the recommendations from the Future Forum about the priority of integrating care around the patient, the resident, the person. That was the key bit that we needed to promote. In the first Future Forum, that was made absolutely vivid to us by all the organisations, patient representatives and patients themselves that we met. There has been a wider acceptance than in the past of that priority and I see that as the important thing.
A number of our recommendations in the integration report in the second Future Forum were about how to make that happen-things like a care coordinator for an individual and improved information. We then had recommendations in relation to things that would make the system work, measures in relation to improved outcomes related to integration and so on. But we have already talked about the key recommendation, which was trying to get closer to joint commissioning and seeing the Health and Wellbeing Board as the vehicle for achieving that. I am a passionate believer that we will do that better if we allow the local people responsible for those services to have the freedom to get on and do as we put in the report. It remains to be seen how much that is the case. But I would say-and we made some recommendations in relation to funding following the patient and the issue of tariff improvements-that those have been pretty universally accepted and adopted. In my experience, they begin to show in the sorts of commitments that people are thinking of in relation to the mandate, the sort of commitment that we are looking at in terms of the agreement between the LGA and the NHS Commissioning Board about how it will work together, the recent report from Monitor looking at its responsibilities now in relation to integration, and so on. I think the bits of the system are in place but they are not yet tested in terms of delivery.
My last point, to answer your question about what would I still want to argue for, would be on the recommendation in relation to sharing best practice and breaking down barriers. I believe there is a greater commitment now than there has been, but it is still an open question as to whether we can achieve the scale of taking forward integration that we know is necessary. We may make improvements in the tariff system and so on that will enable that to happen but there will still be problems on the way. I want it to be the case that there is an ownership by the sector of resolving those problems. I want it to be the case that there is a place where there is a responsibility for seeing integration through and that the people who are responsible for that are going to be representative leaders of CCGs, of local government and the Commissioning Board themselves owning the issue of how to ensure that all those individual locations deliver on that integration promise.
Q145 Andrew George: Can I accuse you of being overly optimistic-
Geoff Alltimes: It has not been unknown.
Andrew George:-about both the Health and Wellbeing Boards commissioning services-which does not look particularly likely at the moment-and also as to the CCGs themselves? The purpose of the change from GP commissioning groups to CCGs was the argument that it was going to be a broader range of clinical and professional expertise. Is there a lot of evidence, do you think, in the emerging CCGs that those groups have taken on clinicians other than the GPs? For example, in terms of this concept of integration, they are still very narrowly based, coming from only one perspective. Do you really believe that services are going to be easily integrated as a result of these changes?
Geoff Alltimes: I certainly don’t believe any of it will be easy, but, to answer your question, it is probably fair to start an answer by saying that I don’t know the answer to that question. I don’t know the position overall, and Andrew may want to comment on this too. All I can say is that, anecdotally, in my own continuing discussions with the CCG and GPs that I have contact with-mostly in London but some others-there is a stated commitment to the goal of integration and joint commissioning and an interest in how that might be done. It is certainly the case that the learning network in relation to Health and Wellbeing Boards is trying to take that forward, but it is also the case that GPs, in their CCGs, are pretty preoccupied, understandably, with the authorisation process. So there has not been as much time for engagement about how we might support, at the national level, that happening at the local level.
Q146 Andrew George: Can I also put a cynic’s perspective to you with regard to your report and the claims made in it? In terms of the benefits of integration, as you have described them earlier-and you were particularly emphasising the benefits of avoidable unnecessary hospital admissions, which clearly is a benefit if you know, but possibly only in retrospect, that it was unnecessary and should have been avoided-a cynic might say that what this is all about is cost shunting from health to, in fact, a feepaying social care service, which then is about saving money. That is one cynic’s view. It is about putting barriers in the way of the freeatpointofdelivery element of the service. The other is that this surely conflicts with the Government’s choice agenda. If you have integration, how can you, at the same time, provide a genuine range of choice, particularly if the patient’s choice is to seek an acute opinion on something and you are trying to create a barrier to that by arguing that integration avoids a person migrating into the secondary care sector, for example?
Andrew Cozens: I could do with a chance to think about that because it is quite complicated. I think quite a lot of this relates to the design of the system and the balance between putting in place an infrastructure that tries to make the best use of resources in the system and the role of individual advocates-GPs, in this respect-to make sure people do have choice and diversity.
