Oral evidence: Care for adults in England, HC 1118
Oral evidence, 26 March 2014.
Witnesses
Sir Bob Kerslake, Permanent Secretary, Department for Communities and Local Government, Helen Edwards, Deputy Permanent Secretary and Director General for Localism, DCLG, and Jon Rouse, Director General, Social Care, Local Government and Care Partnerships, Department of Health, gave evidence.
Chair
I am going to start with paragraph 3 in the summary of the Report, where it says “The government wants to continue reducing public spending while maintaining spending on care and support, and improving outcomes for adults, as need for care rises.” That is the policy. Is it deliverable?
Sir Bob Kerslake
I think it is deliverable, but it is very challenging. That is what I would say, Chair; and we do not yet know the full way in which you need to achieve it.
Chair
What indications have you had that it is moving in the right direction? I do not want to bore people; we had a report this morning from Nuffield. We have had endless reading from Age UK and everybody, demonstrating an inevitable reduction in the number of services and probably in the cost of those services. I am sure we will come back to private providers. So what makes you think, in that context, that you can sit here and tell us you can deliver this in the time frame that the Government has set?
Sir Bob Kerslake
As I said, I think it is challenging but deliverable, for these reasons: first of all, I think what we find when we look across authorities is there is a huge variation in how much things cost, actually, per unit of delivery, whether that is in the community or residential care; and not all of that can be explained by local circumstances. So I think there is still some work that can be done to strengthen commissioning, to get a more consistent approach to getting best value through the commissioning process. So that is one thing. I think the second thing I would pick out is—and I would emphasise this is far from a proven position yet—there are some really good examples up and down the country of people innovating and doing things differently to improve the experience for the user of the service, or the receiver of the service, and reduce the cost. A lot of work was done through the pilots that we had—the community budget pilots last year—that showed that the system, with everybody’s best intent, is still quite fragmented, and people experience what we heard earlier, with lack of clarity on who is taking responsibility for somebody in the round. The lead professional model is being piloted in a number of places as we speak. I heard today of Cheshire West and Chester, where they are following a model of a lead professional. There is early evidence—I would say it is early and we are not there completely—that it is making a difference, and pointing to the way in which you can make the system both more effective and more efficient. I will stop there, because I think you have now got a vote.
Chair
I will come back to you on that because there is a challenge with your localism agenda. You might think about that. If some local authorities’ costs are higher, how can you, with your usual mantra, tell us that you are going to get them down? Sitting suspended for a Division in the House. On resuming—
Chair
Let’s go. We will stick with this theme, then I will bring in Stewart. Sir Bob, you said to us that it is challenging, but deliverable. I would come back to you on two things. First, you said “If everyone gets to the best,” but your policy, particularly in DCLG, is not to interfere and to tell local authorities what to do, so I do not know how you can square that circle. Second is the time frame really, because it is yet another of these areas in which there will be no quarrel with the intent of the Act; the danger is that you will raise expectations among a whole lot of carers and individuals about their rights, and you simply cannot deliver. I think that that is what this Committee would want to avoid: we are not trying to intervene about the policy, but the deliverability. It is localism, timetable and an honest view of whether, when we get to 2015 or 2016, you will be able to deliver in that time frame.
Sir Bob Kerslake
I will go through all those points, and I am keen to bring in Helen and Jon on this, in particular to flesh out the points about variability in costs and efficiency across the country. On your first point, about localism, we are doing quite a lot here to shape or nudge—call it what you want—local authorities towards improving the way that they do things and, more particularly, the whole health and care system in places. I mentioned the community budget pilots earlier; they told us a lot about what needed to change. For example, the tri-borough authorities did an interesting piece of work about the experience of users in the health and care system, which told us a lot about what we needed to change. I would say it has proved the concept and told us that if we change the way things work, there is potential to save money and improve quality. The second thing that we are doing is a lot of work on sectoral improvement, which we have sought to do through the Local Government Association. That is one of the things that funding goes into the LGA to do—to work with the sector to peer review and peer challenge to improve the quality of operations. The third thing is the Better Care Fund itself, which I see as a catalytic fund. It has clearly been set up to put in new money in return for local places changing the way in which they run things.
Chair
What new money? It is not new money, let’s all accept that. It is a redirecting of resources.
Sir Bob Kerslake
I will rephrase that. It is pooled money across the health and care system, but it is new money towards the agenda of integration. That might be a better way of putting it. It is a way of catalysing change in places, and I think that that is very powerful. The last bit of it is that, as you yourself have said, the financial imperatives on local authorities are very considerable, so the driver to change is very strong indeed. Jon and Helen will speak for themselves, but I do not pick up, up and down the country, any lack of will or intent to transform. The task is to help them to do it. On your last point, about timetable, we have set some time scales for the delivery of the Better Care Fund, which starts from 1 April 2015, but I am not expecting that every part of the country will have transformed its system by April 2015. What we would want to see is measurable progress in the direction that we have set. That is why we are putting £1 billion into, in effect, an incentive scheme to make changes. So this is not going to happen overnight. I would hope that we will accelerate the process through the Better Care Fund—that is critical—but I suspect that this will be a process of change that will go on for a number of years.
Chair
May we have a reality check on this? I am sorry about this, Sir Bob, but according to the stuff that Nuffield put out today, which I assume you have seen, a quarter of a million fewer older people received publicly funded community services in financial year 2012-13 compared with 2009-10; that is a 26% drop. Home and day care spending by councils fell by 23% over the same period. The number of older people receiving home-delivered meals has more than halved since 2009-10, falling by 59%. Around 42% of people received lower intensity care over the same period, with the focus on people with greater need. Transfers of money from the NHS to adult social care have more than doubled since 2009-10. This suggests that cuts in social care services could have been even more drastic. This is the reality check. Of course we need change, and we will come on to how you can encourage that and work on that, but I want a real reality check about what is deliverable, given the financial imperative that will be there whatever happens in 2015.
Sir Bob Kerslake
I think we are very clear about what the reality is on the ground. All three of us go out regularly to talk to local authorities about the issues they are facing. I cannot validate the Nuffield figures; they came out today.
Chair
You can rely on Nuffield. They are not a leftie think-tank.
Sir Bob Kerslake
I am not making any comment about the accuracy or otherwise. I am just saying, as you would say, that it is not possible to validate late data. My point is that we will use the data in the NAO Report, which show a real-terms reduction of 8% over three years. We recognise that that is what has happened. We also recognise that there has been a reduction in what might be called the lower end of care over the period. In fact, it has gone on for a decade now. We are not unaware of these challenges to the system. What we can say is that, as the Report says, there has been an improvement on delayed discharge, and we know that satisfaction levels with the service are high. So there are some positives here against some very challenging figures as well. We believe that with the right actions and the right leadership, it is possible to transform health and care services to improve outcomes with the funding that is available
Jon Rouse
I will start with the issue of variability. First, local government have done tremendously well in this area over the last few years in terms of driving efficiency. That is widely recognised. Clearly, their ability to stay within their means over the next few years while still providing a reasonable quality service is dependent on their finding further efficiencies. We took their assumption for 2015-16, which was that they could find another 3% in that year. The reason why we have some optimism that, at least through to 2015-16, they can continue to find that level of efficiencies is the degree of variation in their costs at the moment.
