UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 832-i

House of COMMONS

MINUTES OF EVIDENCE

TAKEN BEFORE

HEALTH COmmittee

the responsibilities of the

parliamentary under secretary of state for care services

THURSDAY 26 JUNE 2008

MR IVAN LEWIS MP and MR DAVID BEHAN

Evidence heard in Public Questions 1 - 90

USE OF THE TRANSCRIPT

Oral Evidence

Taken before the Health Committee

on Thursday 26 June 2008

Members present

Mr Kevin Barron, in the Chair

Sandra Gidley

Dr Doug Naysmith

Dr Howard Stoate

Dr Richard Taylor

________________

Witnesses: Mr Ivan Lewis MP, Parliamentary Under Secretary of State for Care Services, and Mr David Behan, Director General for Social Care, Department of Health, gave evidence.

Q1 Chairman: Good morning and welcome. For the record, would you give us your name and the position that you hold, please.

Mr Lewis: I am Ivan Lewis, Minister for Care Services.

Mr Behan: I am David Behan and I am the Director General for Social Care, Local Governments and Care Partnerships in the Department of Health.

Q2 Chairman: Thank you very much indeed for coming along. We are doing our oversight of ministerial positions as well as inquiries into issues around health and social care and this is the first session we have had certainly this year, so welcome. I have a couple of questions on the overview and proposed Social Care Green Paper. Why is it that, after 11 years, the Government are now committed to a radical rethink of social care? Is it really an admission that the Department has until now got social care policies wrong?

Mr Lewis: I think that there are a number of issues. First of all, thank you very much for giving me the opportunity of appearing before the Committee. I know that it is not an entirely voluntary arrangement but, as a former member of the Committee, I am really pleased to have the chance to talk about some of the issues that may be are traditionally more Cinderella in the world of health which is social care, mental health, etcetera. In a direct response to your question, I think that it is very important that we start with some of the things that we have actually done because there is a danger that people say, "In terms of social care over the last 10 or 11 years, nothing has happened", but I would actually challenge that contention. We put in place for the first time national minimum standards and we set up CSCI which has done a tremendous job in raising standards overall in the sector. We did, as a consequence of the Royal Commission, introduce free nursing care and we introduced the deferred payment scheme and, although the general perception was that the Government ignored entirely the recommendations of the Royal Commission, that is not totally true. In 1999, we introduced the first ever Prime Minister's Carers Strategy which has meant annual grants to every local authority to support carers. In 2007, we issued new national guidance on continuing care. We have published Valuing People to really try and improve the life chances of people with learning disabilities. We have invested in specific grants in quite a lot of technology to support people to live independently. We set up the General Social Care Council to professionalise the workforce and Skills for Care to improve training and development. We have introduced the Putting People First reform programme which no doubt we will talk about a little later and local area agreements are driving health and local government closer together in local communities. I have asked CSCI to review eligibility criteria. We are extending the Dignity in Care Campaign. We are launching this year the first ever National Dementia Strategy. We are making sure, as originally intended, that the Human Rights Act should cover publicly-funded residents of private care homes. We are reviewing the guidance about the protection of vulnerable adults and, in the next few weeks, we are going to publish our first ever End of Life Strategy. As you know, a couple of weeks ago we published a ten year New Deal for Carers and we are working at the moment on renewing Valuing People in terms of people with learning disabilities. From April for the first time, PCTs and local authorities have a requirement to do joint population needs assessments in terms of their local communities to inform commissioning decisions and of course Lord Darzi's report which is imminent. One of the things that is absolutely crucial about the next stage of the NHS is a recognition that, for many of the people who use the NHS, there is the interconnectivity between health, local government and the voluntary and private sector that makes a difference to their health, well being and quality of life. All of that is a pretty robust track record of response to the social care challenges that we face, but it is also true to say that there are a number of things in the big picture which require a fundamental review and renewed look and a more honest dialogue with the people of this country and those are the demographic realities that we face; the consequences of an aging population for families, for society and for Government; the fact that people's aspirations and ambitions are completely different in terms of what they want from care and support now than what they wanted maybe 20 years ago and certainly the baby boomer generation will expect a very different system to the one which previous generations have been willing to tolerate. Add to that the perceived inadequacies of the existing system; the fact that the system is incredibly complex to access for many people and that it can be over bureaucratic; there is not high-quality information and advice; too many people who are being expected to fund their own care are left on their own; the use of eligibility criteria which I believe has had a whole series of unintended consequences; and that, in many local areas, despite the fact that the real Berlin Wall came down, we still have a Berlin Wall between the different agencies involved in delivering health and well being services more generally. Finally, two things: the affordability and sustainability of this system long term. How are we going to pay for it? Not just how are we going to pay for it in terms of the demographic realities, but how are we going to pay for it in terms of giving people what they have a right to expect. It is not just about demand, it is also about quality in the future. Also, the perceived unfairness in the existing system. If you have a very low income or you have been on benefit for most of your life, social care will fund to 100 per cent basically the cost of your care. If you have worked hard, played by the rules, done the right things, saved a bit of money and have maybe a small pension, you are not rich or not poor, you can end up paying for all of your care. Therefore, understandably, people feel a sense of unfairness particularly when, for many people, they do not actually realise that, in 1948, the settlement was that social care would be means tested and the NHS would be free. The perception is that the State will provide when you get into your latter years and you need help. We should not also forget that social care tries to do a lot of things. It is not just about older people, it is about ensuring that disabled people have the chance to be independently and as equal citizens; it is about the fact that we have a growing number of people with long-term conditions and it is about making sure that people with mental health problems have the chance to have decent lives. I think that the other reason for this new look, this fresh look, this far more fundamental review, is that this is not just about older people. All the work that has been done around Oneness and the other inquiries has said that we need to look at the consequences of the growth in the over 80s and over 85s going forward. What is exciting about this and ambitious about the Green Paper process is that it is about all adults and what I want it to be is an equivalent to Every Child Matters. I want us to have an Every Adult Matters approach to these issues and, in the same way as we have understood in the early years that you need to intervene early and that you need to prevent, we need to move the system, health and social care and other well being services, from a system which only intervenes when people become very dependent to a system which actually prevents and intervenes at the earliest possible stage.

Q3 Chairman: Is it going to look at issues like, what many people believe, the artificial separation of health and social care costs? Will that be one of the things that we can expect?

Mr Lewis: I think that we have to look increasingly at the fact that when you talk to people who use the system and their families, the point they make time and time again is, "We don't experience a joined-up integrated response. We have numerous professionals. We don't know where to go to get help. We are passed from pillar to post". Therefore, we do need to move at a local level to more integration. The Putting People First reform agenda places explicit responsibilities on councils and the health service to work together with the private and voluntary sector and carers and users in every local community. I hope and I believe that Lord Darzi's report will go further and talk about the need, if you are going to achieve your NHS objectives going forward, to have to have a much closer relationship with other agencies. I also believe, as you said, that the review of care and support has to increasingly think about a system which focuses on the personal needs of either the individual or the household where you are talking about a carer situation rather than look at the system from the point of organisational silos.

Q4 Chairman: Looking at things in a comprehensive way, I do not think that any member of the Committee is going to disagree with that in view of what you have outlined. Why is it that, since the publication of The Case for Change, the Department has begun a consultation exercise? Why is that taking place before the publication of the Green Paper? You have just described the breadth of it all and how it is going to encompass what has not been covered in the last decade.

Mr Lewis: For a number of reasons. First of all, I think that we have a massive information job to do, not just for example with this generation of older people but with the baby boomer generation and indeed younger people, about the nature of the existing system and why it has to change. Until you have that kind of information and that kind of dialogue with people, to have a public debate and to get people to face up to some of the really tricky trade-offs and difficult choices is incredibly difficult.

Q5 Chairman: We have always had that, have we not? We have had the UK comparisons about costs of healthcare versus social care in different ... We have been having this debate for years. Do you feel that to have this debate prior to the publication of what we believe will be a very wide Green Paper that is going to cover all the areas that you have suggested to us have not been covered in the last decade is the right thing to do?