Where I sit, a lot of the success of this rests on the bravery and the willingness of local people to take risks in a context that is hard-wired to keep things separate by a whole variety of different legal, regulatory and performance management and other arrangements. In the early days of the CCGs there was a lot of interest in innovation and flexibility about the things that people wanted to do together. We are now in a stage where people are, in a sense, being consistent in order to get the subsequent permission to then innovate and be flexible. There is a danger at the moment that we stick with the consistency model rather than seeing this as just a stage to test competence before people are encouraged to be flexible. If we are going to have real success with this, we have to be prepared to dismantle a whole range of things that keep health, social care and other local services separate: tariffs, performance management, what is deemed to be good, clinical governance and related issues, and also regulation and service contracting, which keep things separate, distinctive and different. The answer almost certainly lies, in addition to the other things we have talked about, in commissioning services that can straddle those boundaries and also, where appropriate, the rollout of genuinely integrated personal health and social care budgets, where either people have the resources to manage themselves or where it is managed on a joint basis by a joint case manager on their behalf.
Q147 Andrew George: You think that personal budgets provides the answer to most-
Andrew Cozens: It provides an answer for some people, particularly those with longterm conditions who make heavy demands on both health and social care.
Geoff Alltimes: I was going to respond to that point about the cost shunt. In that inner northwest London integrated pilot that I was part of in Hammersmith & Fulham-and is still going, looking at being extended geographically and in terms of the longterm conditions that it tries to respond to-where we are looking at a reduction in hospital admissions, we are certainly including in there those people with diabetes where there is quite a lot of evidence that people can be supported to live at home and not need a hospital admission and can take care of themselves better if there is a system around them that reminds them of appointments, checkups and so on. Those individuals I have talked to certainly welcome that different emphasis in the system and support for them to live at home. On a number of occasions where we have talked to patients and their carers in the context of personal budgets, both social care and health, there is no doubt from the stories that some of those individuals relate that the quality of life they have been able to achieve as a result of that change and the flexibility to manage it in a way that suits them is genuine and a desirable outcome. You would not doubt that.
Going back, finally, to that integrated care pilot model, it is definitely the case that part of the funding formula and the way it is modelled is to recognise, if you are going to have fewer people in hospital and more people supported in the community, that some of the saving needs to be spent on additional community health and adult social care services.
Q148 Andrew George: Do you think the health reforms-the Health and Social Care Act-is helping by making big strides in that direction, or do you think that it does not contribute very much and that what is happening on the ground is happening in spite of the reforms?
Geoff Alltimes: I think what is happening on the ground is in spite of the existing system, where the tariff model does not help. Health and Wellbeing Boards will be helpful. They already are helpful in their shadow form in terms of the CCGs being part of managing what the system should be like in the future. So I am overoptimistic, in your terms, in relation to that.
Andrew Cozens: There is a lot of emerging evidence from the priorities chosen by Health and Wellbeing Boards that this issue about, particularly, older people being in the wrong part of the health and social care system is a low priority for the vast majority of them.
Q149 Chair: One of the things the LGA has been saying publicly recently is that the cost shunting is, if anything, not out of the Health Service into the local authority world, where services are charged for, but, because of resource constraints in the local authority world, is cases ending up in acute healthcare that didn’t need to be there. What evidence is there?
Andrew Cozens: There is some evidence of that, and it is reflected in emergency admissions and other things of that kind. The other major factor-and recent research during Carers Week emphasised this-is that a lot of the slack is being picked up by carers who are carrying a substantial additional burden.
Q150 Chair: Has the LGA published-I know it has published opinions-assembled evidence from the local authority base over the last 12 months of any trends in this area?
Andrew Cozens: We have not recently. The most recent evidence is the Association of Directors of Adult Social Services’ budget survey which gives broad indications of trends within the system. I do not have it to hand but there is regular data about the pattern of discharges from hospital that are delayed for a variety of reasons. There is no massive increase in relation to issues that relate to social care, but there are, nevertheless, hotspots and trends that suggest the system is under strain.
Q151 Chair: Is there any evidence that links changes in eligibility criteria for local social care services with hospital admissions and other healthcareassociated costs?