Chair
They don’t understand their costs. I bet you don’t, either. I don’t think anybody understands their costs. That is what we established in the pre-hearing.
Jon Rouse
Let me talk about the variability first and then the structure of the costs. In terms of variability, there are two ways you can look at this, and both are helpful. First, you take the cost per older adult—the cost of providing older adult services against the older population; it is a straight ratio, and you take out other externalities that might explain difference. Then you put authorities into their statistically similar groups—authorities that have similar characteristics. I will give you a few examples. Bristol spends, we calculate, £1,604 per head of older population. That is £150 a head more than any of its statistical neighbours. Bristol scores very well on outcomes, and we should recognise that, and they do tremendous work on carers, but that is a big differential. In another example, Warrington spends £1,232 a head, which is £100 a head more than any of its statistical neighbours. There are outliers in each group and a number of authorities that are well above the median in terms of costs. We need to really get underneath that and understand what those differences are, and through mechanisms that we have with ADASS and LGA we need to try and support those authorities to see if there are ways of reducing their costs structure. You mentioned the unit costs in domiciliary care, and it might be worth highlighting the variation there. The costs in each authority varied from around £10 per hour up to above £20 an hour. Again, even if you take statistically similar authorities, such as Gloucestershire and Dorset, there is as much as £7 or £8 a head difference in terms of what those authorities are paying. There is a number of things we can do. One is transparency—just hold up a mirror and say, “What’s going on?”
Mr Bacon
Sorry, £7 to £8 an hour difference?
Jon Rouse
Yes. Some of that might be explained by different case loads or different levels of complexity, but across a whole county you would not expect it to be that different. So there is transparency, and then I think it is about providing support, help and assistance and working through how you can transfer best practice from one area into another area. Of course, you can pay too low. There will come a threshold—it will be different in different localities—where it does start to impact on the quality of care.
Chair
Well it is already, isn’t it? One of the pretty shocking statistics in the Report is that up to 220,000 domiciliary staff are being paid below minimum wage.
Sir Bob Kerslake
I think we should just be clear on this minimum wage point. It is unacceptable for providers to pay below minimum wage. It is against the law. If local authorities find that this is the case, they should challenge them and ask whether they should still be providers for them. They should certainly be referred to HMRC. This is absolutely clear-cut.
Chair
It depends how you define it, doesn’t it? I know somebody who does this work. This person works in London and they get paid only for the quarter of an hour that they are with the elderly. They do not have a car so they travel by bus. It takes half an hour to get from client A to client B, for which they do not get paid. It seems to me that that is outrageous. They are on minimum wage. It is outrageous.
Sir Bob Kerslake
We agree with you. It should be tackled. I think it is worth talking about the efficiency issue as well.
Helen Edwards
To add to the point about whether there are resources in the system that could be used more effectively, the whole point of the integration argument is that we know that resources are not used effectively at the moment. People tend to be passed from pillar to post; they see different professionals. It does not work for them and it certainly does not represent good value for money. The other thing we see, and I think it was a figure in the Report, is that about 20% of emergency admissions to hospital could and should be avoided because people are getting treatment and care that they could get in the community. This goes to the point about timing as well. Trying to integrate services is not new for health and local authorities; the best have been at this for some time. In the areas where they have been working at this, we have begun to see some falls in emergency admissions. I am thinking of the West London Alliance, the group of six local authorities, which have seen quite a significant drop. In Wigan, they have seen a drop, and in Tameside, too. If you join things up better, are able to look at different models of care, try to get upstream of the problem and look at how you can prevent people coming into the acute system and allow people to live independently for longer, there are savings to be had. As Sir Bob said, the objective of the Better Care Fund is to accelerate the work that is already going on, to give it real impetus and to see if we can reap more efficiencies and savings as well as preserve services.
Chair
The problem with that argument is that I was around when the same argument was used when we introduced community care. It was going to save a whole load of money. It was going to be absolutely wonderful, but actually, it never saved a penny. What you are fighting against here is the demography as well. You have a mix. First, you have a theology that tells you, integrate it and you will save money—let’s wait and see if that translates into actual practice. Secondly, the demography is against you. All my experience from the community care experiment in the ‘80s is that it never actually saved money. We ought to learn from those things.
Helen Edwards
We should learn the lessons of that.
Mr Jackson
Do you think that there is an element of moral hazard in the bias against self-funders? The Report says self-funders were spending £10 billion a year in 2010-11, the last year for which data have been collected. They do not have the capacity to block book and deliver economies of scale in the same way that local authorities and other commissioners do. Are they effectively subsidising those who are under the auspices of local authorities? There is a bit of moral hazard there, because they have the money built up. Local authorities generally have not built up any money. Therefore, how do you get that balance right?
Sir Bob Kerslake
This is referred to in the NAO Report. It is a valid issue to raise. The Care Bill will certainly help with this. Jon, do you want to say a bit more about that?
Jon Rouse
It is a really pertinent question. The first thing to say is that we don’t know whether cross-subsidy is going on at present, and if there is, how much. It may be, and it is likely, that to a certain extent some self-funders are paying a quality premium as well, in terms of a better quality of product.
Chair
Let’s ask the NAO. Why did you put it in?
Aileen Murphie
Because a significant amount of care is being bought with that £10 billion.
Chair
But why did you put in the assertion that there appears to be cross-subsidy?
Aileen Murphie
Because that is what it looks like.
Mr Jackson
You cannot prove that it does not happen.
Aileen Murphie
Providers told us that. We had evidence for it, that is why we put it in.
Amyas Morse
You have positive statements from providers that in some cases at least they are cross-subsidising.
Chair
Either there is evidence or there is not evidence. That is what I am driving at.
Jon Rouse
How shall we put this? There is anecdotal evidence in that providers say that. When I speak to directors of adult social services, some say there is and some say there is not. In some ways it comes back to the question Mr Bacon asked earlier about really understanding as a local authority what is your true cost of care and are you paying it—not too much and not too little. There may or may not be some cross-subsidy within the system, but the good thing is that the Care Bill will make that much more transparent, because each self-funder will come into a relationship, if they wish to, with the care system, in terms of opening a care account and starting to progress towards their cap. If they want to, they can ask the local authority to organise the care on their behalf, which potentially could bring them into the local authority’s pricing mechanism. That should really begin to expose whether cross-subsidy is going on. We would expect to see some level of market response if there is.
Amyas Morse
Thinking about it from a business point of view just for a second, let’s visualise ourselves as one of these homes. You have x number of beds and you are getting your guaranteed volume by doing stuff that is local authority funded. You fill up on that and know that it is at a controlled price; then you fill up on private self-funders at a higher price. Is it not inevitable, looking at your accounts, however you describe it, that there is going to be cross-subsidy, because you have a set of accounts for the business that contain the two sources of income and they are not kept segregated? It cannot be a realistic proposition to say that there is no cross-subsidy.
Sir Bob Kerslake
Let’s be clear about what Jon said. He did not say that there is no possibility that this is happening. What he is saying is that we do not have good data that tell us the extent of it or the nature of it. The truth is that the market for those who are self-funding is more competitive in some parts of the country than in others, so people will very quickly get to know what the charges are and make decisions. We want maximum transparency so that they do not have to work hard to find those figures.