Mr Lewis: I do believe that because I believe that, by going around the country and talking to people, by opening up the debate, by making it clear that this is about older people but it is also about disabled people and people with long-term conditions and it is about families and carers, but also it is about making some really difficult choices which are not just about ... The headline is always "The £6 billion black hole. How are we going to pay for it all?" Actually, the other headline should be, "What kind of system do people have a right to expect in terms of quality, in terms of personalisation and in terms of prevention?" I think that there is a great deal of value and a great deal of worth in engaging the public in a far more meaningful debate and making it clear that this is not a wish list, this is not "you can have everything you want". When you sit with people who use social care and they say that they either want a much greater level of State subsidy or they want things to be free rather than to be paid for, when you then sit in the next room with them and they appear as taxpayers rather than users of the system, they say, "Actually, I am not prepared to pay any tax. I feel that I pay too much tax". It is important that politicians are honest and I welcome the fact that for example none of the mainstream political parties are now claiming to people that this can all be free, that personal care can all be free. The Lib Dems have had that in their manifesto for the last two or three elections. They no longer claim that that is realistic and they are being honest to say that. The Conservatives do not claim that you can offer people everything free and, if you examine the detail in Scotland and the realities of what is happening in Scotland, we know that it is not free but, worse than that, we know that there are a number of unintended consequences of implying that it is free such as waiting lists to access services shooting through the roof. I think that we have to use the period as an information period but also as an engagement period with people. You have essentially the State, you have families, you have individuals and you have communities and what we have to feel our way through in this whole debate is, what are the respective responsibilities financially and behaviourally of each of those players? What do I mean by that? To give an example, we always look at social care in terms of highly professional statutory formal services, interestingly 75% of which are provided by the independent sector and not by the State and a number of people do not realise that out there either. When we have debates about care homes, I think that most people assume that they are run by the State local authorities. The point I was going to make is that we tend to look at the system entirely like that. What about the contribution of volunteers, of community networks and of informal networks to support older people to have a decent quality of life? It is not just about formal and traditions ---

Q6 Chairman: There are many charities in my own constituency that help in areas of social care in terms of daily things, not necessarily dressing and feeding but in terms of keeping people active.

Mr Lewis: And I am not suggesting that.

Q7 Chairman: When is the Green Paper going to be published?

Mr Lewis: In early 2009.

Q8 Chairman: What is early then?

Mr Lewis: It could be January, it could be February.

Q9 Chairman: Do you think that it will be before March?

Mr Lewis: I think so. My birthday is 4 March, so that might be a good day.

Q10 Chairman: What is the timetable following the publication?

Mr Lewis: We have not made any decision on that yet.

Q11 Chairman: Why is that? Is it because if you clearly know the outcome, you do not know exactly what you are going to recommend or not?

Mr Lewis: I think what is quite unusual about this process is that there is not a Blue Peter prepared earlier end game. There are many consultations and there are many engagements where essentially you know broadly the final destination. I think that, on this issue, there is a whole range of choices, of dilemmas and of issues that we have to address. Therefore, to be absolutely clear about it, once we have finished the consultation in November and we publish the Green Paper early next year, to then say that the White paper and the legislation will come by the following date ... Then of course we will be accused of raising expectations and letting people down if we cannot honour those timescales. At the point that we publish the Green Paper early next year, we will also lay out the next stage of the timescale in terms of a White Paper, for example.

Chairman: We might want to test one or two of those areas.

Q12 Dr Stoate: It is nice to see you, Minister. It is good to have you in front of the Committee as a former member. Thank you for coming along. I want to talk about something that Age Concern has raised with us and I quote from them. They said, "... so far much of the conversation has been about possible financial models. We would like assurances that improvements in quality will be the focus of any reformed system". What is it going to be? Is it the creation of financial models that you are concentrating on or will it be genuinely about improving quality of the service?

Mr Lewis: It has to be about both and the starting point has to be the nature of the service that people and their families have a right to expect from a care and support system. We have made it very clear that this not about tinkering with the existing social care system. This is about a new ambitious vision for care and support. What are the ingredients? A system which is easy to access, a system which is high quality and personal, a system which supports people to have maximum independence, power and control over their own lives and a shift to prevention and early intervention. Those are the elements of the kind of system that people have told us time and time again they want and expect and those are the kinds of things that they feel are often lacking from the existing system. This is the problem with the debate thus far. When people have talked about a £6 billion black hole, they have talked about only older people, they have not talked about disabled people or people with mental health needs; they have not talked about the fact that the £6 billion figure that Oneness identified is purely based on us offering the same level of support as we offer now over the next 15 or 20 years. Most people are incredibly dissatisfied with the nature of the existing system. So, the first point that we have to resolve is the quality and the nature of a model care and support system recognising that it is not just about also what the State can do for you. It is much more a view of a partnership approach between State, family, individual, communities and I think employers because, if you think about the number of people who are going to be in the workplace where, over the last 20 or 30 years, maybe the issue has been childcare, increasingly for families, the issue is elder care and this requires an entirely different view. So, the starting point is, what kind of system do people have a right to expect? Once you are clear about that, you can build on some of the economic modelling that has already been done and then you can talk to people about what the appropriate way of sharing responsibility behaviourally and financially is.

Q13 Dr Stoate: What I want to talk about now is the Putting People First policy which was published in 2006 which sets out to my mind a very ambitious timetable for making "significant progress" in adult care by 2011. What progress has been made to date?

Mr Lewis: It is June now and local authorities began putting this into practice on 1 April. If you want my honesty, I suspect not a lot. We need to understand that this is building on work that has been going on in some local authorities anyway. We have had the 13 local authorities that have been doing individual budget pilots. We have had the authorities that have been working with the Social Enterprise in Control around giving disabled people a far greater level of control and power over their own lives and over their own care packages. There are some local authorities that have already begun to recognise the weaknesses and limitations within their existing system in terms of the way self-funders are treated and in terms of shifting to prevention and early intervention. There has been what is described as the Pops(?) pilot for older people looking at the benefits of shifting services to prevention and early intervention from only supporting them when they are dependent and, in places like Knowsley, we already have a far more integrated approach to health and social care with joint deployments of Chief Executives of PCTs and local authorities. So, it is not entirely come out of the blue. Let us be frank about it. If you say, "We'll have a few pilots and then we'll have some trailblazers and then we might have a bit of change and then we might see the system improve", well, I am not really that kind of Minister. In my view, there is an awful lot that can be done with this system within the constraints of the existing resources and it can be done a whole lot better than is being done at the moment. The idea that people are told, "If you have £21,000 a year, you are on your own; here is a list of some care agencies; go and sort it out yourself" is outrageous. That was never the intention of the community care legislation and is nothing to do with resources. If you go down the local authority office and you say, "My mum is not going out very much anymore; people don't seem to be visiting here; she is lonely and isolated" and you are told, "Sorry, that is low level need; there is nothing we can do for you here", the "no help here" culture, when on earth did we ever say that that was the basis on which social care or well being services should be offered? The final point I would make to you is, in a way, health and social care integration is an outdated ambition. It is health and well being. It is all of the services that are commissioned by the local authority from culture, from leisure, from the parks, from the libraries and from the quality of life services. It is bringing all of that together to support people to have the best possible quality of life and it is also about the third sector and the private sector. I am quite perturbed by the fact that local authorities now seem to believe that if you have a commissioning relationship with organisations that are providing services as part of a contractual or commissioning or business relationship, you have to keep those organisations at arm's length in terms of planning improvements to services. This is not the case. You can have a commissioning relationship with provider organisations and equally treat them as partners in terms of coming up with some of the solutions. Seventy-five per cent of social care is provided by the private or the voluntary sector. So, for the local authority to sit there and play big brother with the independent sector is inappropriate. There needs to be far more partnership working. We also need your colleagues, frankly, in terms of GPs and other health professionals, to recognise that social care is a major part of the solution in terms of prevention and early intervention and, rather than writing people prescriptions, sometimes putting them in touch with social networks when they are lonely and isolated and beginning to deteriorate would be far more useful than putting them on antidepressants. The point I would make also in defence of your profession is that often the response they get from social services is very inadequate. So, when you have an older person or you have a family that need an urgent intervention or urgent response, frequently, it can be very difficult to get hold of the lead professional within the local authority who is actually going to take responsibility for organising packages of care and making things happen. So, it is about saying to professionals, "Let's put to one side professional boundaries and professional titles and let's focus ruthlessly on the needs of the individual person and, where appropriate, the family unit".

Q14 Dr Stoate: That is all very optimistic and what you are saying is wonderful but it is also remarkably ambitious. The fact is, you set a target by 2011 and you have come up with a whole series of things that you want to see local authorities doing, but are you confident that they can do it and equally what levers are you going to pull to make sure that they all do it?

Mr Lewis: I think that is fair. Let us focus on what we have asked them to do. First of all, we want them to shift to prevention and early intervention and I think there is a real appetite to move the system in that direction both in health and social care and it is also more cost-effective as well as being sensible in terms of people's quality of life. We want them to offer universal information and advice to all including those who fund their own care. That is not rocket science. There are numerous organisations within every local authority which provide different kinds of information advice. Why can they not bring that together so that it is an easy to access system?

Q15 Dr Stoate: I agree with you but the point is, have you actually spoken to GPs about what happens when you try to get through to social services on a Friday afternoon and why it is that GPs often have absolutely no alternative?

Mr Lewis: In my opening response, I did say that GPs need to work better with other professionals and I equally mentioned the frustration that GPs often face - I did say that - when you do not find ---

Q16 Dr Stoate: But what are you going to do about it? The point of the matter is, as things are at the moment in the current culture, if you speak to any GP in most towns around the country, they will say, "You try and getting the relevant social services person when you want them". What are you going to do about that?

