Examination of Witnesses (Questions 460
WEDNESDAY 24 APRIL 2002
460. So are you saying this did not happen?
(Mr Hassell) What I am saying is that, at that stage,
when this publicity was occurring, many of the home operators
had, in fact, not received the cash from statutory authorities,
from the health authority, generally speaking. At one stage, one
of the groups, in fact, where they were acting as agent to receive
what was approximately £3½ million, only half a million
pounds had actually been received from the health authorities,
yet there were suggestions in the media that they were withholding
it; in fact, there was no mechanism in place, the cash had not
been received, so they were certainly not withholding it.
461. May I send you though a letter from a particular
nursing home group that outlines the policy, which says that the
policy will be to withhold funding until fees rise to an adequate
level; that was clearly the stated policy of that group?
(Mr Hassell) I am not aware of such a letter, but
you have one.
462. This was to a resident. So no home withheld
the money, as part of a
(Mr Hassell) I am not aware of any home withholding
money, the free nursing care money. I am aware of the fact that
some homes have adjusted their fee levels, at the same time that
free nursing care was introduced, but by relatively small amounts,
compared with the free nursing care contribution.
463. If I can just pursue the beds that are
being blocked as a result of exercise of right to choice. The
exercise of right to choice, effectively, is about the long-term
placement. There is nothing, therefore, to stop someone being
discharged from a high-tech hospital bed to an alternative level
of care, pending the solution of their right to choice over a
long-term placement. Would you think there is any scope for reducing
that number of blockages by the provision of alternative levels
of care, in the intermediate period?
(Mr Hassell) It may be that Mr Lewis wants to comment
on it, but I am sure that there are opportunities to reduce the
number of people who are blocking beds, it is an unfortunate term,
but everybody seems to understand what it means, blocking beds.
But I think we revert to what I was saying earlier, in response
to Julia Drown's question, which is, of course, that you move
into problems, I think, psychological and philosophical problems
of moving people too frequently. I think there is also a risk,
of course, that, if the person does not hold out for the home
of their choice, they have little other leverage over the local
authority; whereas I would imagine there is a distinct risk that
if you compromise on your choice you may find yourself remaining
in whatever placement takes place, but I have no evidence of that,
that is just a personal comment and thought, but others may have
(Mr Lewis) I can certainly add to that, and I think
that we can bring in, too, the whole question of intermediate
care, because, for many of the people, a period of rehabilitation
is appropriate, and is a move to a further placement, whether
it be back home or, indeed, in a permanent alternative accommodation.
We feel that the Government's strategy in introducing intermediate
care, and indeed putting money into intermediate care, was something
to be commended, and, therefore, we have experienced great regret
that the potential of working in partnership with the independent
sector has not been taken on board by the NHS and by local authorities,
and indeed, had it, then I believe that we could have addressed
many of the issues of blocked beds. We quote in our evidence to
you our experiences in Birmingham, I could add other locations
where we have developed relationships particularly with specific
consultants and particularly with specific health managers, where
we have been able to provide transitional care, if we do not call
it intermediate care, provided a positive period of care, not
just containment, because it is very different from long-term
care, the sorts of skills that you require in that period following
a phase of acute illness. And yet it has not been extended, has
not been continued, and indeed, in some ways, is contributing
to the problem of people being unable to be discharged from hospital.
I do not think the choice is quite the issue, the choice often
is authorities agreeing to fund the sorts of services that ought
to be provided, that should be based on the individual's needs,
and not merely warehousing people until they have got the place
that they feel is most appropriate for them.
464. Just to pick up a point that Mr Lewis actually
made in his evidence, on the need for longer-term planning to
get over the problem of delayed discharges; you said there needs
to be a minimum of three-year plans and contracts with earmarked
funding. Can you say a bit more about how that would work, and
particularly picking up the point I was raising with Mr Hassell,
about what happens if you have made a contract for the use of
a certain number of beds and then the care home does not want
to take that particular person, because they are only a temporary
(Mr Lewis) The Government have encouraged trusts and
health authorities and local authorities to consult the independent
sector; sadly, that consultation, all too often, and again there
are very good examples where that is not the case, but they are
the minority rather than the majority, sadly, too many authorities
have consulted the local independent sector when the decisions
have been made, when the policy has been established. Now, if
we are to create partnerships, they have got to be partnerships,
and partnerships mean pooling of ideas, pooling of skills and
sharing in the decision-making processes; that, sadly, does not
exist. I believe that if it did exist and if the timescales were
longer, clearly, you cannot expect, indeed a local authority would
not be allowed, to enter into commitments for ever, there have
to be review points, there has to be a period when you can go
back and say, "Are we doing the right thing, and, if not,
can we get out of what we have committed ourselves to do?"