Amyas Morse
I totally agree with that. Forgive me Chair, I have one more point. In the absence of good data, which, after all, is pretty pervasive in a lot of the areas we are talking about, would you not think it right to make a prudent, mid-range assumption rather than an optimistic one of whatever proposition you are arguing?
Jon Rouse
I think it comes back to what Mr Bacon was arguing earlier, which is the importance of local authorities themselves understanding what the true cost of care is and negotiating on that basis, including a reasonable profit margin.
Mr Jackson
That is my next question. Although the report is generally quite positive—our witnesses earlier made reference to this—everyone says that things could be better: we could reduce duplication or have fewer case conferences where we have 17 people coming along. How do you improve contract management? On the one hand, Sir Bob, you quite laudably say, “Well, we don’t want to micromanage what every local authority does,” but at the heart of this is the contractor and client relationship. How do you encourage local authorities to improve that in order to keep front-line services at their optimum without using, say, the stick of the Treasury saying, “If you don’t do it, we’ll cut your funding.”? It is a self-fulfilling prophecy.
Sir Bob Kerslake
Two or three points: first, I want to echo what Jon said. I think local government has done a huge amount to manage these financial restraints and done it very well. The NAO Report points to the fact that a significant amount—I think a quarter—of the savings have come through tighter commissioning. I think the ways you can help the sector are the things I spoke about earlier: the work with the LGA, sector improvement, finding the best people and getting them working together on how to improve collectively. Peer review is a very powerful model as well. Jon touched on transparency. The more transparent the information is, the more likely it is that one authority will say, “Well why are we paying more?” At the moment we are not transparent enough. If we can work with the sector to get that data out there—
Mr Jackson
There are more examples, such as Worcestershire, where the whole portfolio of stakeholders is working together.
Sir Bob Kerslake
On the last point about where I think the drivers for change will come, we touched earlier on the £3.8 billion being pooled. It now has to be, if you like, released by agreement with the health and wellbeing board and the partners working together. Given that the money has come through reductions in the overall money for the NHS, I would expect all the players at local level to be testing whether the money is being used and whether the commissioning good enough. I think it will drive better collaboration at the local level and better commissioning as well.
Mr Jackson
That is my next question—you keep teeing me up, Sir Bob. We are a great tag team. I do not think I saw anything in the Report about something that is quite dear to my heart: palliative care. That is quite important. It is a separate issue. I just wonder what your thoughts are on that. Obviously that is a very sensitive area and a very cost-intensive area. With the prevalence of cancers, and as people get older and have other neurological conditions, it is becoming very important for local authorities.
Sir Bob Kerslake
You are absolutely right. It is both sensitive and very important. In my experience, they are often quite reliant on money they raise through fundraising.
Jon Rouse
You know the background to this, which is the move away from the Liverpool care pathway. We are into a review of palliative care at the present time. What is interesting about it is that the more we get into it, the more it becomes clear that the same principles of integration that apply in terms of the rest of the Better Care Fund also apply in terms of palliative care. That means putting the individual and their family and their carers at the heart of the decision making and the planning, ensuring that there is a lead professional who co-ordinates what is going to happen, when it happens and how it should happen. One significant outstanding issue from a social care perspective, which came up prominently during the Care Bill, is around the cost of social care at the end of life and whether it should be means-tested. We have pledged to review that. I think the Government would like to be in a position where that would not be the case but we are just working through the affordability and what that would mean at the present time.
Chair
But you do not even fund the hospice movement, do you? No public money goes into that.
Mr Jackson
Clinical commissioning groups do, but substantially the funding stream is from the voluntary charitable sector.
Sir Bob Kerslake
My experience is exactly that.
Mr Jackson
Certainly capital.
Sir Bob Kerslake
Yes. A large part of it comes from voluntary donations.
Mr Jackson
Can I make a capital appeal for the new Sue Ryder hospice in Peterborough? A number of key points occurred to me. One thing that comes out of the Report, apart from the lack of data collection by some local authorities which is unhelpful, not least to both your Departments, is this question: is anyone actually plotting demographic trends on a regional or local authority level to assist local authorities to draw up strategic plans for dealing with older people in particular, but also younger adults, who are living longer, as we know—20 or 30 years ago they died quite young—and children and young people who are in receipt of this care. That is my first question. Linked to that, which we did not have time to ask the previous witnesses about, is the question of extra care housing. It is an important aspect of keeping people out of acute care. It is good for them, I would argue, and good for the taxpayer. Are we joining up the dots for tax policy and planning policy and adaptations to try to get more of those facilities built for the growing population? I know that they are big issues, but they are quite important.
Sir Bob Kerslake
I will say a few words about extra care and then colleagues will fill in the detail. On the first point, the health and wellbeing boards are required to produce strategic needs assessments and those will heavily rely on demographic data. Of course, the public health role is being transferred into local authorities—in my experience, that was often where that demographic analysis was. So I think at local level there is a way in which data is collected, analysed and forms the foundation for the health and care plan for the area over time. That is getting well established now. Your point about extra care is entirely fair. There is a limited amount of funding going into extra care through—
Mr Jackson
The HCA.
Sir Bob Kerslake
The HCA. Whether there is more that we can do to encourage extra care is certainly worth exploring. As you know, it is typically more expensive to provide, but it is growing and it certainly provides a level of care, in my experience, which is very high indeed. I am happy to give you a separate note on what some of the issues are.
Mr Jackson
That would be very helpful. Thank you.
Helen Edwards
On the housing point, in terms of the £3.8 billion pot, a number of local authorities are pooling other funds as well. In some areas, some of their housing funds are coming into that pot. So they are seeing an opportunity to bring other forms of public money to the table to give a more joined-up response. I think Sheffield, significantly, has something like £40 million through the Better Care Fund but is pooling something like £180 million all told. So we hope that this can act as a catalyst to the better joining up of public money on a more ambitious scale than we have seen.
Mr Jackson
My last question. Reference was made earlier to and we had a discussion about respite care, which is very important, and obviously the Care Bill is an important piece of legislation. How will you monitor the efficacy or otherwise of local authorities’ policies for respite care? We discussed young carers earlier, but we also need to think about older carers. As people are living to 85 or 90 these days, they are likely to have children in their 60s and 70s themselves who are potentially unwell, quite stressed and so on. How will you monitor the impact of respite care?
Jon Rouse
In the 2010 spending review, we put the money in for carers’ breaks through the NHS: that was £400 million over that period. But we have decided that, for 2015-16, we will put it in the Better Care Fund. That gives us a number of advantages. One is that it means that local areas have to think about how meeting those needs for carers fits with the overall package of care, so it is not just something in isolation. The second is that each of those plans requires ministerial approval. It is quite unusual these days for such a decision to have that level of sign-off, but we deliberately wanted that because of the level of transformation we were expecting, and Ministers agreed to that. One of the criteria in the guidance we have put out to health and wellbeing boards is that they must be explicit about what the fund will do for carers and carers’ breaks. That is one of the things that we will be looking at, and are looking at now, in terms of analysing the draft plans and whether they are going to do what they need to do for carers.
