Community Care
We now move to item 15, under which—thank goodness—we will discuss community care.
As members know, we have gone a long way towards setting our agenda according to what we think is important. There was a great deal of support for an examination of community care. We will have a general discussion about the issues that come under the community care umbrella. I thank Murray McVicar and Morag Brown for the research notes that they produced for us. Last week, I was told that they would not be able to do that, so I appreciate that they have made a real effort to give us something on which to base our discussion.
I hope that at the end of our discussion we will have some idea of the direction and remit, and of the aspects of community care that we are interested in examining. That will be helpful for our choice of background reading and will enable us to give specific research topics to the researchers.
As we want to examine community care and the Sutherland report, our consideration should be in two sections.
First, we must examine community care at present, particularly in terms of the funding to local authorities. It is difficult to get information about the number of people on local authority waiting lists for long-term residential or nursing care as, I understand, the figures are not held centrally, but must come from each local authority. I suggest that, to start with, we undertake a trawl of local authorities to find out how many people are on waiting lists for long-term residential or nursing care, and what the funding is.
For example, I know of a local authority that has 113 people on a waiting list and which has the funding to place only four people a month. We need such information, so that we know the real state of affairs and whether there is a crisis in placing people. That concerns disabled as well as elderly people. One can see from the briefing that mental health organisations are involved. Bed blocking is the emotive issue. Let us consider the situation by local authority and establish what the problem is in Scotland.
Secondly, many people believe that the way forward in the funding of community care is to follow the recommendations of Sir Stewart Sutherland's commission. We will want Sir Stewart to give evidence to us, and we will also want to talk to people who are involved with mental health associations and Age Concern. We should talk to a selection of directors of social work—we cannot meet all 32—from differently sized rural and city authorities, to find out what the problems are.
At the Labour party conference, Sir Stewart Sutherland made the alarming statement that £750 million that is allocated to care for the elderly in the UK is lost. We do not have a Scottish figure, but I have lodged a written question on the matter.
We must consider the interface between councils and the NHS. We need to ask why more than 1,600 patients are lying in beds in acute hospitals in Scotland, costing between £700 and £1,100 per week. That clogs up hospitals and waiting lists. Those patients could be cared for in residential homes or in the community at less than half that cost. That would alleviate bed blocking.
As well as considering the care providers that Kay mentioned, I suggest that we hear from the Scottish Association of Care Home Owners, which is a good example of public-private partnership. I would also like to consider good practice. In Monday's Edinburgh Evening News, I was pleased to read that Lothian Health is uniting the funding of social work and the NHS to provide a single budget for care of the elderly. That will ensure that the patient really is at the heart of the health service.
Mary's key point is that we need to ensure that people receive the appropriate care. There has been a tendency for people to think that politicians who discuss bed blocking and so on simply focus on the financial aspects of care; the crucial issue is the appropriateness of care for the individual. Many people in acute hospital beds would, with some support, be able to remain in their own homes with their families, or they could have another form of residential care.
We must be careful not to pre-empt our investigation into the delivery of community care. Bed blocking is a very emotive term. Community care must be needs led, rather than resource led. People are left in inappropriate hospital wards because—if there are more than 100 people on a waiting list and only four can be moved each month—local authorities and social work departments give priority to people in the community as people in hospital are seen to be safe, if not appropriately placed. The bed blocking continues because of that.
We must make a list of people from whom we want to take evidence. Mary mentioned that the Federation of Small Businesses has a private nursing home section that might give us some useful information. There are also local authority residential homes, Church of Scotland homes and various other Churches that are involved in the provision of care for the elderly. It will be a big list.
We want to hear from organisations such as Age Concern and the mental health charities. It will be an extensive list, because there is a large client group of people with different types of disabilities, such as dementia, but also HIV and AIDS, and drug and alcohol problems.
It is important that we hear from carers. The committee should put on record the great debt that Scotland owes to the thousands of people who care for relatives and friends. Those people save us an incredible amount of money and make the lives of the people for whom they care immeasurably better. I want to take the opportunity to mention young people who care for their parents at the same time as going through the difficulties of growing up. We should try to listen to what carers organisations have to say about the issue.
Sir Stewart Sutherland has made recommendations on caring about carers.
I should begin by declaring interests. I am still the director of a nursing home company, albeit one that does not operate in Scotland. My son is a health service researcher and published a paper in Health Bulletin in March on the subject of inappropriate placement of patients. The paper gave a conservative estimate of the costs arising from inappropriate placement of £41 million per year.
As Kay said, the money is the lesser of the two problems. Obviously, it is a problem that we cannot avoid and, being responsible for the public purse, we should try to use money as best we can. However—and here I disagree with Kay—hospitals are not safe. They are perceived as being safe, but they are not. Of course, staff do their level best, but inappropriate placement leads to two problems for hospital patients. First, they run the risk of infection and, secondly, they run the risk of institutionalisation and dependency, which makes it more difficult to maximise their potential thereafter.
