Examination of Witnesses (Questions 560
WEDNESDAY 8 MAY 2002
MR J RANSFORD
560. Are you clear what the definition should
be and which way it should be collated? Could you help us with
(Dr James) I am not clear how it should be collated.
I am sorry to disappoint you. We should be very clear how we can
count these figures so that we can readily benchmark across our
organisations. I should like to mention in terms of definition
the concerns about the scope of the definition. A lot of the discussion
so far has been around the patient, which is fantastic. For me
the tragedy of delayed discharges is that for that patient in
that bed care has ceased. Rather than their delayed discharge,
which is an organisational term which means they are felt to be
a waste of space unfortunately, in reality their care has stopped.
Maybe one of the ways we can define a delayed discharge is not
necessarily in how long they have been staying but whether they
are there appropriately or not, whether their care has stopped,
whether they should be elsewhere. If, however, the assumption
is that that delayed discharge solution will create capacity in
our health services, that is entirely wrong. I am very happy to
give some examples of why I believe that.
561. It is not that their care has stopped:
many of those people are still getting nursing care. It is just
not the most appropriate care. Anybody else want to help on this
definition issue? If not, we shall just have to take it forward
(Dr Morgan) We can give you written evidence on it.
I shall come back quickly on that for you.
562. May I turn to capacity problems? In your
evidence you identify the major losses in capacity which have
occurred in independent sector care homes and also pressures on
the home care side. As a Committee we have had a blizzard of statistics
about the loss of places in the independent sector. A new figure
was quoted in your evidence of 35,000 places having disappeared
in the last three years. The Independent Health Care Association
use another figure of 50,000 places lost and the Department would
point to a net figure of 19,000 lost. Could you shed a bit more
light on exactly how you arrived at that figure of 35,000? Could
you comment on the 50,000 figure and the 19,000 figure, as to
which is the most accurate?
(Mr Ransford) I do not know which is the most accurate.
We would all agree that a significant amount of capacity has been
lost and there is no doubt of that. It is a tremendous number.
563. Was there over capacity?
(Mr Ransford) There was over capacity; historically
there was over capacity. Mr Leadbetter mentioned in evidence earlier
the system in the 1980s which was driven by cash through the social
security system. There is no doubt that there was a perverse incentive
in the system then for residential care as an outcome. As commissioning
came in, with the passage of the community care responsibility
to local authorities in the early to mid-1990s, the market stabilised
somewhat and I know personally that some capacity disappeared
because it was no longer of the type that was acceptable in terms
of quality or space or whatever for individuals. So some capacity
needed to go. The point was whether the providers were part of
an overall planning system to ensure that capacity developed to
meet the needs or whether we got perversities coming into the
system, as I am sure we did, capacity going for the wrong reasons,
that providers could no longer afford to provide it or they could
use their facility for different purposes. The equity in residential
accommodation changed as a result of general market conditions,
a whole series of factors changed things. What we saw was a significant
loss of space, a lot of it targeted in particular areas. It happened
all over the country but in the South East, as a result of high
property prices, high wage costs, changing regulations, a whole
series of things gradually disappeared.
564. It would seem that 50,000 is over-stating
it. You suggest 35,000 and it is fair to say that it seems that
50,000 is a conveniently large figure.
(Mr Ransford) We stick by our figure, but the situation
has moved on.
565. Your figure is different from that of the
Independent Health Care Association, is it not?
(Mr Ransford) Yes, it is. There is no denying that
it is a significant figure and has severely affected capacity
in terms of having the right choices available to people, the
right choices made professionally to meet their needs.
566. Do you recognise the Department's net figure
of 19,000? Obviously some places have opened while others have
closed. While some have clearly closed, do you recognise that
net figure? That is obviously the important one, is it not?
(Mr Ransford) Yes. I would need to go and research
before I gave you a definitive answer on that. I would need to
go and research that. Certainly we need to look at the net figure,
we need to look at the figure for places in the context of what
other resources are available. We talked about intermediate care.
If intensive home schemes have opened which are alternative to
residential care and meet people's need better in their local
community, then that is a genuine alternative and must be looked
at in terms of the whole system.
567. Is not the real thing, the one which is
of use to this Committee, how many places we are short of?
(Mr Ransford) Yes.