Chair
Are you signing them off before they spend?
Jon Rouse
There is a decision as to whether that plan is sufficiently robust and meets the conditions that we have set.
Chair
And if you say no, they cannot spend?
Jon Rouse
If they say no—
Chair
If you say no, sorry.
Jon Rouse
If Ministers say no, they will effectively go into a remedial process with NHS England and the Local Government Association, with a degree of oversight from ourselves, to put that plan right. Remember, we have got until April 2015 to do that.
Sir Bob Kerslake
That is the key point. We have started early and the plans are essentially being looked at now, so the process allows us to improve the quality over time, well ahead of 1 April 2015.
Chair
And none of that money can be spent on bin collection?
Helen Edwards
There is quite a lot of conditionality set around this fund.
Chair
Is it ring-fenced?
Helen Edwards
No, but we have set national conditions and local metrics as well.
Chair
So what happens? What does that mean? Give us the nitty-gritty.
Helen Edwards
In terms of the plan––the assurance processes––it has got to be signed off locally. We have got to be clear that it is a joint plan, that it will safeguard adult social care, that the acute sector has been involved and that the impact on the acute sector has been looked at. There is an assurance process, then an assessment by NHS England and the LGA, the local authorities. They then send it up to an advisory board that Jon and I chair, where we again try to make sure that the plans are ambitious enough and that they are spending on the right kind of things. Then we recommend to Ministers that they sign off the plans. But of course a good bit of the money has to be earned through payment by results, so there is £1 billion that is conditional on areas making good progress against some of the national conditions, particularly things like unplanned admissions and delayed discharges, so it gets paid in April 2015 and another tranche in October 2015, depending on the progress that has been made. That is quite a lot of oversight. That is the point.
Chair
Why don’t you just ring-fence it? Either it can be spent on bin collection or it can’t. Be honest and open, Sir Bob.
Sir Bob Kerslake
I think we are being very honest and open. First of all, if you think about it for a minute, if you ring-fenced this extra money on better care, we are not ring-fencing the substantive part of the money, which is the £17 billion they are spending on the main care programme. It would be a completely fictitious ring fence to ring-fence their share of the £2 billion when you have left the whole sum un-ring-fenced. It is much better, as Helen described, to say, “You will get your share of the £2 billion if we see that you have conscious plans to protect care levels.” It is a much more effective way of influencing the money. Secondly, look at what has actually happened in local authorities. They have seen something like a 29% reduction in real terms on their grant. Their spending power fell by 14% over this period. They have, in relative terms, substantially protected adult care. They have worked incredibly hard to avoid reductions in adult care, so the suggestion that they have willingly moved money out of adult care to other places is just not borne out by the facts.
Nick Smith
There are three things I want to touch on. Mr Rouse, in Blaenau Gwent in south Wales, there is a very good project trying to stop frail elderly people having falls. It is good preventive work. What evidence do you have that preventive work like that works and reduces an individual’s need for care or reduces the costs of that care? It all sounds great and I am really pleased to say that we have more able older people in Blaenau Gwent but I have not really seen the data.
Jon Rouse
It is a really good question. Being honest, we have good data in some areas of preventive intervention but it is not good enough in others. We did a piece of work a couple of years ago through the School for Social Care Research where we did a deep dive into 11 authorities and asked, “What are your main preventive interventions?” They came out with three. By far the most significant was reablement and enablement. It is stopping people having accidents and going into crisis in the first place. If they do get into crisis, it is getting them back into independent living as quickly as we are able to, within their capabilities. The second one was around telecare and telehealth. The third was around what we might call low-level community support, the sorts of things that Sandie does brilliantly in Leeds. Our evidence on the first, reablement, is really good and very positive. The evidence consistently shows that over 50% of people are able to sustain independent living following reablement interventions. Some authorities do even better than that and it definitely saves money. Reablement is very positive, but on the other two areas, I would say that our evidence is pretty weak, if I am being honest. We need to invest in better research in those two areas.
Nick Smith
Sir Bob Kerslake was talking about cost reductions for local authorities, but some of us remember what happened a few years ago with Southern Cross and other big residential care providers. I am interested in your concerns about the financial sustainability of those private sector care providers, given that local authorities are driving down costs.
Sir Bob Kerslake
Can I quickly deal with Southern Cross? The issues with Southern Cross were not to do with the fee levels they were paying; it was do with the financial structure. They are the only recent case of any major provider that has got into that sort of difficulty and it was entirely to do with how they ran the financial structure of selling the assets and then leasing them back. It is fair to say, Jon, that you monitor the five biggest providers on a regular basis and that more providers have come into the sector than have left.
Chair
Are any at risk?
Jon Rouse
At the present time, no.
Meg Hillier
Of the five biggest?
Jon Rouse
Of the five biggest. We also do some more general monitoring of the medium to bigger sides of the market in terms of trying to identify the risks. As you would expect, quite a lot of this work goes on behind closed doors. There was a period after Southern Cross where we did need to get into quite deep dialogue with one or two providers, but it feels, particularly over the past 18 months, that conditions have eased, particularly around debt structure and servicing debt. Obviously, where they own assets, those assets are for the most part going up in value. That does not mean that we are in any way complacent, and we are heading towards 1 April 2015, which is when the Care Quality Commission will take on this responsibility with a proper statutory underpinning, whereby they will be able to require information and data from the top 40 or 50 providers and take early action if necessary. I want to make one more point. It does all sound quite heavy in terms of market intervention, but our purpose, which will be the same for the CQC, is not in any way to shore up the market. Our interest is safeguarding the individuals in their homes in terms of receiving care and ensuring continuity of provision. That is why we are doing it. It is not about trying to fix or support what is a market sector.
Nick Smith
And how are you ensuring that the users are getting quality services even though fees are being squeezed? How are you testing that?
Jon Rouse
Partly, it has to be said, on the back of what happened at Mid Staffordshire and Winterbourne View. We have, as you know, completely overhauled the Care Quality Commission and its inspections and ratings process and, again, there is statutory underpinning for that in the Care Bill. The new inspection regime under the new chief inspector, Andrea Sutcliffe, is starting to roll out this summer with a really clear rating system for all providers.
Sir Bob Kerslake
And I think the NAO Report talks about the annual reviews and the findings there about—
Chair
Can I just—
Nick Smith
I have one final question.
Chair
I am coming back to you. I just have two questions on that issue. First, I read in the Health Service Journal that the CQC—I do not know whether this is true—do not have the skills to deliver their market oversight. Why on earth are we giving it to them if they do not have the skills to do it? Secondly, what is your failure regime? You are monitoring, but what do you do if you get another—I cannot remember the name. Four Seasons Health Care was one that was at risk when we looked at it.
Jon Rouse
Shall I deal with both of those? In terms of the skills, the HSJ is right that the CQC do not have the skills now because they have not needed them, but they have until April 2015 to put those skills in place. I am confident that they will do so, and we are working very closely with them to ensure that that happens. Why were they the right body? What we felt trumped any other consideration was their depth of knowledge of the care sector and the strength of the relationships with providers and commissioners at local authorities that they already have through the inspection framework. You can have a statutory underpinning, but a lot of this is based on trust, relationships and sharing information. Yes, you need the financial analytical skills to examine ratios and be able to interpret them, but a lot of this comes down to the quality of relationships. In terms of intervention, without going into the detail of what the statute says, what it comes down to is that they have the powers to ensure there is continuity of care for individuals within that situation, working very closely with the local authorities as commissioners.
