Examination of Witnesses (Questions 720
WEDNESDAY 19 JUNE 2002
MP, MR RICHARD
720. This is the distinction, which is part
of the problem.
(Jacqui Smith) That is part of the distinction, but
the other distinction is around whether or not you are using a
net figure or a gross figure.
Sandra Gidley: No.
Chairman: We can kick this one around all afternoon.
The conclusion from the advice we got was that 19,000 was a broadly
independent figure if one took the net and gross issue that you
have referred to.
721. I am advised that the 50,000 figure was
a convenient number to use as a bargaining figure to raise care
home fees by various people. I think it is an irrelevance. The
relevant figure clearly is how many care home places we are short
of. Clearly, that is what matters. There may well be a lot of
over-capacity in the market. Can I ask you whether the Department
has done any analysis of as a country are we currently short of
places, do we have too many? Clearly that might be 19,000, 50,000
or 100,000 or whatever, or it might be something far different.
(Jacqui Smith) My understanding is that there is nationally
some spare capacity in terms of residential care. However, I do
not think that what I accept is an argument that says that what
actually matters is what is available for people in any particular
locality. But here as well it seems to me that what we need to
take into consideration in a localityand this is what I
was talking about earlier in terms of how we commission services
as a wholeis not in this locality how many residential
care beds there are out there, important though that might be
to meet a particular demand, but in this locality how do we commission
to make sure that we have appropriate levels of residential care,
home care packages, housing in care, so that we have the configuration
necessary in order to enable older people to get help.
722. Is there spare capacity? Some homes are
refusing to take local authority residentsnon-self-funders.
(Jacqui Smith) I think there are some issues, as I
understand it, in some parts of the country, about some providers'
attitude to local authority placements. There I think that what
it makes sense to do at a local level is to develop, along the
lines of the agreement that I was talking about earlier, much
better and more mature relationships in some cases between the
independent sector and the commissioners, in order to make sure
that the local authority has the provision necessary, is able
to commission the provision necessary, and the independent sector
has at the same time the certainty about what is being expected
of them in the long term that will enable them to plan with some
723. It has certainly been a problemand
I have seen this locallythat companies with not particularly
a track record of care have moved into this sector, and some of
them have moved out of it as well; there has been a lot of change
of that kind. When we are talking of something where it is a question
of people's life and death, it is vital that they have a stable
environment in which they are living and that they are not subject
to any fear of being moved or whatever. Picking up the Chairman's
point earlier, have you thought about whether, when a company
is providing care, you would seek a commitment from them that
they are in it for the long term, because it is incredibly destabilising
if there is this threat of homes closing and this is used as a
bargaining tool to up the fees? Do you think that in such an important
sector of society the companies that are involved need to be involved
in the long-term?
(Jacqui Smith) Firstly, I agree with you that clearly
in any situation where a care home closes, the people that we
need to be most concerned for are the older people, the residents
in that home, which is why I think it is reasonable, as we say
in the agreement, that local authorities in their commissioning
recognise the cost pressures through the fee levels that they
pay, but also that there is a responsibility on care home providers,
which we have now, of course, formalised through the care standards,
firstly to provide some evidence of their financial liability,
but also to have in place appropriate procedures if they do get
to the position where they have to take a business decision to
close. So I do not think we can be in a position in relation to
private businesses where, for example, we could ban them from
closingof course that would not be possiblebut what
we can do is get into a position where there is more long-term
certainty through commissioning, fee levels that recognise what
is necessary from care providers and recognise quality in their
commissioning, and then also ensure that we have standards that
do not allow, if anybody were minded to do itand I am not
suggesting that it does happena sort of fly-by-night approach
to their residents. That combination of things I think is important
to provide the certainty for residents in those homes.
724. My final point is that you mentioned fee
levels there. What assessment has the Department made of the current
level of care home charges? Are they too low? Do they need to
(Jacqui Smith) What I think is interesting is that
I think it was Laing & Buisson in fact who identified that
what happened from some of the investment of the £300 million
and this funding in the last year is that local authorities have
recognised, by increases of fees in some areas as high as 10 per
cent, the need to recognise fees as an important way in which
you stabilise capacity. We have also recognised, through our analysis
of the way in which that £300 million has been spent, that
local authorities have invested in higher fee levels and in more
places, so some of that money has gone directly into the independent
care home sector to stabilise and to provide services. I do not
personally believe that the most effective way forward is for
the Department nationally to attempt to set fee levels, because
to go back to what I was saying before, what we need to develop
locally is a situation where we recognise the particular pressures
that there might be locally and we recognise the need to develop
diversity. In those areas where, as you yourself have suggested,
there is a surplus of capacity, you may well have a different
approach to developing other sorts of care than you do in those
areas where there is a shortage of capacity of residential care.