568. You could have closed 300,000 if 300,000
needed to close. How many would you say were needed?
(Mr Ransford) How many spaces we are short of and
how many other resources have been made available through innovation
and new practices which meet people's needs must be considered
569. May I ask whether you would agree that
the availability of the cash in the 1980s to purchase care in
homes actually acted to prevent the development of the home care
and domiciliary services needed?
(Mr Ransford) Yes; certainly. There is no doubt that
was the case.
570. One of the mysteries to me is why we are
so hung up on this debate about the need for care home places
when other countries seem to manage completely without care homes?
We went to Denmark a few years ago and saw a system there which
has developed alternatives to institutional care which was in
my view quite refreshing. Do you not feel we ought to be moving
in that direction? If we are not moving in that direction, why
not? We seem to be bogged down with the whole debate around the
interests of the market as opposed to the interests of the people
who were placed in care; the interests of the patient and the
(Mr Ransford) My answer to that is that there is a
case for care homes, there is a place for nursing homes, depending
on the needs and wishes of individuals. Just as we must look at
the acute sector as providing its service to people at that time,
we have to look at it in the context of a system which should
be primarily community based. What has happened in recent years
is that there has been insufficient investment in community alternatives
and considerable investment for different reasons in residential
care and acute care, which has made the problem worse. We are
stuck with a double whammy of having a crisis in terms of demand
and a crisis in terms of historic investment being in the wrong
places and it takes time to change that round.
571. I may differ with you on the issue of needing
care. In all my time in social work I must have dealt with hundreds
of people going into homes. I have yet to meet one for whom it
was a positive choice. That is an interesting factor from my point
(Dr Morgan) What I have here that may helpand
it is only one data sourceis the Laing and Buisson report
which comes out every year looking at the beds lost and the new
beds. The figures go back to 1996-97, so I am happy to leave that
with people because it has both the ins and outs in probably the
most authoritative data source that we have.
572. Is it fair for me to conclude therefore
that the 50,000 figure has been raised by care home owners and
the care home industry and perhaps picked up by some of their
friends in Parliament and blown up when in fact it slightly misleads
on the changes that are going on in the home, community and residential
care sector. Would that be a fair conclusion?
(Mr Ransford) It may be your conclusion. I am not
going to speculate. I am not going to speculate on why figures
have been put forward and why people have drawn conclusions from
it. All I say is that we have to keep all statistics in perspective
in terms of the requirements we need to provide the right service
for people in need.
573. I just wanted to clarify a point. Is the
50,000 figure not the one that Laing and Buisson has produced?
Is that not the source of it? It is not care home owners or some
of their so-called friends in this place.
(Dr Morgan) Yes, their figure going back to 1996-97
is a total bed loss since 1996-97 of 51,1147 and a total new bed
figure of 18,924. That is the best source we can find which looks
at it comprehensively.
574. In the evidence from ADSS, it says, "The
local Health Services are paying more and aggressively recruiting
from the nursing home market, with dramatic consequences on the
sustainability of that market". Can you give us any sort
of figure or any feel for the severity of that as a problem?
(Mr Leadbetter) I can give you a feel. After the Coughlan
judgment certain authorities changed their purchasing practices
in line with the judgment and health trusts started purchasing
care. Our view was that because they were not as experienced at
commissioning some of the nursing providers used the opportunity
to increase prices. We found locally significant increased pressure
on prices in the nursing care sector. We had been purchasing in
larger numbers and it was not necessarily being picked up that
the nursing homes were using that new business opportunity to
increase rates. Combine that in Essex with the very significant
problems we had, particularly around the London and Hertfordshire
fringe, actually recruiting staff to work anywhere.