Nick Smith
I wanted to touch on some safeguarding issues. Safeguarding vulnerable adults from abuse and neglect is still a major issue. Between 2011 and 2013, safeguarding referrals by local authorities went up by 13%. Do you think that reflects increased awareness of abuse in the sector, overstretched resources, pressures in the system or something else? What is going on here? Is it some national phenomenon?
Jon Rouse
I think it is a mix, if I am being honest. First, there is increased awareness in the system. Remember that, in the whole context of adult safeguarding, the system is much newer than it is for children. It is only now, in the Care Bill, that we are putting that properly on to a statutory footing for the first time, giving adult safeguarding boards the status that they should have. I think there is also an increasing awareness among the public about what is right and wrong and how you can actually refer concerns to the safeguarding system. So this is partly about the system growing up and there is a lot there about increasing awareness. Having said that, 43% of those safeguarding referrals were either substantiated or partly substantiated last year. That is clearly far too many. Therefore across the system—national Government, local government, providers—we have a lot of work to do in terms of how we bring the principles of the Francis report and embed them within the social care sector as well.
Nick Smith
What do you think we can do, or you can do, to help families of people in residential homes, who suspect there is an issue or have concerns, to raise those concerns and draw attention to neglect or abuse that they think may be there?
Jon Rouse
I think it is families and staff, so both. If you think about Winterbourne View, it was an ex-staff member who actually whistleblew there and raised the alarm. So it could come from either place. I think the CQC have a very significant role here. They have their whistleblowing helpline now. I know that the number of calls to that helpline has gone up tenfold in the last year and a half or so. Then it is about making sure that those sorts of arrangements are replicated at the local level as well. If I could just give you an example of best practice on this: I visited Nottinghamshire a few weeks ago and their multi-agency safeguarding hub. When I say that, you will probably think children. Actually, in Nottinghamshire they have a single MASH that covers both children and adults. It is a fantastic idea, because it allows you in many of those cases to take a family perspective. An issue around safeguarding one part of the family may have knock-on effects and implications on other generations. I was really impressed with that.
Helen Edwards
I hope that trusts are also strengthening their whistleblowing policies. Every trust has them and I think a lot of trusts are asking themselves: “Why are people using the CQC and not the whistleblowing policies that are actually in the trust?” It is not that they have not been in place, but they have not been used. So there is a huge amount of work going on to make sure that this issue is taken much more seriously and that the systems work.
Sir Bob Kerslake
The user ratings, as the NAO Report says, are low as well. I think there is potential there to do more.
Meg Hillier
I want also to touch on the quality aspect. I know that you have answered this to a certain extent, Mr Rouse, but I want to ask again about the CQC. I remember the days two regimes ago when, pioneered by the council that the Chair used to lead, an independent inspection regime was embedded in a different section of the council. That meant you had local knowledge and a lot of local gossip and stuff that you could pick up because of that very embedded local team. Plus, local councillors, who were pretty cheap, frankly, could look at inspection ports very regularly. Again, that local knowledge was really important. I know that things are changing at the CQC, but we were unimpressed when we last looked at its ability to deal with some of these areas. Why have you gone for that route? Is it because that is the body that is there? Sir Bob, you represent local authorities in Government, in a sense. Given their local knowledge and understanding and the fact that they have to deliver this, why not let local authorities have a role?
Sir Bob Kerslake
In the inspection process? It is interesting, because I recall those times when it was done that way. To be frank with you, I am not convinced that it was better. Even though there was local knowledge, I do not know that there was enough separation to get the rigour of the inspection process right. Given the change in the market, with a much higher proportion now being through the independent and private sector, there is a lot more sense in having—you will get a lot more consistency and professionalism through it—a distinct inspectorate process through the CQC. That is my view. That does not mean that local authorities should not be involved. They should give feedback if they have issues and concerns. Having seen both systems, however, I believe that it is the right way to go. Jon, do you want to add anything?
Jon Rouse
Yes. If my ex-director of adult social services from when I was a local authority chief exec was here, she would be laughing at this point, because I used to argue regularly that inspections should be done at the local level, but I have genuinely changed my view. The reason why is that I have learned that there is an inherent conflict of interest in having the commissioner also as the inspector. Let us say that the inspector goes into a local area and finds a pattern within providers of poor quality of care. That points back to the commissioner, because there must be something going on in how the local authority is commissioning those services. If that commissioner is also the inspector, will they really hold themselves to account for their influence on that system? There is a pretty strong case for a separation.
Meg Hillier
I suppose it depends. In the case that I was talking about, a separate bit of the council did it. They were embedded in a different department and given clear political direction to be brutally honest. We have heard about relatives in a residential setting, but let us say that you are a councillor picking stuff up through your local knowledge, and the CQC seems quite distant and passes it on. It is that local accountability that is not so readily there. How do you ensure that that happens in the model? Is there any room for flexibility as you move forward?
Jon Rouse
I think there are other mechanisms that can be used at the local level to supplement and support the work of the Care Quality Commission, and there are two in particular. One is HealthWatch. If you have a really strong HealthWatch in the area, they have powers to do thematic reviews, shine a light on the system and represent the care user’s and the carer’s voice, and that is powerful. The second, linked, mechanism is the role of scrutiny and overview. Scrutiny and overview is taking some of those CQC inspection reports and asking the hard questions about what is going on in local commissioning.
Sir Bob Kerslake
Can I just add two points to that? One is that in the end the local authorities are the commissioners. If they pick up consistent feedback about the quality of the provider, they have the ultimate power to stop using that provider. They have quite a lot of local influence. The second point is that if the system was set up in the way that you described and you could be absolutely confident that that conflict of interest would not happen, I would go along with you, but I am afraid that that is not the case. You cannot take the risk that a local authority will give it the necessary separation.
Meg Hillier
I hear what you are saying. While we have talked a lot about residential care, what about the domiciliary setting? If you look at in part 2 of the Report, on page 47 at paragraphs 2.31 onwards, it says: “72 per cent met all essential standards of care. However, 27 per cent (3,241 locations) required an action plan for improvement.” That was locations, so presumably the care agency has inspected. We need to ensure that someone in their home is not getting bad care. There is a real difficulty and there is no easy answer, but how much have you thought about that in what you are looking to do? The new vetting and barring arrangements at the DBS, as it is now called, should pick things up, but it will not necessarily do so if that older person does not complain or the relative does not see it. There could be some bad abuse going on that is not picked up. It is difficult to answer, but what is the plan? It is not clear that this measure will resolve it.