Mr Lewis: First of all, the Primary and Community Healthcare Strategy that will be published alongside Lord Darzi's final report will of course major on the relationship between primary health care and social care. That is commonsense. So, that will begin to drive change; the fact that health and local government for the first time by law are required to do joint population needs assessment; the fact that in many localities now a focus on low area agreements is health and well being outcomes, health and well being objectives; the fact that I think it is about 80 local authorities in terms of their priorities within area agreements have opted for the way they treat carers as being one of the important issues; and also giving people what is described as self-directed support which basically is the whole personal budget agenda. There are lots of levers in the system actually with Putting People First but also with Lord Darzi's report. You will see of course the NSH constitution in due course as well. I have to say that, as well as those levers and incentives, there is local leadership, there is a willingness to put organisational and professional preciousness to one side and, in some of our communities, there is some really exciting integration that has been taking place. Long ago, the Chairman championed the issues to do with older people and so-called bed-blocking in hospitals which was really about delayed discharges. There has been massive progress in terms of that situation where people were inappropriately staying in hospital for far too long. So, it is building on some progress. I would also say to you very honestly that there remain barriers that have to be removed. Some of them are legislative, some of them are cultural and some of them are attitudinal. For example, people will say that one is a means-tested system and one is free and there will always be a tension there because of that. My response to that would be, "Yes, there will always be a tension, but that in itself is not an excuse or a reason for not having a joined-up approach around the needs of individuals and families". The final point I would make on this is the opportunity is presented by personal budgets. We know about personal budgets in social care, but of course the ambition of a vision for personal budgets is that you maximise the number of funding streams that can go into a budget that is focused on the needs of an individual and a family. The Secretary of State and the Prime Minister have opened the door to the notion of health funding also over time being part of personal budgets. For example, for people with long-term conditions, if you can bring together some health funding and some social care funding, put it in a single budget and give the patient a lot more control with a family where appropriate, that is surely going to achieve much better health and well being outcomes than the existing system which is very much organised around the bureaucracies of the organisation.

Chairman: We are going to move on now to previous reports of the Committee. I have to say, Minister, I am pleased to see that you have not lost your skills at cross-questioning witnesses although you have left the Committee, in terms of general practitioners anyway!

Q17 Dr Taylor: Minister, now is the chance to address delayed discharges. You have already mentioned that there have been improvements and certainly the figures we have from September 2001 to March 2008 are that the number of people aged 75 delayed in hospital declined from 5,600-odd to 1,600 and it was just because they were so bad that we conducted the inquiry into this in 2002. How do you think this has been achieved? What has led to this improvement?

Mr Lewis: I think that it is clearly, again not to be too negative but to be positive, that there have been improved relationships between local government and the NHS on the ground. I think that that has to be one of the major factors. Some would say that the threat of fines and the jolt into the system focused and exercised people's minds, but I would also like to believe that most professionals want to do their best by patients and nobody wants people to stay in hospital any longer than they should do and in fact we all know that, if people do end up staying in hospital longer than they should, those people will often deteriorate and become less well. There is no doubt that there has been an improvement in relationships on the ground. I have a slight concern that the debate about the relationship between health and social care is usually about PCTs and local authorities. For me, at the sharp end, the relationship between provider Trusts and local authorities is really important and we must not take our eye off that ball and we must not take our eye off that ball as we move towards population needs assessments joint commissioning. There is also that relationship between provider Trusts and local authorities with regard to preventing admission to hospital and making sure that, when people are in hospital for too long, we do something about it.

Q18 Dr Taylor: There were several suggestions that we made. One was the actual management of discharge and you could use the toolkit I think in 2004 with ten strands. Do you think that that has been taken up? Is the management of discharge better? Is whether they are using the toolkit or whether the management of discharge is being efficiently handled something that the Healthcare Commission actually picks up on?

Mr Lewis: Yes, that is one of the things that is undoubtedly looked at. I would say to you that of course the toolkit has made a difference and of course the sort of threat of punitive action has made a difference. I would also say to you that it is still patchy. I think that in some areas it is still better than others in terms of those discharge arrangements and, if there were many people watching this hearing, there would still be families who would probably contact us saying that they have had very unsatisfactory experiences, but I would say that there has been a whole series of factors, including the Healthcare Commission, CSCI, the guidance that we issued, the threat of financial penalty, and just simply best professional practice, professionals wanting to get it right and good leadership on the ground that has made a difference.

Q19 Dr Taylor: Do you have any measure of the number of people who have been discharged prematurely or too hastily because I am sure that all of us occasionally get complaints about people who are discharged on a Friday afternoon requiring GP services over the weekend which of course do not exist.

Mr Lewis: There are figures. I do not have them to hand but I can get you them. There are figures that suggest that there are people who are readmitted very quickly, which raises questions about whether some of these judgments that are made are inappropriate judgments. There is evidence. What is more difficult to prove is, what is the problem? Is it that the care package that has been created is not up to scratch or is it that the person is not well enough to go home or go into intermediate care? I suspect that in some communities we still do not have the capacity for example with regard to intermediate care services and that we desperately need to get this right. There are figures, I do not have them to hand but we can get you them.

Q20 Dr Taylor: One of the other things was to avoid inappropriate admissions. Again, are there any figures to say that we are avoiding inappropriate admissions better than we were?

Mr Lewis: Yes. I am not sure if there are hard figures but there is all sorts of evidence that increasing numbers of older people are being supported to remain in their homes quite successfully and the danger is that we only present social care in a deficit mode. We talk about care homes that neglect old people and we talk about old people living lonely and isolated lives, but there are a tremendous number of older people who are supported very, very effectively and successfully within the community and, as a consequence, are not admitted to hospital. We do have some modelling evidence from the Pops pilots in X number of local authorities - and again we can get you the hard-edged statistics as much as we have them at the moment - which prove the virtues economically and from the point of view of people's health and well being of shifting to prevention and early intervention and keeping people out of acute care.

Q21 Dr Taylor: There are huge savings available.

Mr Lewis: There are very significant savings.

Q22 Dr Taylor: Coming on to people with complex needs such as dementia, the NAO gave us a briefing and they said our case "study undertaken ... found that in Lincolnshire 68% of people with dementia in acute beds had no further need to be there and that the average length of stay for orthopaedic patients with dementia was 44% longer than for those without". Are you doing anything to try and help speed up the discharge of these sorts of patients?

Mr Lewis: We are publishing in the autumn the first ever National Dementia Strategy which will focus on early identification, appropriate diagnosis and referral and the nature and quality of support and care that older people with dementia receive and the family support that is provided. We published the consultation document last week. The consultation will last through the summer and then in the autumn we will publish the first ever National Dementia Strategy and that will tackle this issue. Also, back to the point I made earlier, I think that some of this is around the continuum of care in every local community which is about world-class commissioning because what you need is high-quality home base support, good day care services, good residential nursing care, good intermediate care and, for some people, sensitive, personal, compassionate acute care and it is getting that continuum of care right in every local community that is absolutely crucial as well as of course getting care and family support right. We should not forget the pressure that dementia puts on so many families. It is a pretty challenging condition.

Q23 Dr Taylor: Especially for the families with younger demented people for whom there are even less arrangements for.

Mr Lewis: We said last summer that we were determined to bring dementia out of the shadows. I think the figure is that, in the next 15 or 20 years, one-in-three people who die over the age of 65 will have dementia. That is a pretty stark fact for us all to face up to.

Q24 Dr Taylor: Yes, terrifying. You have mentioned fines and, in that report, we were a little worried about fines not thinking how productive they would be. Have you any measure of how much use has been made of reimbursement charges?

Mr Lewis: Yes.

Q25 Dr Taylor: Is it known that that is one of the things that has improved?

Mr Lewis: I think that it was a relatively small number in terms of fines. Fifty-three of 80 councils surveyed had abandoned the notion of fines in favour of partnership working which is quite interesting.

Q26 Dr Taylor: Roughly when was it that they had abandoned?

Mr Lewis: By 2005, 53 of 80 councils had, in partnership with their NHS partners, abandoned it in favour of partnership working.

Q27 Dr Taylor: Is there anything to say whether they thought that they had been effective and that they had used them before that time?

Mr Lewis: I think that, when you send a jolt through the system, it is always effective. The question is, why did it require that for them to say that we need partnership working? Why were they not doing it in the first place? My own view is that the Government sometime get criticised for these sorts of shock tactics but sometimes you need shock tactics to focus people's minds, so I actually think that it was the right thing to do. Perhaps I can help by explaining where we are going with this now because I think that is probably more important arguably. The sort of things that we are doing now is that we have embedded and indicated the delayed transfers of care in the national indicators for local authorities and local authority partnerships and in our Vital Signs. The definition covers all delays in all settings.

Q28 Dr Taylor: Including non-acute and mental health?

Mr Lewis: Yes. The approach does not involve attributing blame and imposing fines and it says that delays are everybody's business and that each partner must contribute appropriately. So, it is one of the things that we have put in the system in order that local authorities know that one of the things they will be most judged on is whether they get this right in the future.

Q29 Dr Taylor: So, a short, sharp jolt and no longer really necessary or being used in any of the ---

Mr Lewis: There is no evidence that it is being used very much at all. I do not think that it is being used at all.

Q30 Dr Taylor: Coming on to extra care housing, we went to visit some rather effective communities where sheltered housing and nursing homes were all on one site. In the Department's response, the Department indicated that it would consider commissioning cost-benefit research looking at extra care housing relative to hospital or residential care provision. Was that ever looked at?