otherwise it becomes institutionalised. But the short-term nature
of agreements, the fact that the majority of placements are spot
placements, makes it very difficult for us to have this joint
approach, and yet I can recognise that there are the focused skills
that are around within the independent sector, combined with the
commissioning responsibilities within the public sector, that
make sense in being brought together. And what I was trying to
illustrate was the fact that, despite, I believe, the right sounds
coming from central government, it has not yet got to practical
implementation at a local level.
465. You have been around local authorities
a long time, and I knew the area where you spent a fair bit of
time. Would you accept that there are some fairly obvious reasons
why a lot of local authorities are uneasy about involvement with
the private sector, and that relates to a genuine sort of concern
as to the consequences of having a profit sector and the impact
upon the care involved? We have heard from Mr Hassell's evidence
about thousands of residents losing their homes; a lot of people
would say, "Well, should we allow a market to prevail, in
terms of care for vulnerable, elderly people?", that is an
issue. Do you think we can ever overcome that problem, because
I suspect that the kind of people that I know and you know will
continue to be very uneasy about profit being made out of vulnerable,
(Mr Lewis) I welcome the introduction of best value
tests. I accept that maybe the mechanisms need to be refined,
but the concept of applying best value is something that I was
quite at ease with. However, what I have been saying, with my
colleagues in the independent sector, is that best value applies
to them as much as it does to the public sector. I noted with
interest your question about profits. We have shared with Laing
and Buisson, with the King's Fund, indeed with local authorities'
own auditors, our expenditure, the return that we would expect
on the investment, because I think it was fair to try to arrive
at what is a reasonable price for the service that is being provided;
and the measurement about the reasonableness of the service is
an important aspect. What I think that the independent sector
can bring to the debate, particularly around discharge of people
from hospital, is a focus, a specialism, that perhaps is difficult
to achieve now in local government, and indeed within the NHS,
because they are not direct providers of services themselves.
You have only got to look at the statistics on the amount of residential
care that is being provided by local authorities, the amount of
home care that is being provided by local authorities. Partnerships
have got to be made to work, because, in fact, without partnerships
with the private sector then the whole structure of our public
services for elderly people will collapse. So let us be real,
but let us also recognise that we have to be transparent and honest
and apply the same tests across the whole sector; because in some
ways we are as much the public sector, in providing, shall we
say, in some areas, almost 100 per cent accommodation funded via
the public sector. We must be part of both the planning processes,
to come back to the original question, and also the audit processes,
in ensuring that we deliver best value.
466. To Mr McClimont. Earlier, you said, in
response to a question from Dr Taylor, about your conversations
with Government on the reduced fee, your estimated cost of the
impact of regulation from £150 million to £25 million,
so I am pleased to hear the Government listened on that. Could
you tell us a bit about what is remaining in that £25 million,
and particular recommendations you might want the Committee to
look at, with respect to that? You also said, and I do not know
whether this would still apply now the number is much smaller,
but, without funding to meet these standards, there would be severe
disruptions in the home care sector and a loss of capacity. Do
you have an estimate of what that sort of loss might be, and perhaps
you could say a bit more about how that remaining £25 million
has been costed?