Jon Rouse
That is a really good question. There are inherent risks in any system of care that is personalised and based in people’s homes. Successive Governments have been very strong proponents, quite rightly, of increased personalisation and people being able to control their budget to employ their own PAs and so on, but that clearly makes for a more fragmented system and more inherent risk that things might go wrong. I therefore think there are two things that you can do. One is to be absolutely clear about the registration of domiciliary care agencies and about the way they are inspected: there are certain fundamental standards that cannot be breached, and if evidence is found that they are breached, the consequences will be very serious. That is what we are now doing with the new CQC regime. The second thing is to try to get more transparency into the system, which is why we are introducing the duty of candour, which will go across into social care, too. There will therefore be corporate responsibility—when you know that something has gone wrong, you have to say so and be transparent. Those are two very important safeguards that we are introducing.
Meg Hillier
Going back to the issue of costs, how much can local authorities take into account the calibre, training and professionalism of the people who are delivering on the front line? If you are dealing with, say, a learning-disabled adult, it is very challenging to get information about what might or might not be going on. A lot of older people just don’t want to be bothered to complain because they feel a bit ground down and humiliated by lots of little, minor things that can add up.
Jon Rouse
There are two levels to this. One is the role of the registered manager. Registered managers are absolutely pivotal to the quality of care, both in organising domiciliary care and particularly within a care home or similar setting, and within that subset, particularly where you have high levels of vulnerability. The CQC gains a level of assurance because, first, there is a registered manager in place and the setting isn’t without a registered manager for any length of time and, secondly, that individual has the right level of training, attitude and approach. That is very important. Secondly, there is the broader care work force, particularly care assistants. Following Camilla Cavendish’s report, we are going to be rolling out the care certificate across the sector to ensure that there is at least a minimum standard of competence.
Meg Hillier
Okay, thanks. I have a couple of very quick things. On the GP issue, we have heard about the lead professional being the GP. What do GPs earn from this? I do not know the language, but what incentive fee do they get for every person for whom they are the lead?
Jon Rouse
I haven’t got the exact numbers, so if you want them, I’ll have to give you a note.
Chair
Are they going to get extra money for it, then? Is that the way the system is going to work?
Jon Rouse
No, not quite. I will explain, but I do not have the exact numbers, so if you want them, I’ll have to give you a note. Essentially, we have done a deal whereby we take away roughly a third of their QOF indicators, which are boxes they have to tick for the procedures they have carried out or things they have met, and we have taken the money that they would have got for doing that QOF activity. Instead, we are giving the money to them for being a named accountable GP for the top 2% of the population.
Meg Hillier
So it just evens out?
Jon Rouse
I haven’t got the exact numbers, because I didn’t expect to be asked about it.
Chair
Wrap it up, Meg.
Meg Hillier
I think Sir Bob wants to come in, and then I have one final, very tight point.
Sir Bob Kerslake
On GPs, Jon is right that there has been a redistribution of work rather than more money. I have actually been to GP practices where they are doing this integrated approach, and they are doing it not because they are being paid more—the approach predated the deal—but because they see the potential of a collaborative approach across agencies.
Chair
Oh, Sir Bob, I wish that was true. The best GPs in my constituency cannot see it.
Sir Bob Kerslake
I can’t talk about your GPs, but I can happily take you to the place where they are doing this of their own volition because of the way they see it working.
Meg Hillier
So the vision is that they will all do it of their own volition. Fantastic. I have a final quick point, because I know the Chair is itching to move on. Data sharing comes up as one of the challenges in the work in figure 18. What progress is there on that? How much will have to be spent on IT systems to sort it out?
Sir Bob Kerslake
One of the provisions we will want to see in the plans is how they are going to improve data sharing between the agencies at local level. As part of getting the money, we will want to see a strengthening in what they are doing on data sharing. I am sure there will be some IT issues here, but from all my experience and talking to people on the ground, most of it is about culture, processes and attitudes. You can do a huge amount here. I don’t think myself—I am happy to be corrected by either Helen or Jon—that this is about big investment in IT systems. Much of it can be done by simple, practical collaboration at the local level.
Meg Hillier
And will you make sure that best practice is shared, because it would be silly to reinvent the wheel?
Helen Edwards
We will. We really do want to ensure that best practice is shared across the piece. This agreement that the NHS number will be the identifier—we are not approaching this on the basis that there will need to be huge investment. But what we have said is that where people are coming across genuine barriers at the local level—whether it is to do with data sharing, contracting or anything like that—then we will look at it at the national level to see whether there are things we can do to make things work better on the ground. But we are not looking at huge investment.
Chair
Right, let’s have Fiona, then Amyas and then Nick, and then I want to begin to draw things to a close. I have a couple of issues that haven’t been covered.
Fiona Mactaggart
Jon, you are enthusiastic about the evidence about re-ablement services. One of my concerns is that the focus of most re-ablement services is on physical disability and doesn’t include mental disability, mental illness and social isolation, which is very significant for this care group. Have you done any studies about the value and the importance of that?
Jon Rouse
I don’t know whether there are any studies, but I know it is true.
Fiona Mactaggart
So how are you going to make sure that, within the care packages and the preventative mechanisms that people are offered, there is an appropriate focus on that issue? Scope, for example, have suggested to us that there is not.
Jon Rouse
There is a formal and informal level to this. Let us just deal with the formal first. First of all, there is an unwanted and unacceptable under-representation of older people receiving access to psychological therapies. The percentage is about 5%, and if you think about the proportion of over-65s in the population, that cannot be right. Let us think about why. Some of that is a generational thing, to a certain extent, about talking about mental health. So we have work to do to break down stigma, particularly around that generation. Secondly, it is about where those individuals would be most comfortable receiving those services. My instincts are that they would probably be more comfortable in a primary care context, in terms of their relationship with their GP, than necessarily being referred to a specialist centre. So there is some work we can do about embedding older people’s psychological therapeutic interventions within primary care. That is the first thing to say. At a more informal level, it is about how you break down isolation and loneliness. I cannot do better than to talk about Sandie’s brilliant neighbourhood team structure in Leeds. They have broken the city up into 37 neighbourhoods. Each one has a voluntary sector organisation, or a social enterprise that works as part of the team with the professionals doing the joined-up care. So it is not just about the occupational therapist or the physio going into the home; it is about saying, “Did you know that Ethel has just come out of St James’s? She’s back on her feet but she’s struggling. Could we as the voluntary organisation make sure we go in three days out of the next five, just spend an hour with her, chat to her and make sure she is okay?” We need to ensure that in each place that sort of informal infrastructure is in place as well. There are lots of good examples around the country. Cornwall is doing some fantastic work which is another pioneer, particularly in Newquay and Penwith. I am aware of some very good work in Cumbria as well.
Helen Edwards
We heard this morning about the work going on in White City, a befriending scheme from local people in the community for isolated older people. It is heavily correlated with health problems. It is something that local people are prepared to invest time and energy in doing, if someone will take the trouble to organise it. Again, this was another social enterprise bringing this together.
Fiona Mactaggart
I am slightly surprised that none of you has mentioned the importance of family there. It is the family that the ill person is most likely to have contact with. Surely making sure that you support family carers more effectively is one of the ways to deal with this issue? That brings me to my constituent who is currently in an acute mental hospital. It is a very expensive bed. She has been assessed as being eligible for continuing care funding. Her daughter is being—I think this is the politest way to say it—squeezed out and kept in the dark, not knowing what is going on. Every time she finds a care home that she thinks, and that the care home thinks, is appropriate for mum, she is pushed away and told, “That won’t do.” The people who are deciding it have offered mum a dementia home, which is not a sensible place for her, as she is not in the least bit demented. She is isolated and mentally ill, and does need support and help. My constituent’s daughter actually believes that this system is designed to keep families in the dark. I hope that she is wrong, but that is absolutely what she believes. She thinks that the decision support tool is being kept away from her; she feels almost as though her mum would not have got any support if she had not had an articulate, bossy daughter. She is getting some support, but not what she needs. Why is this still happening today, because it seems to me that this system is the closest one to the new territory that we are looking at?