Mr Lewis: We provided two lots of funding in terms of extra care housing to actually stimulate the growth of extra care housing in the country. CLG have recently published a document Housing in an Aging Society which is looking at the whole question of the continuum of the housing that older people will want in the future. I have to be very clear that I am not sure whether we conducted that specific research project and I will go back and have a look at it for you.

Q31 Dr Taylor: One of the other things that we were very impressed with was telecare and the way that that can be installed into people's homes and really alert people and we visited a firm called Tunstall. In the Department's response that we have for this, the very last point says, "National strategy for telecare" and "The Preventative Technology Grant provided £80m funding over the two years ... to help mainstream and embed telecare services ..." Was that entirely extra new money or was that money that people already had?

Mr Lewis: It was very much extra new money but it was a two year one off, if you know what I mean, if that is not contradictory. It was two year one off extra new money. The point that is important is that, in Putting People First, we make it very clear that telecare now has to be integral. I think there is a danger that, when you look at a care package for an individual or for a household, you do all the assessment and you do the usual things and then, at the end of it, you ask, "What about telecare?" You actually need to put telecare in the mix right at the heart of organising and thinking about a care package in support to enable people to live reasonably independently. In the Putting People First reform programme that local authorities are implementing over the next three years, they have signed up to the fact that telecare needs to be integral to those care packages.

Q32 Dr Taylor: Was there a published national strategy for telecare?

Mr Lewis: There was a grant; I do not know if there was a strategy.

Q33 Dr Taylor: Our recommendation was that there should be a national strategy.

Mr Lewis: There was extra new money and a grant but I am not convinced that there was a strategy. There was at the time with the grant advice about best practice in terms of how ... In a way, there was a strategy of how should this money be best deployed, how can it achieve maximum effect and where can you get advice from about telecare. So, when the money was distributed, there was a lot of guidance with that.

Q34 Dr Taylor: In your current job, have you been to visit firms that do this? Have you visited some of the show homes that are all fitted with the telecare?

Mr Lewis: I have and I have had meetings with Tunstall. I should not be broadcasting on behalf of individual companies but I think they are good and innovative as are some of the other suppliers in this area. I think that it is worth mentioning another project that has not had a lot of oxygen publicity, which was to set up three demonstrator sites looking at bringing together telecare in health and in social care across a whole community and evaluating the benefits of doing that. I recently visited New Ham which is one of the three and the Committee may at some point in the future want to go and see - they are only just beginning - and the idea there is to put telecare in for a significant number of people who need it in three communities, but also to compare the impact of doing that with people in similar circumstances in those communities who will not get that level of telecare. So, to actually evaluate the economic and well-being benefits of having that level of investment.

Q35 Dr Taylor: Have you any idea when those will report because that sounds first class?

Mr Lewis: These are two-year projects and they are only beginning now.

Dr Naysmith: I would like to ask a supplementary on what Richard was talking about. When we were conducting the investigations into care, we did visit a place called Hartrigg Oaks in York and we were very impressed with what went on there with this sort of community where people moved from the periphery to the middle as their needs changed and the people there were extremely happy living there. We asked you specifically to look at the benefits of that because it was very expensive or appeared very expensive but, if it had been evaluated overall, it might well have provided a much better way of funding people's retirement years, if you like, right through to needing healthcare. I think that it would be nice if the Department could re-examine what it thought it was going to do there and did not. I only say that because one of the things that we are about to do as a committee is look at some old reports and pick up things in them which the Department promised to do and has not done, so this might be a good chance to have a look and see why you did not do that. It might be useful.

Q36 Dr Taylor: That was the cost-benefit analysis that we were talking about.

Mr Lewis: As far as I know in the Lifetime Homes report that TLG has recently published, there is quite a lot of emphasis on these issues. I do not think that it is that we have not done it. I also think that we have made significant amounts of funding available to stimulate extra care housing - there have been two waves of funding - but I also agree entirely with you, Doug, that one of the areas in which we need to do a great deal more work is stimulating what I describe as innovation on the provider side of care. For many older people, the kind of setting that you described is what they are going to want in the future. Other older people are going to want to stay within their own homes and there is going to be a whole range of option that older people are going to want to have access to. As I say, one of the things that I think we have been quite poor at is innovating in this area or supporting the independent sector to innovate, which is probably a better way of putting it. We definitely need to look at that. One of the things which the Green Paper is going to have to address is this question of the different models of care and the relative financial ways in which those are paid for because it is usually a combination of benefits and, where people have their own means, individual contributions. If you are going to get people to make informed choices about saving for the future or thinking for the future, it also has to be clear to them about how you pay for these kinds of facilities. For example, there is a big debate about equity release. Some older people are having a wonderful quality of life now going on cruises and having a great time because they have gone for the equity release option. There are other older people who are really lacking on confidence in a financial services industry and they going for equity release is a risk that they feel they cannot take. All of those issues definitely have to be addressed and it is right to say that they need to be an important part of the Green Paper. It cannot just be about who is going to pay for it, it also has to be about the kind of models of care that people are going to want to have access to or choices that people are going to want to have access to.

Q37 Dr Taylor: I am very glad that Doug emphasised that because, in the response to that report are the words that the Department is considering commissioning a cost-benefit analysis to see how the cost of caring schemes such as Hartrigg Oaks and Bury Hill compare with hospital admissions and, in the helpful paper which the Department of Health has sent us, there is absolutely no mention of that bit.

Mr Lewis: We will definitely look at it.

Q38 Sandra Gidley: Now we are moving on to our report on elder abuse which was published in April 2004 and, in that report, we recommended a national recording system for instances of adult abuse and we are only just getting round to a pilot. Why has it taken so long?

Mr Lewis: Because I think that it is actually very complicated to be clear about what it is that you want to record and what you want to identify. It requires buy-in from all of the agencies, the Criminal Justice System, the police, Social Services and other professional agencies, and it is important that we get that right. We are slightly contradictory as politicians on this stuff because we say that we do not want people bogged down in paperwork, red tape and bureaucracy and then we ask people to keep ever more data and information. It is about getting it right. We are going to start with 40 local authorities in the pilot this year and then, by the following year, I hope from everywhere in the country we will be collecting data which allows us to assess properly the scale, the level and the nature of elder abuse which is taking place in our country.

Q39 Sandra Gidley: Four years is a long time, so was there a lack of political will here or resources or did somebody just forget about it?

Mr Lewis: These things are ongoing processes. I do not think it would be fair to say that there has been a lack of political will. For example, we did commission a study with Comic Relief to look at elder abuse in terms of within people's own homes and how prevalent that was. We have just commissioned another study with Comic Relief to look at elder abuse within institutionalised settings. I am happy to accept some gentle criticism that it should not have taken as long as it has taken, but there has been plenty of work going on in this area as well. We did also introduce No Secrets guidance.

Q40 Sandra Gidley: Moving on to the prevalence, a fairly widely accepted figure was that 500,000 adults experience elder abuse, but the Government are on record as disputing that and saying that the figure is less. What actual evidence does the Government have for disputing those figures?

Mr Lewis: The only evidence that we have really is the prevalence study that was done with Comic Relief on abuse within people's own homes. We are now going to do another prevalence study with Comic Relief on abuse within institutions, NHS and social care institutions. We are going to be collecting this data from 40 local authority areas and then across the country, so then we will have the evidence. Why would you dispute it? For the very reason that I have just outlined, we do not have comprehensive evidence at the moment. What we know - and I think it is very important that we are not in denial about this - is that it is a real problem; we know that it is an issue and we know that it is one of those things that is hidden. We know that in the same way as we did not like talking about child abuse very openly as a society until ten, 15 or 20 years ago, there is a similar problem with elder abuse. We know sadly that there is not the same level yet of outrage about the abuse of an older person as there is about the abuse of a child and there should be. In society in terms of social and public policies, you will always find yourself dealing with new challenges and so you should in government. You should be responding and facing up to those new challenges. Let us not pretend that these things are easy. Let us not pretend that it is easy to get people to talk about it, to disclose. We are also of course this year reviewing No Secrets to see how effective that guidance around adult protection has been. There are different views. In some communities it has been quite good and, in others, some of the agencies have simply not taken it anywhere near seriously enough. Some people believe that there is a case of legislation. Other people think that it is more cultural and attitudinal issues. These are complex issues and the reason why we dispute headline figures is because if there is not adequate evidence to support them, then it is very important that we do diminish the problem of elder abuse in our society and try and play it down. It is equally important that we do not exaggerate and terrify people to death with it. I would like to say one further thing on this and this is challenging but I am going to say it. I think that we have a brilliant relationship with our stakeholders; we meet with them regularly; we include them; we involve them; there are no surprises as much as we can, i.e. the voluntary sector across the piece. Every time they want to get publicity, they have to head a press release with a shock or sensational statement about one thing or another.

Q41 Sandra Gidley: It is the same for politicians.