So I do not think we crack this problem through a national approach
to fee setting. I think we crack it by making sure that there
are sufficient resources in local authorities to develop the whole
range of long-term provision, and by levering better practice,
where it is necessary, in commissioning and partnership between
independent and voluntary sector partners and the local authority
725. I have one very final point. We went so
see some schemes this week which are neither residential care
nor sheltered housing, but almost in the middle. Would you favour
a move towards those? Do you think we are over-reliant on residential
care in this country?
(Jacqui Smith) I think I have already said earlier
that where I think we want to see growth is in housing in care
options, in home care options and in developing new forms of residential
care, but we need to maintain capacity as we go through that changing
configuration, and there will always be a need, I believe, for
some forms of residential care.
726. The Chairman referred to the growth in
the 1980s when there was this shift and the massive expansion
into residential care, whether we say people were "banged
up" or use the expression "moved towards geriatric".
Is it not a possibility that we should be celebrating this less
reliance on residential and institutional care? Was it not that
growth in the 1980s of some fairly unscrupulous people running
old people's homes and so forth which actually provided the disincentive
for the provision of those supporting schemes for long-term services?
(Jacqui Smith) Where I agree with you is that what
should not drive the development of long-term care provision is
funding streams, and that, it seems to me, was the problem with
the development throughout the 1980s. What should drive the development
of long-term care is a careful analysis of what older people actually
want, what we need to provide in order to promote their independence,
and that should be the basis on which we commission.
727. Very briefly, you were talking about fees.
What is happening in a number of councils now is that there is
a differential rate, with new residents on one rate and existing
residents on another. Do you think that is equitable? Is it not
an admission that actually social services have been underfunding
nursing homes for too long? There is about a £50 difference
in my part of the world.
(Jacqui Smith) I think that is a judgement that needs
to be made locally on the basis of decisionsfunding decisions,
where people want to see developments, what sort of quality they
want to pay for, what sort of provision they want to pay for.
728. Do you believe it is inevitable?
(Jacqui Smith) I do not know the circumstances, so
I am not going to make a judgement.
729. Fair enough. To come back to capacity,
although there may be over-capacity in the system as a whole,
then certainly locally in the south of the country I believe there
is a real problem, but presumably the Department has some forward
planning. Therefore, do you actually expect the care home market
by, say, 2007which is not in the too-distant futureto
expand or contract? What does the Department think is going to
(Jacqui Smith) Once again, we are getting into a position
where we are highlighting one particular part of the capacity
for providing long-term care. We have been quite explicit that
what we think needs to happen is that we need to maintain capacity
in care homes in order to ensure that that option is there, but
we also need to develop alternative forms of care. So the answer,
I think, would depend on what you already had in your locality.
Where you had an over-provision of care home capacity and an under-provision
of intensive home care packages or other forms of care, I would
expect to see a shift out of care homes and into those other forms
of provision, but where you have a situation where clearly there
is a demand for care homes and there is a tightness on that capacity,
it makes sense to reflect, in your fee levels and the way in which
you commission, the need to maintain or perhaps in some areas
even expand that residential care provision.
730. So are you saying that you do not know
(Jacqui Smith) I am saying that it depends on local
Sandra Gidley: I would like to pursue this,
but I am aware that there are a lot of other questions, so I think
I had better leave it there.
731. When you said, in answer to a previous
question, that the number of extra beds and places were 6 per
cent of the yearly divide, did you take account of the fact that
some places were having to increase care home charges by 10 per
cent? Obviously that wipes out more than half of the three years'
(Jacqui Smith) We recognise, both in the £300
million and in our analysis of what was necessary to maintain
and develop capacity, that there were issues about fee levels,
so we recognise in that 6 per cent, as we did in the £300
million, that in some cases the correct response is to increase
732. So it was taken into account in those figures?
(Jacqui Smith) Yes, it was.
733. What about the choice? We have had the
British Geriatric Society raising their concerns that there is
not any legal mechanism to insist on interim placements. Are you
considering having to deal with that concern?