(Mr McClimont) I have to say that the 150 was the
wastage element, the element that we considered to be limited
impact on quality with cost, and I would have to, here, be totally
fair, to say that the remaining £25 million is the subject
of some dispute about one's approach to human resources management,
and say that we think that there is an excessive concentration
on things like group staff meetings, which have been long the
tradition in public sector but which, as yet, the independent
sector remain to be convinced of the value. So I would say that
that is an area where we would probably rest and not die in a
ditch over that £25 million. The impact, if the remaining
funding gap is not covered, is a very, very difficult one for
us to pick up, and, as I said earlier, it does separate into the
pay and standards issues. Real life, I think, probably says that,
because of the change in the balance of supply and demand now,
effectively, prices are going to go up, so it is not possible
to have this theoretical position where the price does not go
up; and the result will be that the funding issue is not one directly
for the provider, but becomes one for local authorities, as the
intermediary between Government, who give most of the money, and
providers, who need to fund what they deliver. But my best guess,
from talking around the market, is that there is likely to be
a short-term drop in capacity over this coming year, before the
new monies start to come in and before purchasers universally
react to this change in market provision, of something of 3 to
4 per cent overall of the home care market, and that is probably
going to exist mostly in the smaller providers, rather than the
larger ones who have got cushioning against the effects. That
implies, probably by the end of winter 2003, that we could see
a reduction in capacity across Britain of around 20,000 places
in home care. I would have to say though that I do not think that
is going to be the way it looks, because we were talking earlier
about local markets, there are some where local authorities are
already paying quite close to viable numbers, so there will not
be much effect there; there are others where things have been
screwed down to an unsatisfactory level at the moment, particularly
in metropolitan areas, where a home care service can simply go
and provide to the next-door authority, you may see virtually
all publicly-funded and independently-provided care evaporating,
which would amount to something like 35 to 40 per cent of the
total capacity in that area.
467. Those smaller ones though, which you were
saying might not be able to withstand the change, is that because
structurally they are not big enough to function, given the new
regulations, or is it the case that if local authorities properly
planned for this those could survive as well?
(Mr McClimont) I think there are a few, particularly
the very smallest, who will find the structure of a very defined
and clear quality mechanism, find it difficult to marry with that.
I have one member, for example, who provides eight care hours
a week, and it is simply not going to be viable for them to pay
a registration fee, and so on. So that kind of size will disappear
because of the nature of what we are doing on quality. But there
are other elements that are much more to do with pricing and with
recruitment; and recruitment I cannot overemphasise. We are already
in a position where local providers are turning away work from
local authorities trying to buy from us, simply because we have
not got the workers to deliver the job, but the local authority
will not permit the kind of increase in fees that would enable
us to pay more to recruit in competition with Tescos and Safeways.
We have got people in the north east of England being paid £7
an hour to stack shelves, in a nice warm environment, where they
get 10 per cent off their shopping as well, and we are being forced
effectively into minimum wage levels.
468. So just a quick follow-up on that. Where
the small provider, you gave us a good example there of somebody
providing just a few hours' care, is going to find it difficult
to continue, does your organisation have a role in trying to make
sure the care that is provided there, if it is quality care, is
subsumed under something larger that can cope with the regulation
and make sure it is of a sufficient standard?
(Mr McClimont) No; our organisation is very much professional
standards enhancing, or that is our aim, enhancing professional
standards, we do not have any involvement in the commercial operations
of our members, so that is not a role that we could take. Although
we have looked at trying to broker buyers with sellers, but there
are many services that do that, so that is available.
Chairman: I know that Mr Amess had a
question to you and to others, I think, on the issue of recruitment
and retention; you may have partly answered it. David, have you
anything to add?
469. Without wanting to do it to death, but
there is a considerable part of your submission, and I have got
a sister who, for many years, has done this sort of work in Derby;
now she has just thrown the job in, not because she has had a
row with anyone, or because of the pay, but basically it is her
back, keeping lifting these people who are so frail. Now, other
than money, have you got any other issues that you would want
to bring to the Committee's attention, how we can resolve this?
Because it seems to me, going through the homes, it is not that
we have not got marvellous people working in them, but, for many
of them, unfortunately, the relatives do not even visit, so the
person looking after them forms a very close relationship, and
it is hardly a trivial matter. Do you have any bright ideas what
we can do about it, and will this £6 billion help?
(Mr McClimont) That will depend entirely on which
direction it heads in. I think there are many ideas and many things
going on that should help. The care standards implementation,
for example, will, we believe, have a very significant effect
in job satisfaction levels, on two fronts. One is that we are
going to raise the status and the perception of the work and the
levels of training and involvement, which is reportedly having
a very promising effect on recruitment and retention in some areas.