Mr Lewis: To some extent, but Government cannot exaggerate the scale of problems or when you are dealing with really sensitive issues. All I would say to you is that sometimes it is very easy to immediately accept the headline and jump on the bandwagon. There is a serious, no doubt growing because of demography, problem growing of elder abuse in our society, but equally we should be quite measured and reasoned in the way we respond and deal with this issue without being complacent.

Q42 Sandra Gidley: Moving on to something practical that perhaps can be done to help reduce, the Government did set up the General Social Care Council - you mentioned that earlier - and probably dealt with the easy hit first, the registration of care homes and care home workers. To some extent, there is a certain amount of self-regulation there because people are working in a public environment with others around them. There seems to have been a bit more of a delay with registering domiciliary care workers and I wondered whether you would like to comment on that and also how, with the move towards personalised budgets, the system will work then. If someone were to employ somebody directly, will they have to be registered because there is a huge potentially grey area there?

Mr Lewis: We are moving on to registered domiciliary care workers; we are finalising the details at the moment with the GSCC. What we need to be clear about is the legislative framework within which we register, so how much compulsion - we think on balance that it probably does need to be compulsion - and how do we give that proper legislative force. We have also had to weigh up the cost of this. It is going to cost quite a lot of money, so we have had to work out how much money we are going to need to give the GSCC to do this. You are absolutely right to raise the question that you need a regulatory system generally which is consistent with the changes you are making to the services and, as we move towards a much greater use of personal budgets, we are already seeing, I am delighted to say, a growth in the number of people choosing to have direct payments. As that continues, we need a regulatory system which properly reflects that. We have to get the balance right between saying that we believe on the one hand in people's right to self-determination, to control over their own lives, to choice, whilst at the same time saying that we have a responsibility to protect those who are vulnerable. I do not think that you will ever totally answer the question. What you need to do is keep struggling with it and keep coming up with the necessary changes to legislation and regulation which strive to get that balance right. So, what you will see in the period ahead from us is a look at the regulatory and legislative framework with regard to the Putting People First reform programme and the Care and Support Green Paper and No Secrets to make sure as much as possible that that regulatory legislative framework appropriately supports the policy agenda because where people get very frustrated on the ground, quite understandably, is where there is a contradiction between the regulatory and legislative framework and what you are actually saying is policy. The final point I would make on this is that there are a number of people out there who are using direct payments or using increasingly personal budgets, but how do we know that they are getting a good deal? I will tell you now that that is a good question, but equally there are a number of people who have received traditional and conventional services for years who have not been getting a very good service or high quality service as well. So, we should not be too precious about giving people a lot more control and power, but, yes, of course, there needs to be protection so that people are not exploited or abused but equally we should learn to trust people.

Q43 Sandra Gidley: You mentioned that the work on domiciliary care workers was ongoing and that there are still some discussions going on. Can you give us a rough idea about the timetable of when we can expect the steps to be in place. When will registration be compulsory?

Mr Lewis: The reason why I cannot give you a straight answer today but will be able to do so in a couple of weeks is because we are looking at the moment at the timeframe involved in terms of the legislation that will be required to ensure that this backed up with compulsion, but I will be able to write to the Committee with an answer very soon.

Q44 Dr Naysmith: Following up on one or two of the points that Sandra has been raising which we hope will be adopted as policy, have you made any progress in the protection of vulnerable adults, the POVA scheme? Has the incidence of the number of people working in the care sector without a Criminal Records Bureau check fallen?

Mr Lewis: Yes, we have. There is evidence that the POVA scheme has been successful. There are a number of people who, as a result of the POVA scheme, are on the list and there is no doubt that it has been successful, but we need to be ever vigilant. We know of some of the horrendous stories that have taken place because again I think culturally perhaps a long time ago we accepted the need to protect children to maximum effect and it has taken a little longer to realise that we also have to protect adults in a similar way. I can give you the statistics if that would be helpful. At the end of May 2008, 9,298 people were referred to the POVA list, 1,915 people are actually confirmed on the list and 500 people are listed provisionally. The remaining people are either under investigation or have had their case closed because of insufficient evidence. There are 2,400 people who have been prevented from working in regulated care settings. I think that it was introduced in 2004 and, since then, there is no doubt that, as a result of it, some very unfit and unsuitable people have been dealt with appropriately.

Q45 Dr Naysmith: These are useful figures. The other area is the treatment of things like chronic pain and looking after elderly people and ensuring that they get proper treatment for chronic pain. Can you work with PCTs to try and ensure that this happens?

Mr Lewis: I think that we are trying to do that on a number of fronts. Obviously, through the health and social care co-operation that I talked about earlier, the primary and community healthcare strategy that will be published very soon will seek to address that issue. Some of the issues are connected with dignity as well and the way in which older people are treated. We have had a major push over the last 18 months on raising awareness about the importance of older people being treated with respect and dignity and I think that, by providing national leadership on that issue, we have begun to make a real difference. We have lots of dignity champions around the country now working in different sectors. We have appointed Sir Michael Parkinson to be our Dignity Ambassador. Dignity and respect have been the focus of the Healthcare Commission and CSCI work and Alan Johnson announced last week that he wants to see a much greater focus on dignity and compassion than nursing than perhaps has been the case in recent times. I think that there has been a great deal of improvement, but I still think that probably you will find that the relationship between primary care and residential care and nursing homes in local communities again can be quite patchy and that we need to do two things. One is to make sure that the staff who work in those homes have the necessary skills and professionalism and training but equally that they have access to those professionals who have qualifications and expertise in this area.

Q46 Dr Naysmith: Another area that has had a fair bit of publicity over the years is the routine prescription of drugs to control the behaviour of patients suffering with dementia. What have you done to try and ensure that that diminishes?

Mr Lewis: I announced last week that we are going to have a major look at that in the Department and, before we publish the final National Dementia Strategy in the autumn, we will decide on the appropriate action that we intend to take. There are two elements to this. One is the inappropriate prescribing of drugs where those drugs are not the solution and it is not consistent with professional best practice. The other of arguably more alarm even is where two drugs are being prescribed but where the guidance makes it very clear that those drugs should not be being prescribed. It does not say, "thou shalt not", it just said that it is very unwise to prescribe those two drugs to people with dementia and yet the evidence that we now have as a result of some BBC work and some research is that this is happening quite frequently. My commitment is to act very decisively on those issues and, as I say, we will announce the specific action that we propose to take in the National Dementia Strategy and, if we can do it earlier, we will, but we have to get to the bottom of exactly what is happening out there. There is an audit trail from PCTs in terms of prescribing patterns and therefore we should be able to collect the evidence but it does cause me concern and alarm if older people with dementia are being given drugs to suppress them which is nothing to do with actually dealing with any particular clinical or medical problem.

Q47 Dr Naysmith: This matter is not related to your responsibilities directly but I suspect that it must be mentioned in the report which is going to come out in a week or so and that is the diagnosis of dementia at an early stage by GPs. I am sorry to bring you in again on this again, Howard! There is quite a lot of evidence to suggest that GPs are not very good at diagnosing the early stages of dementia.

Mr Lewis: It is right at the heart of the National Dementia Strategy that I am publishing in the autumn. The strategy has four elements now: one is the early identification of dementia, then appropriate diagnosis and referral, appropriate high-quality care and support and the final element is research. So, the question of appropriate and early diagnosis is absolutely at the heart of the National Dementia Strategy.

Q48 Dr Naysmith: You mentioned earlier a review of No Secrets which was announced in June 2007 and you said that it is going to be completed quite soon. Have you learned anything from the review so far?

Mr Lewis: I think we have learned. I should be clear to the Committee that we will publish a consultation on that soon and next year we will produce recommendations in terms of how a new adult protection framework should look. I guess that we have learned two things. One is how patchy this is across the country and how some agencies are taking it very seriously and others are taking it not so seriously. We have also learned that, as we design a new protection framework, it has to be consistent with this debate about, if you are giving people more control and more power but at the same time have a duty to protect people from exploitation and abuse, you need to get that balance right. So, any new system that we build has to be consistent with a policy agenda. I would say that those are the two things we have learned.

Q49 Sandra Gidley: I want to come in on the Alzheimer's drugs. When NICE was reviewing treatments for Alzheimer's, one of the concerns raised by those who were worried about particularly the initial NICE determination was that an unintended consequence of denying access to the other drugs was that there would be an increase in the number of anti-psychotic drugs prescribed as a result because that was one of the few drugs in the armoury, even though it is not appropriate. Will your review look at whether there has been an increase since there has been a reduction of prescribing of other drugs?