575. Any comment on that?
(Dr Morgan) It is a massive issue. The biggest issue
facing health and social services is supply of staff. There is
a shortage of nurses. Anywhere you have a market or a competition
to deliver, nurses will move round the system and organisations
will try to get nurses from wherever they can. What is happening
in a number of places is that people are trying to get out of
that and stop regarding nurses sitting in one other part of their
systembecause this is a whole system problemas belonging
to somebody else. Some imaginative schemes are starting in PCTs,
where they are beginning to look at how they run a pool of nurses
who could both support what goes on in the NHS, look after what
goes on in the community and find ways of providing some of the
input into nursing homes. It is quite fraught because there are
some technical problems about that in terms of legality. It is
also quite difficult, because what we should not forget is that
we require nursing levels and nursing standards in nursing homes
which are significantly higher than we require within the average
NHS ward. We have put in a lot of extra burdens in terms of the
numbers of nurses in nursing homes, because we do not want single-handed
practitioners, whereas in many hospitals we run wards at night
with single-handed trained practitioners. There are some very
complicated things here which are not going to be resolved by
thinking about the nurse sitting in any one block, but thinking
about it comprehensively. There is a second issue which is actually
much more concerning about nursing homes and care homes which
is the availability of care staff in areas which have high employment.
Nursing homes and care homes have driven down wages and in many
places like the place where I was Chief Executive, you could work
for twice as much in Tesco's overnight as you could providing
care to some very disabled and disadvantaged people. There is
a whole set of other market forces which are making it very difficult
for nursing homes as well as nurses. You have to take it in the
round. There are some hopeful things in the NHS. The workforce
development confederations which now have the money to train and
develop staff do have a remit to look at the training and development
of staff in the independent sector. Out of that are coming some
of these innovative schemes to think about how we both maintain
high skills but also begin to use the pool of nurses in the community
more wisely than we perhaps have done in the past. It is not easy.
576. Yes, we have heard about Tesco's before.
This is a prime example of the whole system approach, how it really
could work if there were one pool of nurses which could be shared.
(Dr Morgan) It is. There are some legal difficulties
with that because of independent organisations but people are
exploring how to work creatively through the legal framework.
577. Acknowledging the fact that more money
is being paid to care home providers in many places, the local
situationI do not know how widespread it isis that
Hampshire County Council and Southampton City Council have decided
to up the amount quite considerably, by about £50 a week,
as a recognition that that is a fair rate. The sting in the tail
however is that existing patients are still paid at the old rate.
I have certainly had a case in my constituency where a nursing
home was threatening to throw out all the people on a lower rate.
I do not think it will actually. Do you think this is the right
thing to do? Do you think it is morally defensible or is it a
step in the right direction?
(Dr Morgan) Whenever the system draws rules, we do
not spend enough time thinking about the potential perverse incentives
which go with the rules. We think about what might happen on the
positive, but we do not think about the tiger traps. If you believe,
as I do, that people actually behave rationally, whatever rules
you give them, they will behave rationally for where they sit
in those rules, so it is not surprising we see things which perhaps
do not fit our own perspective of how to manage the system. The
issue is how to get out of that and that is about defining rules,
remembering that people are going to behave rationally and try
to play them for all they are worth, because that is what people
578. I do not think it is just a case of playing
the system. Some of these nursing home owners have been struggling
for some time, particularly faced with the problems of the Care
Standards Act and now feel that it is just one more attack.
(Dr Morgan) Indeed; That is why I think that back
in the communities who are thinking about this there needs to
be more effective engagement at the planning stage of how you
are actually going to put these incentives in, proper thinking
about what the incentives will be and how people will respond
to them and doing that in a joint way. Sometimes it happens with
bits of the system sitting in one room and other bits of the system
sitting somewhere out there feeling badly done to. There are really
good examples of where that is no longer the norm, yet all around
the country there are effective engagements with the independent
sector between health and social care working jointly. They are
avoiding some of these tiger traps, because they are designing
the system to achieve the ends they want rather than putting something
in which achieves the wrong ends.
579. Are these differential rates a good idea?
I did not quite get an answer to that question.
(Dr Morgan) Certainly in the patch I worked in, we
did not go down the route of differential rates because we felt
that would put in a whole set of perverse incentives. You cannot
comment from one place to another because the issues are different.
Where we were, we wanted to protect the marketplace in one of
our four PCTs, not in every PCT. We had spare capacity in some
places and under capacity in others. We had a particular issue
around specialist care homes which provided particular support
for people with complex mental health problems. We were using
our resources to encourage people to come into the marketplace
in an area where we wanted it. It is how you design the system
to meet the ends which are appropriate in a local place. It is
back to encouraging that proper joint analysis of what your local
problems are, what your local opportunities are and then a set
of solutions which will address your local solutions. It is putting
that in place which is more important. You cannot comment from
one place about another place because you do not understand those