Sir Bob Kerslake
From what you have described, it feels like the antithesis of what we are trying to achieve here—
Fiona Mactaggart
Exactly.
Sir Bob Kerslake
It is difficult to go into detail unless we know more, but that is clearly not what we are trying to create in the new system, when we have one.
Fiona Mactaggart
I understand that, but what I suppose I am saying is that in a system that is like the new system—as I understand it, continuing care assessment is the closest thing that already exists to the new system—families are feeling squeezed out and they certainly do not have a transparent system. Whatever else you might think about the decisions, it is not in the least bit transparent for the family. How are making sure that your new system will be transparent, so that someone who has power of attorney and who is the person who loves the patient more than anyone else is actually included in the decision making?
Sir Bob Kerslake
I suppose part of that is about what ways people have of redress and complaint. Jon, do you want to say a bit about this?
Jon Rouse
Yes. There is also complexity when you have got an individual who is receiving what we call tier 4 services, because they are in all probability commissioned by NHS England, rather than locally by the clinical commissioning group. What you are trying to do is take someone from that setting and place them back into a community setting with the right support, and there are barriers that might be to do with the right housing and the right care package. One of the things that the Better Care Fund and the integrated model should help with is that they should cause NHS England, through its local area team, to need to come to the table to be involved in that care co-ordination and to make sure that the transition takes place well. It is exactly the same issue that we had with Winterbourne View, with assessment and treatment centres. It is making sure that those transitions from acute services, which are commissioned through a national infrastructure, connect properly with the local level.
Fiona Mactaggart
How are you making sure that the people who love the patient most are involved in this decision making? What are you doing to make sure that that happens, because I do not think that I see it?
Sir Bob Kerslake
What you are describing is working to the convenience of the system, rather than the family. I think there have to be very clear pathways for people to complain if they think that they are not getting the right result.
Fiona Mactaggart
I agree with you about complaint, but what I am trying to do is to avoid complaints by asking how you involve the family carer in the decisions that are being made about someone. Is that not critical? If they feel involved—if they are engaged in this—then you can make things work together.
Sir Bob Kerslake
We can all trade anecdotes, but my sense is that that happens in the vast majority of cases. The question is what you do with the ones where it does not happen.
Helen Edwards
I have a different hat, which I wear as a non-executive director of a mental health trust. What I do not understand is why that person has not got a care plan. They should have been fully part of putting such a plan together and it should have been shared with relatives. That case sounds like really bad practice. It is the kind of thing that, if the CQC is doing its job properly, it will pick up through inspection, but it is hard to understand, unless there is more to it than meets the eye about why that has happened. It sounds like very bad practice.
Fiona Mactaggart
It does to me. What I am really asking, I suppose, is how what you are putting in place can engage properly with the family carer to ensure that, instead of having to complain afterwards, they are involved from the start.
Sir Bob Kerslake
I absolutely get your point. If you are willing, maybe we should use this as a case study of the system not working. I am happy to do that.
Chair
I am trying to draw you to a close, so we can finish. Amyas?
Amyas Morse
May we just go back briefly? I appreciate that a lot of what we have been talking about—all very admirable direction of travel—is using resources more effectively and seeking to make everyone a winner. In part of our Report we are looking at this invincible onward march of demographics. How would you know when you needed to put more in? I know you should not say “give us more money” as a first plea, but how will you know when you need to put more money in the system because ingenuity is not going work any more to meet lack of capacity? I appreciate that you probably don’t have the information now. Are you going to have that information at some point in the future?
Sir Bob Kerslake
I guess it works at different levels, Amyas. When we come to big events—let’s say the next spending review in 2015—we will do the full analysis across the range of our Government services. We work incredibly closely with Health and we have regular joint boards. We share analysis. We will do in-depth work, and we have in effect joint teams working on these issues. So when we come to a big event—which is after all when these big decisions are made—
Amyas Morse
You will have the modelling in place for that?
Sir Bob Kerslake
We had better modelling in 2013. I think we will have better modelling again in 2015. I am particularly keen that we get more around the welfare side into the system, which is not as good as our working relationship with other teams.
Chair
I was going to say, because we had a session on PIPs—personal whatever they are—
Nick Smith
Personal independence payments.
Chair
And it was clear there that the cuts are going to hit just the group that you are going to have to provide adult social care for. There must be an impact. Somebody has got to monitor that and have a look at that.
Sir Bob Kerslake
Absolutely. One level is when we come to the big fiscal events like the spending review. That is one part of it, but on an ongoing basis we do assess the pressure in the system both at an aggregate level and locally in individual places. You have a set of indicators, Jon. We have a set of indicators. We can put the two together and see whether there are issues emerging in a particular area. That is how I would describe it.
Amyas Morse
Thank you.
Chair
Nick, a couple of questions, then I have three to clear us up.
Nick Smith
Thanks, Chair. At the start of the session I talked about the multi-agency meeting we are having this Friday regarding this young man who is severely disabled, with 17 people from different agencies. Since then, witnesses have talked about a single person, a sort of baton-holder, to help this young man and his family put their life together. We talked about it a bit more, and we have talked about getting the GP to have co-ordinating responsibilities. They are going to get a fee for it. However, I am not sure whether, if the GP might be co-ordinating it but a different health professional or someone from the Department for Work and Pensions actually does the work, that will be recognised. Will they get a fee for that, or will there be savings in the system that mean that is covered off? How is that going to work?
Helen Edwards
There are a number of joint teams already in place. We are looking at joint working and we are hearing, as Bob said, from Cheshire West, where they have brought together joint teams from a range of services. If you have the joint team, it does not really matter which agency you nominate, because you want that co-ordination—although it would be good if it was relevant. I don’t think we are looking at extra money for this. I think we are looking to see people changing ways of working so that they see this as part of their jobs.
Chair
It might be good to get the GP to do that without extra money too.
Nick Smith
But are GPs really the accountable people to make sure that works to plan? Is that clear?
Helen Edwards
They will be in the formal sense.
Nick Smith
Related to that, a couple of weeks ago we had the Troubled Families Unit in. They said that they have done this sort of thing with boutique answers to tricky problems in lots of places around the country, but it was all a little bit informal—it was not properly mapped out. I wondered if there is any chance that there could be one simple model around all of this, which you can all agree is the best way forward, which you can roll out and which has a reasonable chance of working, rather than reinventing the wheel.
Sir Bob Kerslake
This is a very important question, I think, because when we came to troubled families, we did have some practical experience of the family intervention programme and that particular lead professional model, which we could draw on for the model that we were promoting to local government. We are still developing the models in relation to integrated health and care, but we do have the 14 pioneer areas—
Nick Smith
How many?