Mr Lewis: I will certainly have a look at it. Personally, I do not think there is any evidence for direct correlation between the two. I am not even sure at what point the NICE decision has taken effect because, if you are saying that the NICE decision has led to that, then I assume that the NICE decision would have to be in effect now. I think that the problem with anti-psychotic drugs has been going on for years or that is the view of most people, so to make the linkages I think is slightly ... If people want to question the NICE judgment, then fine. I think that Ministers having set NICE up and Parliament having set NICE up, when it makes really difficult decisions, I think that it ill beholds politicians to then, at every juncture when they make sensitive and difficult decisions, to try and undermine them, although I do understand the massive amount of emotion and sensitivity from families in this position. The bigger issue in terms of anti-psychotic drugs is that first of all we should not make excuses for professionals inappropriately prescribing wrong drugs in wrong circumstances. That is unprofessional. Secondly, the bigger argument is in terms of the quality of care and support that people receive. If people received more higher quality care and support and people became more sensitive, more flexible and more skilled, then maybe that would also affect the behaviour of those older people with dementia because older people with dementia become distressed easily and become anxious and insecure and that often is because, if we are all frank, the care and support is not always what it needs to be. I think that that is a much bigger challenge for us as professionals. Look, if we were prescribing on a vast scale inappropriate drugs to other people in our society, there would be uproar. Let us be clear about it. It is not right and where it is being done in a way which is unprofessional we need to clamp down on it, but we also need to accept that, for some professionals, it is quite a difficult judgment call as well. Every time a doctor prescribes an anti-psychotic drug, that in itself is not wrong. There are times when that prescription is the right thing to do. When it is not, just in the same way as if you are prescribing drugs inappropriately for other patients, we have to do something about it.

Q50 Sandra Gidley: I agree with the point about care and support but I do not think it is a case of undermining NICE and surely there is an argument for occasionally looking in retrospect at a decision to see if it was right and I think that this is something which NICE themselves would not dismiss out of hand.

Mr Lewis: I would challenge that. I would think that there are a number of things which should have been done differently - by the way, the courts have tested this - or, where you think that the legislative framework and underpinning of NICE's remit should be reviewed, it is perfectly legitimate to say that and to argue that, but let us not inappropriately make the link between this problem with anti-psychotic drugs and the NICE decision which is relatively recent when this problem has been going on for some considerable time.

Q51 Sandra Gidley: One final practical point: since the introduction of the new pharmacy contract - and I declare an interest here because I am a Fellow of the Pharmaceutical Society - the commissioning of pharmacists to go in and undertake regular medication reviews has not increased. In fact, there is some evidence to show that it has decreased. Would your review look at whether that actually makes a positive difference in this case because I think that the results would be interesting?

Mr Lewis: I will certainly look at that and also look at the implications in the context of the Pharmacy White Paper as well.

Q52 Dr Stoate: I would like to come on to end of life issues and particularly the Palliative Care publication which we published in July 2004. I gather that the Department is expected to publish shortly the End of Life Care Strategy. Over what period of time do you envisage this being implemented and can you guarantee that it will be funded properly?

Mr Lewis: It will be launched soon. The serious implementation will begin in the new financial year, so it will begin in 2009/2010. I believe that it will lead to a significant extra amount of money being spent on end of life care. In fact, I will make a commitment that it will lead to significant additional resources being spent on end of life care. You will be aware of the manifesto commitment that we had on doubling investment and we will set out our plans to do that.

Q53 Dr Stoate: That is helpful and also very clear, but obviously the success of the strategy will depend largely on the performance of commissioners and we have heard from a number of inquiries which we have undertaken that there is pretty variable performance amongst PCT commissioners. What steps can you take to ensure that PCT commissioning really does lead to the strategy working and to better outcomes?

Mr Lewis: Obviously there is the work on world-class commissioning which is taking place at the moment in the NHS; there is the commitment to join population needs assessment with the local authorities and, where appropriate, joint commissioning, but you are absolutely right, Howard, to ask whether we have world-class commissioning now because of course we do not. Do we need to get there? We do. Is it something upon which the Department is focusing at the moment? It is one of the major things upon which Mark Britton and David Nicholson are focusing and I think that we have to be optimistic and positive. The difficult part about this as I have found over the years is that on the one hand people want maximum devolution to the frontline and localism and then, when they have something that they feel passionately about, they want the Government to nationalise the funding and hold national pots of money all over the Department of Health. It is a contradictory position. Some would say that you have to have horses for courses and that there are different stages of the development of health services or social care services where having a greater level of national control is appropriate, but I am absolutely clear that end of life will have a new priority. The fact that it is one of the eight clinical pathways and a part of the strategic health authority work on the Darzi process is a massive statement; the fact that the Government are producing the first ever national strategy is absolutely crucial; the fact that in the operating framework of the NHS it will make it clear that end of life care has to be one of the priorities; and the fact that there will be significant additional resources as part of the announcement of the strategy. All of that in my view will lead to a much greater focus and so it should do. This is one of the most sensitive and difficult issues that any family will face.

Q54 Dr Stoate: I am glad that you are taking that seriously and certainly I hope that we can ensure that commissioning and PCTs have a pretty level playing field when it comes to delivering the service, so I am very pleased about that. I want to move on to the New Deal for Carers review. Will your Department's New Deal for Carers review lead to any further rights for carers in terms of for example paid leave to care for family members or friends towards the end of life? Do you envisage any improvement in that arrangement?

Mr Lewis: There is first of all the right to request flexible working and frankly we have not yet either made carers sufficiently aware of this right or made employers realise that actually it is really a good thing to do in terms of your bottom line to treat your staff and particularly carers in that way. What we have done in the New Deal for Carers is announce some very tangible commitments funded over the next three years and then we have said that, beyond that, there is a whole series of other issues at which we want to look and that will be one of them. So, there is no specific commitment. There may even not be any direct reference to it in the document, but we will certainly look at that. I need to be clear that it is very unlikely that any changes in that area will not take place until post-2011.

Q55 Dr Stoate: At least you are prepared to keep that under review and that is fair enough. What use has been made of the additional annual £50 million that the Department has made for specialist palliative care services?

Mr Lewis: I will give you the overall picture. We provided an extra £50 million for specialist palliative care for adults including hospices, a 40% increase over the level of funding in 2000. Over half this funding went to the voluntary sector and this £50 million is now recurrent in PCT baseline allocations, so it is available for specialist palliative care on a long-term basis and that is of course before the announcements we make associated with the new strategy.

Q56 Dr Stoate: To move on from that, one of your targets is to double the number of palliative care consultants by 2015. What progress are you making on that?

Mr Lewis: I cannot answer that. I have asked the question and I do not have specific data on it, but we will give you as much information as we can. We will write to you about it.

Q57 Dr Stoate: That would be helpful.

Mr Lewis: I am not sure where that commitment was made. The first time it was brought to my attention was in preparing for this Committee. I am aware of the manifesto commitment to double investment but I was not aware of the specific commitment on doubling the number of doctors in this field, but we will have a look at it and write to you about it.

Q58 Dr Stoate: That would be very helpful. Finally, will hospices ever receive a full cost recovery?

Mr Lewis: How do we define full cost recovery? If a hospice is providing a service on behalf of the NHS and is commissioned to do so, then we believe the NHS should ensure the full costs are reflected in those commissioning arrangements, including the on-costs that hospices have for the provision of that commissioned service. I am not being semantic. There is a whole load of services that hospices provide, there is a whole range of costs that they have, but where they are commissioning a service on behalf of the NHS, absolutely, it is best practice that there should be full cost-recovery.

Q59 Dr Stoate: I would have thought that most hospices spend most of their time looking after NHS patients for services which the NHS legitimately probably should be looking at.

Mr Lewis: Yes. The End of Life Care Strategy will seek to address that in terms of the basis on which PCTs should commission with hospices.

Q60 Dr Stoate: At the moment, of course, as you know, a huge proportion of hospice funding is from the voluntary sector. Are you satisfied with that arrangement or do you really want to try to improve it?

Mr Lewis: We most definitely want to improve it. Hospices do a remarkable job. We also need to remember that the majority of people currently cared for are in hospitals, not in hospices - for good or for bad, and I personally think probably for bad. A growing number of people want to be cared for at home. When we look at the debate about the amount of money we put into palliative care, we must be careful to get the balance right between the amount that we need to invest in improving home-based community teams to support people who want to die at home and the right level of investment for hospices, but we also need to recognise that acute NHS care continues to take significant responsibility for people coming to the end of their life. I personally believe that many of the people who are currently spending the end of their life in hospitals would be better in hospices if they were genuinely given that choice. We have to find a way not only of putting extra money in which will benefit hospices - which, by the way, undoubtedly will happen as a result of the End of Life Care Strategy - but also of redirecting resources from acute NHS care to hospices.

Q61 Dr Stoate: You said "when they are given the choice". GPs are now asking patients what their choices are in relation to palliative care strategies. We are expected to deliver those choices if that is feasible in terms of their clinical needs. That is what is happening. Is it going to be adequately funded, given that many more people now are choosing hospices or, for example, Hospice at Home, which is an alternative to that, rather than dying in a general hospital?

Mr Lewis: I think we need to be fair. Hospices, as you say, are increasingly supporting people at home as well, so they are part of the solution in terms of more and more people wanting to end their life at home. At the end of the day, choice should be at the heart of this.

Q62 Dr Stoate: That is my point.

Mr Lewis: It is the responsibility of commissioners to organise local services in terms of that continuum of care so that people genuinely do have that choice. My own view is that there are two things that will happen over time: one is that people will increasingly want to end their life at home undoubtedly. Second, given a real choice, many more people who currently end their life in hospital would rather end their life in a hospice-type environment.