Andrew Cozens: I do not think there is a direct correlation. Despite a lot of conversation about that, only a very small number of authorities increased their eligibility criteria. The vast majority are at substantial and critical now, but the numbers that did that in the last 12 months are not that huge. So I don’t think there is a direct link.
Q152 Dr Wollaston: Can I return to the north-west London pilot and quote from the article in the British Medical Journal by Richard Vize, "Integrated care: a story of hard won success"? He says: "It should not require lawyers to draw up agreements to get clinicians to work together. Nor should it require what Hamilton describes as ‘smoke and mirrors’ to fund it." Under the new arrangements, are you hopeful that we will need fewer lawyers’ agreements or do you feel it is going to get worse? That is a significant barrier to integrated working, isn’t it, if people waste huge amounts of time on lawyers? What are your thoughts?
Geoff Alltimes: It is a very significant pilot. As the article says, it was a 500,000 population, with 100 GP practices and a number of local authorities, acutes and so on. It was a very complicated piece of joint work which started with the leaders of all those services having some doubt about whether this was going to work for them but working through to a process where the group, as a whole, would say that this is delivering patient improvements and working better. There are anecdotal stories of clinicians across primary and secondary care working much better together and understanding each other better and all that sort of thing with those outcomes.
But, as the article says, the funding model in the NHS does not make it easy to do that. That meant there was a complicated agreement as to how the incentives would work and a pretty intensive piece of work to ensure that there was an information system that could enable all those agencies to share information and also create care plans that could be shared by those organisations as well as support the multidisciplinary group. That, in itself, is similar to some of the Torbay stuff. So it is complex to do.
What is being looked at currently-and it was aimed at people with diabetes and the frail elderly-is to move it out to other conditions and also to look to covering the whole of what I guess is still the northwest cluster, that grouping of eight local authorities in the northwest part of London. I hope the learning from the experiences of doing that will enable that to be replicated more easily elsewhere. I would say that of a number of other models. It is not the only one, but it is an important example. The main issue in relation to that flexibility will be changing the tariffs. There is universal agreement-I am sure you would have experienced that too-of the recognition to explore, as our report said, the "Year of Care" model, the general unbundling of the way tariffs work at the moment. The NHS and CCGs need that sort of flexibility in order to be able to come to arrangements for changing the way in which we respond to people with different conditions to keep more people at home to do those things we were talking about earlier.
Q153 Dr Wollaston: So it is tariffs and outcomes. What about the legal side of it? That is also a point he specifically refers to, that you seem to have to have a lawyer’s agreement to get people to work together. Is that going to get less burdensome?
Geoff Alltimes: I think it will. I have the experience of the council joining with the PCT and my being the Chief Executive for both and the staff group being treated as one but providing a service to two separate statutory organisations. We had a minimal legal agreement in relation to that because, essentially, we were agreeing to do it together by bringing our two cheque books into play. That could be part of a model of joint commissioning and I don’t think you have to have, therefore, complex legal agreements. The more we do it, the more it will be possible to have standard legal agreements about how we do it.
Q154 Dr Wollaston: The impression given by the article is that this is a huge obstacle, that everyone is spending all their time with lawyers drawing up complicated agreements. Is that not your experience, that it is not as complicated as perhaps the impression given?
Andrew Cozens: Some are. The issue is not so much the legal framework but the accountability framework and the extent to which the organisations in and around the Strategic Health Authorities or others place expectations on being able to track spend in detail in relation to an integrated arrangement back through the separate silos of funding accountability. So some of the complexity as to the legal stuff related to who is authorised to spend what, under what circumstances and for whom, and related issues.
Q155 Dr Wollaston: Will that get simpler as we move forward and these things become more common?
Andrew Cozens: A lot of that depends on the national climate that is set for integrated arrangements and also the performance management expectations on the individual organisations that the new system brings. I don’t know, is the short answer. It very much depends on the extent to which there is a tightloose arrangement between the centre and local arrangements or we end up with tightloose-loose about how and then tight about how it is spent-and the outcomes. We would like to get to a position where the real judgment was whether outcomes across health and social care improved for individuals rather than whether you could track a pound all the way through the system.