(Jacqui Smith) What is very interesting is that there
is a big discrepancy across the country in the extent to which
older people do stay in acute hospital beds effectively to choose,
and those were their terms. What seems to me to exist is that
where there is good practice in terms of alternative provision,
and where there is good practice in terms of explaining early
to older people what the options are, the fact that actually it
is not good for people to stay in acute hospital beds whilst they
either have further assessments made or make a choice, what we
tend to see is that actually there is a very small amount of people
who are staying in acute beds because they are wanting to exercise
some sort of choice.
734. It is 8 per cent of the delayed discharges
overall. Is there not a relationship between where the problems
are and property prices?
(Jacqui Smith) No, I do not think there is any evidence
that there is that. What there is is a relationship between good
practice and bad practice. For example, in, I think it is, Darlington
they have used some of their £300 million .
735. So you do not think any legal change is
(Jacqui Smith) No.
736. Briefly, on NHS funded nursing care, was
not that really just a subsidy towards a sector which absorbed
it and just costed things out at a different level? I remember
writing to Alan a letter about a constituent who had a component
of £72, but by the time they had got to a review of prices
and all the rest of it, they only actually saw a saving of £17,
and this was going on throughout the country, so all it was was
a huge subsidy to the nursing home sector, was it not?
(Jacqui Smith) It was because there were some places
where there were concerns about the extent to which in that last
financial year £100 million was actually getting to the people
for whom it was intended, which were those people who funded their
own care in nursing homes, that we actually took the action that
we did around strengthening the sort of information that individuals
can have about what sources of funding are for nursing homes and
what the costing is of the constituent parts. So both through
our scheme and the Care Standards Commission to focus on standard
2 of the care standards and through changes that we will be consulting
on or making to regulations and to the contract that we issue
to local NHS bodies to use in their payment of the nursing care
contribution to nursing homes, we have taken action to make sure
that that money gets through, benefits those people for whom it
was intended, and there is much more transparency in the system
than there was previously, because this is a significant investment
into nursing care in those homes. There are actually quite a lot
of good examples of where that is already benefiting not just
financially, but where there are benefits through the NHS becoming
more closely involved in people's care; better advice about continence,
for example, better communication about the sort of nursing care
needs that people might have. Those have been quite important
benefits over and above financial benefits that have come from
737. Are you convinced that the systems are
robust enough now to ensure that that money is directly benefiting
residents in terms of nursing care, rather than being used as
a subsidy by the nursing homes?
(Jacqui Smith) I believe that the approach that we
have taken, which is to cast light on that money going into the
system, is the appropriate way to ensure that people who, after
all, have individual contracts with nursing homes, have both the
information and the clout in order to make sure that it is benefiting
738. Our visits around the country and local
knowledge point to staff shortages being a particular problem,
particularly in the area of occupational therapists. There are
two issues on that. One is, what is the Department doing to try
to make sure that where there are restrictions on what people
dofor example, occupational therapists defend their territory
in terms of saying who should be able to advise on home adaptations,
and that does happen to be reasonablethat does not cause
inflexibility in the workforce? Are you doing anything on that
in terms of creating a new rather more flexible, more multi-tasked,
more multi-skilled person to deal with unnecessary admissions
and facilitate discharge? Also, what are you doing on those workforce
numbers, particularly around therapists?
(Jacqui Smith) As I suggested earlier on, we are taking
action, and it has been successful in terms of increasing the
number of therapists. I agree with what you said that what we
also need to do quite often is to find at a social level a way
of developing teams where there is more of a trust in multi-skilling,
where there is a more co-ordinated approach to the care that is
being provided. Off the top of my head, I could not think of something
specific that we were doing to address the particular issue that
you were talking about, but if we come up with something perhaps
I can let you know.
739. I think we are interested in things like
district nurses and do they also have those skills to advise on
home adaptations and so on. The other thing was that again, we
would like to know what technology can offer in terms of supporting
people in their own homes, allowing early discharge. What are
you doing to encourage the roll-out of successful schemes throughout
the country, which have demonstrated their potential?
(Jacqui Smith) Clearly, as Richard's team goes around
the country more, one of the important roles is to share the things
that are working. I agree with you that there are areas where
technology is actually quite important in terms of developing
alternative support for people living in their own homes. Some
of the best practice advice and the way in which we are disseminating
that, I think, is probably at the moment the best way in which
we are ensuring that that happens. Of course, there is an incentive
on authorities and health care providers to develop. Once people
know what works, and once they know the challenge to reduce delayed
discharge and make sure people are getting the right care, that
gives people the correct incentive to investigate the alternatives
and to invest in the more successful ones.
Chairman: If there are no more questions, Minister,
can I thank you and your colleagues for the very helpful way in
which you have given your evidence. Thank you very much indeed.