Sir Bob Kerslake
Fourteen. We will, in my view, learn about which of the various ways we can approach this is the best way to do it, and therefore have a more consistent model that we can see applied across the country. This year, I think, will be a year when we learn about these issues through those pioneers.
Jon Rouse
That is absolutely right. Can I just ask—I think we may have misheard you—how old you said your individual was?
Sir Bob Kerslake
Was he 70 or 17?
Nick Smith
No, he is a young man—he is in his early 20s, and he is in Wales. I haven’t had the session yet, so I didn’t want to broadcast all of that, but my office sent a few e-mails out, and 17 people are now coming to that session.
Jon Rouse
Just very quickly—I know you are looking to draw things together—I think the key intervention in England going forward will be the integrated education, health and care plan, which was part of the Children and Families Bill. Any young person with special educational needs, up to the age of 25, will have a single plan with co-ordinated care, again, underpinned by statute.
Nick Smith
He hasn’t got special educational needs, he is a young man who was a rugby player, and he got a back injury and is disabled from the neck down.
Sir Bob Kerslake
And he had 17 people involved.
Nick Smith
Yes, and six months after the case was brought up, it has still not really worked for him.
Sir Bob Kerslake
Okay.
Chair
I just want to ask you three questions. First, you are all talking about joining up at the local level through health and wellbeing boards. Why aren’t you joining up at the centre? Why not have, for example, an adult social care funding council, or something that really joins you at the centre?
Sir Bob Kerslake
I think we are really joined up. You are shaking your head, but as I said earlier, we are joined at the strategic level and have regular joint board meetings on these big issues. We have effectively a joint team working on the new Better Care Fund, so that team is working across Departments in a collaborative way. I think we are joining up. We have not gone for a big structural change, and I do not think that is necessary, but in every practical sense we are doing this as a joint process.
Chair
Let me give you an example, Sir Bob. In the new fund, £2 billion is going in from Health, or whatever it is—£1.8 billion, isn’t it? That is from the CCGs.
Jon Rouse
The whole of the money is going in from Health, with a small amount of disabled facilities grant, but—
Chair
The CCG money is £1.8 billion. The rest is existing budgets that you are just bringing together, isn’t it?
Jon Rouse
You are right to say that the new money is around £2 billion.
Chair
It is the CCG money. Okay. But it still counts in your NHS budget, doesn’t it?
Jon Rouse
It comes through the NHS budget, down into the pooled funds under section 75.
Chair
Okay. When I looked at the spending round 2013 documents, it showed up in the NHS budget, so the 0.1% real growth includes the money that is going to this. Then table 2.5, on the local government spending budget, shows that it is added in there. That is a cheat, bluntly. It is a double counting cheat. You are counting money twice, once as the money from Health and then again in local government spending. That sort of distortion of the figures—that is the kindest way of putting it—suggests to me that you would be much better just having one budget, really joined up, rather than pretending to local government that you are increasing the budget when it is actually already counted in the Health budget.
Sir Bob Kerslake
I don’t think it is distortion, Chair. What we were trying to describe here was a pooled budget that is available to tackle a shared issue.
Chair
It is counted twice.
Sir Bob Kerslake
It will be a benefit to local government.
Chair
It may be a benefit to local government, but it is counted twice in the figures in the 2013 spending round documents.
Sir Bob Kerslake
You are talking about the spending power point, aren’t you? That is not about where the funding is. Anyway, we will happily drop you a note on that.
Chair
Okay. I think it is a distortion, which is a bit unfair, and I think you would deal with it if you had a really joined-up system. One other question. On page 36, at the right of figure 15 there is a whole list of potential problems that could throw your plans for getting more for less completely out of kilter. What I want to know is—if you look at all those things on the right—what have you got structurally? How are you working your way through these sorts of challenges?
Jon Rouse
From our perspective, we have two pieces of apparatus that are important. First, I have an adult social care oversight board that reports direct to the departmental board, where I bring together relevant officers in my own team, CQC and CLG. We look at the risks to the system and work out what mitigation actions we need to take. We take a short lead and a long-term perspective on that. The second is about how we implement the care and support reform programme. It is a high-risk programme. We are quite open about that—it is an important programme and the Care Bill is a good Bill, but it is a complex implementation process. What we are doing there, which I am not sure has been done before, is that we have a single, completely joined-up programme management approach with the LGA and ADASS. There is one programme office staffed from all three organisations, which is doing the national implementation, the writing of regulations and guidance, the funding elements and the local implementation together as one programme.
Sir Bob Kerslake
I will add one point, which I made earlier, and reinforce it. We regularly have joint board meetings where we review progress on these risks and progress on the programme.
Chair
The other thing—and I say this from my experience of trying to do the integration when we were doing Every Child Matters—is that if you look at figure 18, you have such different cultures between social care and health. There is a highly professional health capability and a very low-paid, poorly trained social care capability. Bringing those two professional capabilities together into an integrated service is hugely challenging. We read in the Report that over half of GPs say that their relationship with social care is poor or very poor. It is a massive mountain to climb. What are you trying to do to bring those very different cultures together?
Sir Bob Kerslake
I think I said right at the beginning of the session that this is a very challenging agenda that will not be achieved straightforwardly. Our judgment is that it is more likely to happen and will be more effective if it is led at local level by the key partners. We are building in funding to catalyse that and placing expectations on the key partners about how they work together and drive it.
Chair
My experience of this is that it is a massive educational and training cultural change. If you haven’t got the money for it, it will fail, in the same way as quite a lot of the Every Child Matters agenda has not been pursued.
Sir Bob Kerslake
I would not for a moment say that this is not a big agenda. We have put money in to help it happen, but in the end, just as we found with Troubled Families, the best way we can get confidence about this is the fact that it is owned as an agenda by local authorities and it is in their interests and in their ambitions to make this happen. That is the most powerful way of doing this.
Chair
Finally, what keeps each of you awake at night on this one?
Jon Rouse
I’ll tell you what keeps me awake at night: it is the reduction in the number of users, which is what the Nuffield Trust flagged up. If you are in the system and you are receiving care, the indicators are pretty good. Satisfaction levels are up and quality of life scores are up. There has not been any real reduction in provision for those who receive high-intensity care. That is okay. But some people are not in the system and, for whatever reason, are not receiving care packages. Do we know enough about what is happening to them? Do we really know whether these preventative services and lower level interventions are making a difference, maintaining their quality of life and enabling their health and well-being? I worry about the unknowns, and we need to do a lot more research in that area.
Helen Edwards
I suppose it is the scale of the challenge. There is such a lot resting on this, and ambition for it is very high. Our Ministers are investing a lot of their personal time and energy in it. They want to create momentum behind it and create real change on the ground that makes a difference to people’s lives. We all share that ambition. As we have discussed today, some of the challenges involved are pretty formidable so, playing back to you, will we be able to make it happen in the way we want to?
Sir Bob Kerslake
I will finish. If anyone has studied the numbers for beyond 2015, then if we think the last period has been challenging, we still have quite a long way to go. Getting to 2015 is not completion of the task. The challenges will continue and we will have to raise our game even further to deliver the figures that we see in those numbers.
Chair
Thank you. Oral evidence: Monitor, HC 1119 34