Q156 Dr Wollaston: That is what we have heard consistently, that it is all about setting the outcomes and then letting local people have the flexibility to get on and put it in place without an army of legal arrangements or whatever.
Andrew Cozens: Yes.
Q157 Rosie Cooper: So the more private providers you bring in, that will not negate the need for lawyers, will it?
Andrew Cozens: In some respects that relates to the contractual framework for the delivery of services. We have a long history in adult social care, for example, that we can bring to Health and Wellbeing Boards about how those relationships work. It does not automatically flow. Indeed there has been a lot of work over 20 or 30 years of adult social care about standardisation of approaches which would save time.
Q158 Rosie Cooper: From your answer to Sarah, which was basically to let local people decide and all the rest of it-give them the problem and let them decide-what safeguards do you have for them making a mistake and not delivering? How do you protect the people who are paying, that is, the taxpayers of this country, for somebody else’s experiment?
Geoff Alltimes: From where I sit, that is no different from the position in relation to our local government now. I think local government has been able to demonstrate that it can deliver improved outcomes locally across a broad spectrum and be answerable to that local electorate, as you were describing it earlier. I do see that as something that can be replicated in this territory, and I would be with Andrew that we have a good background in relation to contracting and how that might work. I think we can extend that to the new arrangements with CCGs.
Q159 David Tredinnick: You have come up with a whole range of ideas. How, now that the Government has said it is intending to publish a Care and Support Bill, do you see those ideas being implemented? What are the key elements that you would like to see in that draft Bill when it is published, please?
Andrew Cozens: The LGA has set out our position in a paper called "Ripe for reform" and we have identified a range of elements that we want to see in it. In essence, there are four key dimensions that we want to see in the Bill. At the heart of it, we want to see the individual’s experience improved. We want to see a more stable, predictable and transparent approach to social care that encourages a longterm view rather than a whole series of shortterm decisions that the system struggles with at the moment. We want to make sure that there is sufficient funding in total in the system and that it is appropriately directed, and also that social care is not seen in a box but that we look at the totality of resources available to support people in local communities. As I have said before, that would be housing but also significant regard to how best to support carers and a whole range of other issues of that kind.
Specifically, we would like to see the Law Commission recommendations implemented to provide a modern legal framework, not one that is still, in essence, based on the Poor Law, as I have said before here. We would like to see a statutory basis for safeguarding adults. We think that is an important part of the situation. But none of the social care reforms can be delivered without a trained, rewarded and motivated workforce. So we are looking for initiatives in that respect.
We also hope the White Paper is going to do something about the market overview nationally and locally and the clarity of the respective roles of different players in setting standards and regulating the sector, specifically NICE in relation to service standards across health and social care, with their new responsibilities, Monitor as an economic regulator-we are unclear about how they will work in relation to social care, but they will have a role-and the role of the Care Quality Commission in its broadest sense. As you would expect from the Local Government Association, we are looking for local leadership-local government-but in the context of a national framework of eligibility and entitlement, locally designed and delivered.
Chair: Does that give you a clear answer, David?
Q160 David Tredinnick: It is a list that has been drawn up before and does not draw on what we have been doing this morning. Obviously, you need to set out your stall, but we have had this discussion and you have been questioned. I wonder if there are any outstanding points that you feel are not included, or, personally, if there is something there that you think should be included as well. I would like Mr Alltimes to comment on that too.
Andrew Cozens: We very much see adequate funding for the system, integration with health and housing, more choice and control for the individual through personalisation, and so on, and a modern legal framework with rights. A clear framework of entitlement has been part of that. So the conversation we have had this morning about bringing health and social care and other services together is absolutely at the heart of what we see. But we do not only want to see social care nested in specific services. We want to see it in terms of how people are planned and supported to live more independently and how they can prepare with confidence for the fact that they might need social care in the future.
Q161 David Tredinnick: What do you mean by "a legal framework"? Do you mean some form of protection for patients? Do we need a new legal framework? The laws are there, aren’t they? It is just a case of re-allocating resources.