The second is that I think there will have to be changes in the
way that local authorities commission services, as a result of
the care standards work, which will give a greater level of autonomy
and working with the user, so that individual workers and managers
will have more of a responsibility to negotiate with the user
exactly how the care is delivered, and to get in that relationship
that you were describing a higher level of job satisfaction. So
I think that there are good measures there. I have to say though
that there is this hygiene factor, if you like, of money, below
which many people cannot work, or where it is just not worth their
while, and that has to be one of the major issues there.
Mr Amess: It is a bit ironic your giving
evidence today, because only yesterday all MPs got letters from
the Local Government Association, who were somewhat perplexed
at the new arrangements being made, and they are arguing the case
that they do not think, now the problem is apparently going to
be passed on to them, they are very concerned about the funding.
But I just wonder if that is going to have any impact on . . .
Chairman: We touched on this while you
Mr Amess: Did you? I am sorry, I apologise.
470. Mr Rice, do you want to come in on this?
(Mr Rice) Just an observation. I would not discount
the profound impact that domiciliary care could have, on relieving
the pressure, not just on the acute sector but on the care home
sector as well, and that is again part of the broader solution.
There are people who are in care homes and people who are in acute
beds who could actually be in their own homes being monitored
and attended to, and clearly that relieves the pressure in both
those parts of the system.
471. You are talking about the link-up things?
(Mr Rice) It is deploying home care, whether it is
nurse care, it is Care & Repair type support, it is the technology
being deployed in order to relieve the need to put people into
care homes and into hospitals. One of the things we have not touched
472. The technology is marvellous, but, at the
end of the day, for goodness sake, we do want the human contact,
do we not, really?
(Mr Rice) But the psychology, which Mr Burnham mentioned,
is quite important, because we have not touched on carers here,
and I noticed, when reading previous minutes, that you had touched
on carers. One of the things that drives admissions is carers
really believing that perhaps the best place for people is in
a care home or in a hospital, because it gives them a break, and
the ability to have systems that can relieve the pressure on family
and friends of caring for people, which is absolutely profound,
as everyone, I suspect, in this room, has found out personally,
through their own personal tragedies. As I have said a couple
of times before, the problem is a complex one, and you do have,
for example, clinicians believing that monitoring is best done
in the hospital, and we have not done a very good job, I think,
of convincing clinicians that the technology is robust enough
and capable enough to make their life easier, with monitoring
being done in the home. And you have carers often promoting the
admission of people because they are concerned about their loved
ones and they believe that the best place for them is in an intensive
care or intermediate care location, and it also gives them a break
as well. So deploying the right measures to address the problem
is quite important. When we talk about penalties, I am more interested
in incentives to get people to behave in the right way. You cannot
separate this from the issue of ring-fencing various pockets of
funding in order to encourage, addressing all of the issues in
what is a very complex and holistic problem. Certainly, the funding
in the technology area of healthcare tends to be vulnerable to
the immediate demands of the acute and intermediate sectors.
473. I am hoping that, if we ever get there,
we come on to the `high touch' versus high tech sort of argument
later; but can we stick with the intermediate or alternative levels
of care, for a moment. In response to Mr Hassell, I share your
view that, for some patients, more than one move, or a frequent
move, may not be desirable, for many. (I think we have changed
our cultural acceptance.) In the past, people did not necessarily
feel, whatever they were in hospital for, they were going to be
discharged to be in a home, they may not have been fit to go back
to work or to go back to home and they may have convalesced somewhere.
We seem to have lost that culture of convalescence, which do you
think we are trying to reinvent in some ways with the intermediate
or step-down or alternative levels of care?
(Mr Hassell) I think, generally, in this country,
rehabilitation, including convalescence, seems to have gone through
phases, and I think there is still a need in this country for
longer-term, real rehabilitation programmes. In my mind, I think
intermediate care is, in fact, short-term, intensive rehabilitation
and convalescence, as you put it. There certainly are, amongst
our membership, some good examples, not so much of people who
are awaiting placements in homes, as we were talking about earlier,
but there have been some good examples amongst our members where
they have actually developed good, partnership, intermediate care
schemes, which have enabled people to move from the acute setting
back into their own homes, in the community. There are schemes
in Leeds, Mr Lewis has mentioned schemes in Birmingham, there
are schemes in Camberwell, Halifax and, in fact, in Powys; so
there are some good examples, but, unfortunately, there are also
problems in other areas, and I think we have all qualified many
things we have said this evening, that the experiences vary. We
have some good partnership arrangements with statutory authorities,
but I am afraid the independent sector has been frequently ignored,
again, not involved in the planning, not involved in the development
of the services.