I want to know what funds have been transferred from health boards to local authorities as part of the closure of long-term-stay beds. I also want to know what proportion of that money has been used for nursing home accommodation, for part IV accommodation and for home care packages. The main thrust of the Government's—and now the Scottish Executive's—policy on community care is that everybody should be managed at home if at all possible. We need to know whether some of the waiting list crises have arisen because there is not enough money or because there are not enough staff with the right skills to undertake home care packages. We must find out what is actually causing the block, and we must not make too many assumptions until we know what it is. A lot of money has been transferred, but we need to know how much.
There is another side to the coin. If a health board closes a unit or a hospital, the savings that are made are quite substantial. If it closes a few beds in a ward, the savings are much less. We need to know the total savings, how much has been retained by the health board and what the health board has then used that money for. I have heard that up to 50 per cent of the funds have been retained by health boards. That might not be inappropriate, but I do not have a feel for it. If the money is being used to support other services that are not in the community, that might be part of the problem about transfer.
We need to examine those detailed issues. We also need to review the vacancy monitoring arrangements for nursing homes and part IV accommodation in the private, independent, voluntary and local authority sectors. In the past week I have obtained documents about that, but we need a researcher to examine those documents and compile them so that we have a view from 1993—when the Community Care Act 1990 came in—of what has been happening in terms of placement trends. The document has been difficult to review because of the changes in the local authority system. It used to be based on the regions but has now been transferred to individual authorities and, at the point of the change, the tables have been altered. I am sorry to go into so much detail, but we need someone to review that.
Richard, you may recall that, at the previous meeting, I said that we will have access to an intern from the University of Edinburgh who will do some research for us for 10 weeks. The full-time research staff will keep a watchful eye on this issue as well. We will need a lot of research, and it will be useful to have another person who will be able to work full time on this project for the committee, as that will mean that we can probably accommodate it.
My final point follows on from Mary's point. The management executive and the social work services group between them should be able to give us illustrations of good practice, and we should ask for that. For example, I understand that, in Aberdeen, one of the long-stay hospitals was about to be closed but, instead of closing, its management was transferred and the social work department and the health board now jointly manage it, which means that there is a safety valve on the acute system. Along with Mary's example, that makes two examples and we need the social work services group and the management executive to give us more examples of good practice.
There are some examples in the document that contained proposals on community care, which was produced earlier in the year. We need to understand those proposals and to assess why good practice is not being rolled out, if that is the case. Is there a mechanism that the social work services group and the management executive can follow, to ensure that local authorities, health boards and trusts take up good practice? How are they held to account to ensure that good practice is followed?
For the record, I did not say that hospitals were safe places. I said that local authorities see them as safer as opposed to housing someone in an inappropriate home.
I am pretty certain that the term "part IV" is no longer used. Perhaps it was known as part IV when Richard and I were both involved in the delivery of community care services, but now people refer to residential accommodation as opposed to nursing homes.
I hope, Kay, that by the time that we have finished with this, we will be complete experts on such matters.
Yes, we will be experts on jargon.
I back up what Richard said about resource transfer and the problems that surround that approach. A couple of years ago, one of the organisations involved with the elderly—it might have been Age Concern—produced figures that showed a great variation in the amount transferred for a bed from health board to local authority. The amount could vary from about £8,000 to £32,000. It seems that there is a need for national standards and guidelines; we should examine the issue of resource transfer.
I want to put down a marker for inviting to the committee professional social work organisations, such as the British Association of Social Workers, the Association of Directors of Social Work, Unison, the British Medical Association and the Royal College of Nursing—the list is almost endless.
It has been brought to the attention of the conveners committee over the past couple of weeks that quite a lot of our housekeeping discussions are going on the record because the official reporters are present. If everyone is agreeable, towards the end of this discussion, I will ask the committee to continue the meeting without the official reporters, when we can discuss who we want to invite to the committee. That means that the official reporters will not have to spend time writing up our discussion and it will free up the official report's time, which is quite precious.
We are still in public session, but we will come back to those issues and take everyone's suggestions when the official reporters have left.
We have a massive subject—our usual problem. We must try to focus on certain aspects, which might mean making some hard decisions.
The two main areas of community care on which the committee should focus are care of the elderly and mental health, which would open up general issues such as appropriateness of care, funding and co-ordinating social work and health. There are other pressing reasons to examine those areas. Although I should not need to explain why we should consider care of the elderly, we have to take into account the Sutherland commission and the winter problems that always arise. Mary referred to Sir Stewart Sutherland's comments about how much local authorities spend on the elderly.
The issue of mental health was raised in the committee two or three weeks ago in relation to acute beds. I am told that an interesting Accounts Commission report is coming out in November, which I believe will flag up how money from the closure of mental health beds has not always been spent on mental health. Mental health issues such as funding, the appropriateness of care and co-ordination will form a large agenda for the committee. Obviously, as we know what the issues are without knowing the answers, there is no point in repeating matters. We need to find out about the many funding issues that are involved in care of the elderly, such as resource transfer and the earlier Department of Social Security transfer.