Andrew Cozens: We have a framework of legislation that has been put together over a long period of time, fundamentally based on the National Assistance Act, which basically has, at its heart, that you should not look to the state for any sort of support in relation to social care unless you are poor or very needy. That is at the heart of what we currently have. Bolted on to that, subsequently, we have then had rights for carers and individuals to ask for direct payments which assume more of a framework of reasonable expectations that people might have of the state. We need to sort out which of the two systems we want to have. The general consensus of the sector and the review of both the Law Commission and Dilnot was that we should clarify this as absolutely clear and transparent expectations of what the individual should expect and what the individual, themselves, should prepare for.
Q162 David Tredinnick: You might have heard the Prime Minister yesterday setting out a sort of "perhaps, maybe" agenda. Did you pick up anything on that? Was there anything that particularly appealed to you?
Andrew Cozens: You are not going to trap me into expressing a view on what the Prime Minister had to say.
Q163 David Tredinnick: That is what I am here to do.
Andrew Cozens: What I would say about the social care system at the moment is that it neither meets the needs of people with reasonable expectations and no money for support, nor does it offer people who are using their own resources any predictability about how much they might have to pay. Those two things make it very difficult for people to take responsibility for themselves.
Q164 Barbara Keeley: We are obviously at a critical point as to whether the Government will take forward the recommendations of the Dilnot Commission. It is a position that has been described today as "dithering on Dilnot." I understand the LGA chair, Sir Merrick Cockell, has said today: "By the end of the decade councils may be forced to wind down some of the most popular services they provide unless urgent action is taken to address the crisis in adult social care funding."
Can you tell us the LGA’s view of the debate on Dilnot and social care funding reform, which I think you have started on in your previous answers?
Andrew Cozens: Yes. The LGA remains committed to the principles of Dilnot because it offers the best proposition so far for, as I have said, a fair, transparent, stable and, most importantly, predictable funding system. But Dilnot, of itself, is not sufficient. We need to have regard to other, broader issues-the overall funding position on social care, particularly for those who rely completely on the state who would be no better off under the Dilnot proposals; we need to sort out the legal architecture, as I have said before, but we also need to make sure there is sufficient workforce around to view this as an attractive proposition. That is about the status, training and other issues associated with people working in social care. We also need to work out how social care and health can work together better, and that has been the subject of that debate.
May I mention briefly the research published today by the LGA? We have calculated-to fulfil our statutory responsibilities for children’s and adult social care-the position councils were in at the start of the decade and where we anticipate they will be at the end of the decade. At the start of the decade councils were spending about half their money on children’s and adult social care and had about £24 billion to spend on other things. If adult and children’s social care are funded to the current levels of expectation, by the end of the decade we estimate that would account for 66%, or twothirds of the council’s total spend, which is an increase of something like 80% in real terms. That puts a massive squeeze on remaining council services, and I think that is the point that Sir Merrick is making today. If we do nothing in relation to these broader issues about the funding of social care and Dilnot, councils will be in an impossible position.
Q165 Barbara Keeley: You told this Committee in September-I was not here then-that "the social care system is close to collapse, if not fundamentally broken." How would you describe it now?
Andrew Cozens: It certainly has not got any better since I last came. To be honest, I think the situation continues to deteriorate. It is manifest in the impact on carers and their health, it is manifest in the pressures on providers in relation to fee levels but also in relation to their businesses and their viability, and it is evident in who is guaranteed a service in the system as it currently stands. Although, as I have said before, only six councils have increased their eligibility criteria, 83% of councils now only guarantee a service to those with substantial critical need. So the position continues to be very difficult. The overall context, as I said earlier, is not just the impact on those who have expectations of the publiclyfunded social care system and those who face the cliff edge of impossibletopredict costs using their own resources, but we are beginning to see a squeeze on anything else that is available funded by councils as a result of this.
Q166 Barbara Keeley: We did have the situation, obviously, where the Department of Health provided additional funding for social care activities-those that would also benefit health-and the Social Care Minister, in his evidence to us in January, said that, for him, this funding effectively closed the social care funding gap. I have to say that did seem to attract an immediate response from social care stakeholders who all stated the opposite to that. How do you respond to that, because we have been talking about integration of health and social care?