474. Let us look at one of your successes; particularly
you referred in your evidence to Birmingham, where Westminster
Health Care enabled 273 bed nights at the Orthopaedic Hospital
to be freed up, and that seems to me to be an enormous achievement.
If somebody is waiting for a hip replacement but they do not get
it, the chances are they are going to fall over at some stage
and break their hip and spend even longer in hospital, at the
end of the day, so if you can free those up; what is it that has
led to success in Birmingham that has not been successful elsewhere?
(Mr Hassell) It might be more appropriate for Mr Lewis
to comment, because it is actually one of Westminster's schemes,
in Birmingham. I am not sure. I will pause.
(Mr Lewis) The sad thing is that it was not funded
with money that was earmarked for intermediate care, it was funded
through one of the trusts, through the orthopaedic surgeons recognising
the benefits of patients being able to be discharged from hospital
more quickly and receiving the rehabilitation that then enabled
them to go back home appropriately and safely. It comes back to
the funding issue. Everybody was happy with the service, it speeded
up the discharge of patients, it enabled the consultants to admit
more quickly other patients, but it was coming out of mainstream
health funding, and has stopped, I sadly have to say, because
the Trust is no longer able to fund it; so those facilities now
are not being used for the purpose which Westminster had invested
considerable amounts of money in, believing we had a partnership.
So it is a success story, on the one hand, but it is a total failure,
on the other, because I do not think, generally, there was the
recognition of what intermediate care potentially can do.
475. Recognition by whom?
(Mr Lewis) Largely by our colleagues who manage the
intermediate care money that the Government has made available.
Now, I think, in fairness, they may well be able to turn round
and say, "Well, we invested in something else, this has got
a better return." But certainly that was not the view that
was shared by those consultants, in particular those orthopaedic
surgeons, who, in fact, were very enthused by what was happening.
And, importantly, it was a partnership, because the physiotherapy
and the OT were being provided by the hospital-based Trust personnel,
we were providing the care and the environment.
476. At least we are going to ask the question
here, the biggest delays in admissions are often in the area of
orthopaedics, one of the biggest areas of delayed discharges is
orthopaedics; why is it that the commissioners cannot see that
this is an area precisely where the intermediate or step-down
levels of care are required?
(Mr Lewis) And here I stay silent, almost.
Chairman: Dr Taylor is going to ask them
477. No, he is not, he is just going to ask,
with the changes that took place on April 1, and PCTs getting
the commissioning power, is this going to improve intermediate
care, or are you worried that funding will be even worse to find?
(Mr Lewis) I am very hopeful that, as money flows
with the individual, it is going to improve the situation, because
no-one in their right mind is going to pay for an orthopaedic
bed in hospital at over £1,000 a week if, in fact, for half
that amount of money their needs can be met more appropriately
elsewhere; and that just does not mean in a nursing home, it could
well mean by putting a package of services together in people's
own homes, including things like the Tunstall technology, and,
indeed, there are examples of that happening.
478. Do you think plans are in place for the
interregnum between the health authorities and the Primary Care
Trusts; do you think there is going to be a huge gap, or do you
think it is going to be seamless?
(Mr Lewis) I am not sure that there is going to be
a huge gap, I think that would be unfair and I do not have the
knowledge to say that. I am pretty sure it will not be seamless.
What I do fear is that there will be almost a moratorium on development,
because everybody will be so busy establishing themselves; and,
obviously, too, that they will be concentrating on other areas,
perhaps areas where they are being measured, in order to meet
the expectations of those that are measuring them.
479. Is there anything we can do to try to stress
the importance of this?
(Mr Lewis) I think the importance is, first of all,
in ensuring that funding is earmarked and directed in the direction
it is intended to go, and rather than being diverted to alternative
services. The second is that I think that there needs to be evidence
that there really is joint working, with measurable outcomes,
and it is the outcomes we should be measuring, and I am not sure
we are actually there yet. Many of the performance indicators
do not measure outcomes, they actually measure outputs.