Q63 Dr Stoate: You are prepared to commit that the Government will make sure funding will let that happen.

Mr Lewis: I am prepared to commit that the Government will do all the right things in terms of the national strategy, yes. But we really have to decide whether we want ministers and senior officials running the Health Service from offices in Westminster and Whitehall. We will put all the levers in place and we will hold them to account because we have made commitments on this to people. There is nothing more important in a civilised society, frankly, in terms of the sensitivity and the personalisation and the offer that we give to people and family members when they are having to deal with this.

Dr Stoate: Thank you very much.

Q64 Chairman: Can we assume by what you have said, Minister, that whilst obviously you are not going to be directed from the centre, you will be looking at what is happening out there and collecting information on it? I say that particularly. I had a children's hospice open in my constituency last year. Quite clearly, if you look at the national figures, the money that goes into children's hospices is far less than adult hospices - certainly 12 months ago when I last looked at these figures. Is it something that the Department would be reviewing, as it were, or keeping a watchful eye on to see how the money is being spent by commissioners?

Mr Lewis: Absolutely. Any strategy which I am involved in launching has a delivery and implementation plan, and that delivery and implementation plan is overseen either by ministers or senior officials. There is no point in governments publishing strategies and then not focusing on delivery. The danger is you lose interest the day after you publish a strategy. We cannot afford to do that in a whole series of areas, whether it is end-of-life care or dementia care. The good news on children's hospices is that we announced a national pot of money for capital investment in children's hospices but also we published a new strategy for children's palliative care, and, under the banner of Aiming High for Disabled Children, money that is coming through DCFS and money that is coming through health, the Children's Health Strategy that will be published in the autumn, you will see also a significant improvement and more investment in children's palliative care services in every community. We need also to remember that, again, increasing numbers of families, the child, the family, want the support to come into the home and not necessarily into hospices, but children's hospices do do a tremendous job.

Q65 Chairman: They have teams working in the community from there, which is their prime aim at this stage.

Mr Lewis: Yes.

Q66 Dr Naysmith: Could we turn now, Minister, to another area where there is a bit of tension between the centre and the periphery: the National Framework for NHS Continuing Healthcare. According to Age Concern, "Access to NHS funded continuing care is very inconsistent across different PCTs." Has the Department made any evaluation of compliance with the national framework? What evidence is there that the framework does overcome - this terrible phrase - "the funding postcode lottery"?

Mr Lewis: It is important that we finally produce a national strategy, although the Ombudsman's judgments, the court judgments meant that had to happen. There is no doubt that there are more people receiving continuing care as a consequence of that guidance. I think the figure is about 7,000 additional people than was the case this time last year. But it is far too early, in my view, having introduced it in the autumn of last year, to start saying how profound the impact has been in terms of PCT decision-making and trying to shuffle responsibilities between PCTs and local authorities. This is a very difficult area. There are always some people who are going to fall either side of the line. That is never going to change as long as you have one system which is free and the other which is means tested, and a definition of a level of intervention that is nursing care and another level of intervention that is personal care. It is always going to be difficult and tricky and sensitive. But I do believe the national framework has clearly made a difference. It will be quite transparent to see what is happening across the country because we now have information in a PCT-by-PCT basis. If you look at the figures prior to putting in place the new national framework, to be frank it is very hard to explain the variation across the 150 PCTs - very, very difficult indeed to explain it. We will have all the evidence, we will have all the information, we will be able to measure the effectiveness of the new guidance, the new framework, and therefore we will be in a position to judge how much progress has been made. We also have to be careful not to give an impression to anybody who is turned down for continuing care funding that that is the wrong decision. On many occasions, that is absolutely the right decision. I think the national framework is leading to more people getting continuing care funding than was the case in the past but we are a long way from being able to make definitive judgments at this stage.

Q67 Dr Naysmith: It is interesting that you say that it is difficult to explain why there should be differences, but you must have some experts in the department attempting to explain why there are differences.

Mr Lewis: We have one or two experts in the department, yes.

Q68 Dr Naysmith: There is maybe one sitting right next to you.

Mr Lewis: I do not think he wants the title of expert on this issue. Obviously David coming to join the department has made a massive difference in terms of the expertise available in the department on social care generally. It is such a massive, refreshing change to have somebody of David's calibre at that level in the department - and that is a serious point. On continuing care, the reason for variability is that clearly in a lot of PCTs it has been finance led. Decisions have been made not on a needs-led basis, not looking at each case on its merit, but the people at the sharp end have been told, "We are heavily wanting to limit access to this funding because it is expensive." That is an obvious and an honest explanation of the variability. It is more difficult to explain, where you have PCTs with similar age profile populations, for example, why there should be such large variations. There is another theory, to be fair. In those areas where the relationship between PCTs and local authorities is much stronger and much better, you would hope that prevention means arguably that far less people need to access continuing care. Of course, those areas that genuinely have done really good partnership and collaborative working will defend themselves by saying, "We do have less people who need continuing care because we get the other forms of care right in our community." You could learn quite a lot from looking at why there are these differences.

Mr Lewis: Yes.

Q69 Dr Naysmith: Do you intend to review it in the longer term?

Mr Lewis: Yes.

Q70 Dr Naysmith: The implementation.

Mr Lewis: We definitely have to do that. If the variation stays as it is, it will be very difficult to justify, unless we have robust evidence to articulate clearly and explain what is going on out there. Obviously we introduced the national framework so we could get it right for people.

Q71 Dr Naysmith: The next time you are back, we will be asking you how it is doing.

Mr Lewis: Of course you will. Once you have that line in the sand which is free and means‑tested, once there are emotive decisions being made as well as professional decisions, let us be honest, you are always going to find difficulty. But I think the national framework has made a difference.

Dr Naysmith: Thank you.

Q72 Sandra Gidley: I think you said 7,000 people a year more were now benefiting from continuing care.

Mr Lewis: Yes.

Q73 Sandra Gidley: The initial estimate was that the numbers would probably increase by between 7,000 and 31,000. Are you slightly suspicious that it is right at the bottom of that predicted range?

Mr Lewis: Who produced the estimate?

Q74 Sandra Gidley: That is a very good question. I am not sure.

Mr Lewis: Was it Age Concern or Help the Aged?

Q75 Sandra Gidley: I cannot answer that.

Mr Lewis: I will tell you what our estimate was. Our estimate was about 5,500. It is significantly more than our estimate, so, if we were trying to suppress the figures, it would probably be at 5,500 rather than 7,000.

Q76 Sandra Gidley: Fair point. You alluded to the fact - which I do not agree with - that some people, quite rightly, do not qualify for continuing care funding. The problem often is that the family do not understand why that is the case. I think there is a need perhaps to get people to start thinking about how they might have to fund not continuing care needs but the needs that they might have if they do not qualify for the funding, which can be quite extensive in some cases. Has the department done any thinking in that direction?

Mr Lewis: Yes, the whole basis of the review, the Green Paper, the debate about the future of care and support, is right at the heart of our debate. Being very clear about what the state will do, what will be expected of individuals and families long term, having a strategy for making sure that people understand that and it is relatively simple and straightforward - and not just this generation of older people and baby-boomers, but we are going to have a conversation with all the generations - is right at the heart of this. It might be helpful, by the way, for the Committee, to give this some sort of perspective: when the Ombudsman reported in 2003 there was a retrospective review conducted by the NHS in terms of 12,000 cases where there was a sense that continuing care funding should have been awarded and had not been. In 2,000 out of those 12,000 cases it was found that the decision had been wrong and the continuing care funding should have been awarded. If you look back historically, 12,000 people felt aggrieved, out of which 2,000 - which is quite a significant proportion of them - were right to be aggrieved. On your point, that is right at the heart of the review of the care and support system and the debate with the public, the discussions in the Green Paper.

Q77 Sandra Gidley: Moving on briefly to personal budgets for continuing health care, there appears to be a plan to move towards personal budgets for long-term conditions as well. How are the two going to dovetail with each other, given that in very many cases the services are not very joined up?

Mr Lewis: I do not want to pre-judge announcements that may be made soon, but there is a process. First of all, the professional sits with the individual and, where appropriate, the carer. They talk through how that person sees their needs. They then come up with an agreed plan which is linked to making sure that that person has the best possible health and well-being. They identify the amount of money that is available to be spent by the system on that person's care.

Q78 Sandra Gidley: By "the system" do you mean health care and social care?

Mr Lewis: We need to be clear that there is the possibility of personal budgets having more than one funding stream in them; that is, health and social care funding, and there could be other funding streams as well. There will be some personal care budgets which just have one funding stream in them, so it will vary depending on the individual circumstances. I think you are right to highlight the potential of personal budgets to break down the "Berlin Wall". In the way we have focused in the past on merging organisational structures, getting professionals to work together, greater integration, personal budgets are potentially - potentially - a powerful way to break down those silos and focus on the needs of the individual. But they are also, of course, about giving the individual themselves or the family a much greater level of power and control over the care package.