My positive feelings about community care underlie all that. Those issues will open up the whole argument about whether bed numbers are the key issue. Appropriate care in the community would take a lot of pressure off beds and would, in fact, be my approach to the recent controversy on acute psychiatric beds. I hope that we can find out a lot of information, some of which—such as the amount that local authorities spend on the elderly—is not in the public domain. As there is a long way to go in co-ordinating social work and health, perhaps we can also make a positive contribution to more constructive work at local level.
That includes a wide range of different issues. Over the coming year, we will be able to see how the new health care co-operatives deal on the ground with local working. From our papers, I notice that there is a need for better working practice in many areas, between the health service and social work. We need to get the message across about joint training and student training, so that people are not as isolated in their professions as they might have been.
I know anecdotally that the issue of hospital discharge is of great concern. It is felt that hospitals are discharging people without realising the difficulties that they might face when they get home. There should be a seamless transition from hospital to the next stage of recovery with, for example, joint assessments. Those of us who have been involved as councillors know how difficult it is for people to receive assessments of care in a reasonable period. It is almost a form of rationing. People are not having the relatively inexpensive alterations made to their housing—for example, to baths and showers—that will allow them to stay in their own homes. If such inexpensive alterations are the difference between people staying at home and going into residential care or to acute hospital beds, perhaps we should examine that issue.
That impinges on housing, which comes up in a number of the areas that we are examining. We should ensure that as much of our housing as possible is free of barriers to the elderly and people with disabilities. That should include not only people's own homes, but the homes of people they visit. In my experience, assessment and the consideration of ways in which people can make their homes more accessible are relatively inexpensive investments. I would like to ensure that we cover that.
I take on board Malcolm's comments on care of the elderly and mental health—those are probably our two key issues. In discussing them, we will come across the other issues, such as co-ordination of services, resource transfer and so on.
I could not agree more. Being a fresh Parliament, we can make a fresh start and get away from some of the old prejudices. The worst prejudice was—or still is—age discrimination. We should concentrate on trying to help the elderly, their families, and people in Scotland who have someone to look after. That would involve better inspection of nursing homes, private or otherwise, talking to families and paying particular attention to carers. Carers should be asked about their own case histories, although Sutherland covered some of that. Through my work in that area, I have encountered carers as young as six—we must not just make nice noises and pat them on the head.
We have to help keep the elderly on their feet and active for longer. However, that means more home care; we must look at the home help service, which has been cut so much that many people are receiving only half an hour twice a week if they are lucky. Half an hour is not enough. I would like to concentrate on the young and chronically sick, and to try to be of some use to those with multiple sclerosis. That is an area in which we could make a difference early on.
We want the public and patients to be whistleblowers—to be able to clype on bad services. I will give you a brief anecdote about a young woman in Scotland who was aged 32 and had had multiple sclerosis for about four years, for most of which time she had been in a wheelchair. She had deteriorated quite rapidly and had had to give up a good career in banking. A local charity purchased a super-duper electric wheelchair for her. She was promised help to learn how to operate it, not by the charity but by her local health board. The person who had been sent delayed the appointment twice—when the young woman was up to high doh waiting for someone to come—and finally turned up and said, "I have only half an hour until the next appointment." That was not enough time for the patient to be shown how to work the complicated chair. It is still in her garage, just for lack of that bit of efficient care.
People should be given help with employment and encouraged in every possible way, to lift the depression suffered by people with multiple sclerosis and their families. ME is another example—we could go on and on about such issues.
Let us not go on and on. I mentioned the housekeeping part of our business earlier. I have been instructed that we should bring the formal part of the meeting to a close and then—in public—discuss which people we would like to hear from. At that point, Dorothy can suggest organisations that are dealing with particular complaints, disabilities and so on. We will still be in public—and in committee, if you like—but the official reporters do not have to spend their time listening to that. We should return now to more general topics.
The key point that has been raised in connection with community care is care of the elderly. We will be considering the Sutherland report.
The mental health issues on which we broadly agree are resource transfer and the funding of community care, and the need for co-ordination of care between the health and social work services.
If we accept those matters as part of our remit, at the end of the meeting we can discuss among ourselves the groups that we want to invite as witnesses. We will probably unintentionally miss out some people, so we will also put out a general call for written statements from anyone in the field who wants to contribute.
Until we have a better idea of our work load, we should not set a timetable. This is not going to be a quick fix—if we are to do this, we will do it properly and well.
It seems that we will be working on Arbuthnott intensively for two or three weeks after the recess. It is perfectly normal practice, even in this Parliament, to ask for written evidence first. Why do we not put out a call for written evidence to be submitted before the end of October? Then, at the beginning of November, we could decide from whom we want to take oral evidence. As far as I can see from our timetable, we will not be able to hear oral evidence until mid-November.
If there are key people from whom we definitely want to hear, we could give them prior notice.
Sir Stewart Sutherland?
Yes.
We are all agreed that we want to hear from him—he is my constituent.
We should set the ball rolling. That will allow our back-up team to make some initial contacts.
Do you want names now?
No—we will do that after the end of the meeting.