Andrew Cozens: The additional funding was welcome and councils have made good use of it, both to offset cuts that would otherwise have had an adverse effect on the Health Service and obviously on service users, but also to try and invest in preventative and other services and to meet some of the demographic pressures. But the additional resources, even if they were adequate in relation to just the Department of Health’s perspective of councils, dropped into the context I have described-where councils overall were having to make a 28% reduction in funding and facing Council Tax freezes-a very hostile context, as I said at the time. So things would have been very substantially worse without those additional resources, but they did not solve the problem.
Q167 Chris Skidmore: Have you done any research tracking what individual councils did with the money they received from central Government or the NHS regarding services? I know there was a debate that we had in the Committee, going back, about the nature of whether it should have been ringfenced or not. I remember the LGA-I think, Geoff, you were there at the time-saying they disagreed with the ring fence, and there was agreement in the Committee at the time. But have there been any adverse reports that you have found of councils, as a result of there not being a ring fence, abusing that extra money, placing it in transport budgets under excuses that this might cover up potholes that elderly people might fall into-a public health issue-the sort of worry that not having a ring fence would mean that money would not go into the right resources?
Andrew Cozens: There were two tranches of money, as you will recall. There was money that came through the overall settlement and then there was the transfer from the NHS. The position on the overall resources, certainly in the first year and it continued into the second year, is that councils did not pass on to adult social care the proportion of cuts that they should have got as 40% of a council service, so there was some considerable degree of protection.
On the money transferred from the Health Service, which you will recall was subject to an agreement with the PCT as to how it would be used, the recent ADASS survey for this current financial year shows that it has been distributed roughly as follows: about 13% towards demographic pressures, about 36% specifically to offset cuts that would otherwise have been made to services with an impact on health, and about 25% to fund new services, particularly new services that would prevent unnecessary admissions to hospital-but I should stress that the demographic pressures issue is primarily associated with learning disabilities, as I have said before-and then about 26% specifically on new schemes jointly with the NHS to benefit the NHS directly. So the new services were not necessarily new services with the Health Service but about a quarter was spent on jointlyarranged services that benefited the NHS through social care activity.
Q168 Barbara Keeley: There was a report, which I am sure you have seen, that gave maps of how the funding was used across the country which said-I think I remember-that Manchester and Sheffield had entirely used that funding to prop up its current eligibility criteria. What hope is there of developing the integration of the other things we have just been talking about if large councils like Manchester and Sheffield need to use the funding to prop up what they are currently doing?
Andrew Cozens: I haven’t seen that and I don’t know whether that relates to the two tranches of transfer or to the NHS transfer.
Q169 Barbara Keeley: It was the NHS transfer.
Andrew Cozens: The overall position is the one that I gave. I cannot comment on individual councils. But it was subject to a joint agreement with the local PCT about how it would be used so there would need to be a joint understanding that was the right thing to do with it.
Q170 Barbara Keeley: This is the final question. Do you have, in terms of the LGA position, particular future funding options that you favour for social care? You have already said that you don’t want social care put in a box, so are there other aspects of the funding of social care that you want to put forward from the LGA?
Andrew Cozens: I don’t think I have a great deal to add to what I have said before. Our fundamental principle is that Dilnot offers a good platform for these discussions but there must be parallel discussions about closing the gap overall, so the two need to be side by side.
Q171 Barbara Keeley: How do you close the gap with a Social Care Minister who says there isn’t a gap and that he has given you the funding?
Andrew Cozens: We continue to provide evidence that such a gap exists. You have had previous evidence here and commentators-all to varying degrees-say that there is a gap. It depends on where you start measuring the gap from and in particular, for example, whether you should calculate on the basis of people with moderate needs having a reasonable chance of having their services met rather than only those with critical and substantial needs.
We think that there are practical things to be addressed in the implementation of Dilnot that still need further work. We have an open mind about where the cap is set and how it is calculated. We also think further attention needs to be given to how it works across residential care and home care-how we, in the system, incentivise prevention so that we do not get a rush to spend in order to reach the cap. But, also, there are particular issues to do with closing financial loopholes, about what will be eligible spend and issues associated with that. We are not convinced by arguments that voluntary insurance or housing equity release or other issues could resolve these issues because all our conversations with providers of those services say that they will not fly without a more predictable system and a capped liability.
Chair: I think, in truth, we have had a full canter round the scene. Thank you very much for your evidence. We shall be returning to this subject in the next few weeks.