Q79 Dr Taylor: Before we leave continuing care, I have a supplementary question. When we did the inquiry, we were very concerned about definition because we had witnesses coming to tell us quite clearly that if a wife gave the same care that a nurse would give, then it did not qualify as nursing care. It seemed to be not a definition of what was given but who gave it. In the paper you have sent us from the department you say: "Definitions around personal care and nursing care are unhelpful. Personal care and nursing care are terms which are widely understood." I do not really think that is quite right. Do we still have people giving the care that a nurse would give, which would be paid for if it was a nurse giving it but it is not because they are giving it?

Mr Lewis: You are absolutely right and, of course, I apologise for that statement. I do not think it is widely understood. It may be widely understood by the officials within the department who work on these areas but it is not widely understood by normal people. With the new framework we tried to look at practice on the ground in different PCT areas and amongst different professionals about how they reach these judgments. We tried to ensure that the new national framework appropriately identifies and is transparent about those different definitions. You will always have a debate about this. It will never, ever be straightforward. The whole point of the new framework was to seek to at least have consistency across the country. The guidance is very clear and very consistent. Then there is the application of the guidance. One of the things we are going to have to look at when we look at whether the variability does indeed continue is what is going on in terms of application - because the guidance is the same everywhere.

Q80 Dr Taylor: It is really quite easy for a nurse to train a spouse to do what is needed.

Mr Lewis: Yes.

Q81 Dr Taylor: Just because the nurse does not then do it, the payment should not cease. As long as you have that point on board.

Mr Lewis: The Chairman raised this question earlier on. It is at the heart of the debate about the future of the care and support system. That dividing line has to be one of the issues that we address. My own view, to be frank, is that there will always be an element of care and support that is means tested. Under this Government, the NHS will always be free at the point of need. If that is the reality, we have to be much better at teasing out the obstacles and the barriers, and giving people a sense of clarity, but also a sense of fairness as well.

Q82 Dr Naysmith: I am going to turn to audiology services. That was the title of a document you published the day before your last appearance before this Committee, when the subject was Audiology Services - so that was quite a clever ploy. Anyway, was the March 2008 target for a maximum wait of six weeks for all diagnostic tests met?

Mr Lewis: Not quite. It was nearly met. Can I give you the latest figures to give you an indication?

Q83 Dr Naysmith: Has it been achieved now?

Mr Lewis: Yes. In April 2008 - and this is the latest month for the data that we have available - it has fallen to 2,562 people compared to 110,000 people two years ago. I think that is a remarkable demonstration of progress. I think the Committee frankly focused the minds of the department on this issue. The same people who have been project managing, getting us to this achievement with regard to the assessment wait, are getting us now to a position where, by the end of the year, I cannot promise you we will hit the 18 weeks for audiology but I can promise we will be a lot nearer to the 18 weeks than we ever imagined we could be. The people who have been project managing this approach with PCTs up and down the country and strategic health authorities have done a tremendous job to achieve those figures from where we were - and there was a lot of scepticism when I appeared before this Committee about whether they could be delivered.

Q84 Dr Naysmith: The benchmark was that, by the end of 2008, 50% of people accessing audiology must do so within the overall 18 weeks.

Mr Lewis: That was a guarantee. The problem was the other 50%. I can tell the Committee today that we are very optimistic with the other 50% that we will make heavy progress on the 18 weeks. I am not sure we will quite hit it, but we will make major progress.

Q85 Dr Naysmith: I probably should not do this but it is interesting to speculate that there is a political party not a thousand miles from here who are proposing to abolish targets. Is this not a good indication of what targets can achieve if they are properly managed?

Mr Lewis: The days of top-down targets have served a purpose. If we had not had targets, there is absolutely no way we would have made the achievements that we have made in A&E waits, in waiting lists, and waiting time waits. There is no way, if you look at the history of the NHS, the generations of politicians who promised to get waiting times down and never, ever were able to achieve it. Interestingly, they have stayed stubbornly the same - as Alan Johnson often points out - through history. So it was clear to me that there was a place for targets. Arguably they have done their job and we now need to move to a much greater focus on quality and we also need a much greater partnership really between ourselves and between the managers and the frontline staff in terms of doing the right thing by patients. But we should never, ever apologise for the targets that this Government introduced alongside the investment, without which we would not have seen the massive advances we have seen in the Health Service over the last 11 years.

Q86 Dr Naysmith: Thank you for that. Going back to the audiology services, do you think the Audiology Advisory Board has achieved much since its establishment during June 2007?

Mr Lewis: I would be happy if most of my advisory boards had achieved that level of progress that I have been able to report to the Committee. They have made a major contribution. To be honest, it is rare we pay tribute to Civil Service or officials. The officials who have project managed this have promised me that progress was being made, have given me regular evidence of that. On the whole, they have delivered a very impressive improvement.

Q87 Dr Naysmith: Finally, what progress have you made to assess the medium- and long-term demand for digital hearing aids?

Mr Lewis: I think we will be in a better position to answer that question at the end of the year. The focus, obviously, is on having improved a system which desperately needed fixing based on the evidence that I gave you two years ago. This is the other issue about targets: it is not just hitting the target, it is then the sustainability. It is making sure you can, long-term, keep that progress going. Part of keeping the progress going in this area is assessing demand. We are doing that at the moment.

Q88 Dr Taylor: Minister, you have done a splendid job: you have kept your colleague completely out of all the questions. I am going to aim part of a question to David, just to make sure he gets a chance. We are moving on to the Care Quality Commission. Drawing on your background with CSCI, how do you think the Care Quality Commission will be an improvement on CSCI?

Mr Behan: I think the theme of the Committee's questions this morning has been about the integration of health and social care services. The Minister has talked about levers and incentives to the system. Indeed, the last question was about targets. We need to align our levers and incentives. Therefore an integrated regulator across social care, health, and not to forget the mental health dimension to the new Care Quality Commission, is part of the new system that we design which will see not only integrated services at a local level but integrated regulation. The work that has gone on to establish the Care Quality Commission is key to ensuring that social care is prominent within that new organisation. As the Bill has gone through the House we have been keen to establish that it will focus on social care and mental health as well. The face of the Bill, as it is presently, lays out the importance of the function of social care and, indeed, the continued importance of reporting to Parliament by the new regulator on the functions of social care and the way that social care is delivered in this country. I think the greatest gain is really around being able to be part of the system that incentivises integrated care for individuals who require care from the health and social care system.

Q89 Dr Taylor: Turning to the Minister, how are you going to make sure that social care is not marginalised when you have all health care and mental health care? How are you going to make sure? Is the Care Quality Commission going to be really big enough and financed enough to cope with all these three aspects?

Mr Lewis: First of all, I want to refer to the Government amendment that we tabled to reassure people: "The main objective of the Commission in performing its functions is to protect and promote the health, safety and welfare of people who use health and social care services." We tabled that amendment. We made it very clear that CSCI's current move to star ratings in terms of the performance of social care providers is to continue. A separate annual report to Parliament on the state of the nation with regard to social care is to continue. However, you can put all the words you want on the face of a bill, but the reality is that it will be the leadership of that organisation, the management of that organisation, and ministerial oversight. I am absolutely certain that social care will be treated with the seriousness and the status it deserves. After all, the majority of providers that will be regulated by this organisation are in the social care sector. There is a bit of me who goes to work every day making sure that social care is not marginalised within the Department of Health - I have got the grey hairs to prove it. There is a bit of me that believes it is time that social care stopped playing the victim. We now have a massive amount of public attention on this agenda. It is a source of massive concern not just to government but to families and society, because of, largely, the ageing population, because more and more of us are finding ourselves as carers. I think social care needs to be confident and positive about its future. The legislation underpins that. The requirement is that it continues to report in a distinctive way on social care performance. Also, social care has asked for years for a sense of "We want to be part of a more joined-up system with our Health Service colleagues." Surely bringing together regulation helps us long-tem to be part of that new joined-up approach.

Q90 Dr Taylor: Do you think you have taken measures to ensure that the transition from the three existing bodies is not going to mean there is a sort of hiatus and set back to the assessment that has really been pretty good, certainly by the Healthcare Commission.

Mr Lewis: I think we have recruited an excellent new leader for the organisation. The three separate organisations are all clearly preparing their management and staff for that transitional period. It will be difficult, it will be tough at first, but many of the programmes of work, the pieces of work that are in train, will continue irrespective of the organisational banner that those people are employed under. It will take time. When you create something new, you also have to look at the values, the culture, the professionalism, the relationship with stakeholders. Denise Platt has done a brilliant job in every way, but particularly in involving users and carers. Usually regulators have no real regard for engagement with users and carers, other than to tick the box, so it is crucially important that this new regulator also retains that notion of constantly engaging in an active way, not just in one of these arm's length consultation ways, with those people who use the system and, where appropriate, family members. I am optimistic and positive. Of course the creation of a new organisation brings with it new challenges, but let us be positive.

Chairman: On that positive note, could I thank you very much indeed for coming along and giving evidence. I have no doubt at some stage in the future, if not this year next, you will be back in front of us again, Minister, but thank you very much indeed.