Session 2007/2008

Tenth Report

PUBLIC ACCOUNTS COMMITTEE

Report into
Older People and Domiciliary Care

TOGETHER WITH THE MINUTES OF PROCEEDINGS OF THE COMMITTEE
RELATING TO THE REPORT AND THE MINUTES OF EVIDENCE

Ordered by The Public Accounts Committee to be printed 28 February 2008

Report: 24/07/08R Public Accounts Committee

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Public Accounts Committee
Membership and Powers

The Public Accounts Committee is a Standing Committee established in accordance with Standing Orders under Section 60(3) of the Northern Ireland Act 1998. It is the statutory function of the Public Accounts Committee to consider the accounts and reports of the Comptroller and Auditor General laid before the Assembly.

The Public Accounts Committee is appointed under Assembly Standing Order No. 51 of the Standing Orders for the Northern Ireland Assembly. It has the power to send for persons, papers and records and to report from time to time. Neither the Chairperson nor Deputy Chairperson of the Committee shall be a member of the same political party as the Minister of Finance and Personnel or of any junior minister appointed to the Department of Finance and Personnel.

The Committee has 11 members including a Chairperson and Deputy Chairperson and a quorum of 5.

The membership of the Committee since 9 May 2007 has been as follows:

Mr John O’Dowd (Chairperson)
Mr Roy Beggs (Deputy Chairperson)

Mr Jonathan Craig
Mr John Dallat
Mr Simon Hamilton
Mr David Hilditch
Mr Trevor Lunn
Mr Ian McCrea*
Mr Patsy McGlone
Mr Mitchel McLaughlin
Ms Dawn Purvis

* Mr Mickey Brady replaced Mr Willie Clarke on 1 October 2007
* Mr Ian McCrea replaced Mr Mickey Brady on 21 January 2008

Table of Contents

List of abbreviations used in the Report

Report

Executive Summary

Summary of Recommendations

Introduction

The Pattern of Care for Older People

Promoting the Improvement of Care Services for Older People

Providing Quality Domiciliary Care Services for Older People

Appendix 1:

Minutes of Proceedings

Appendix 2:

Minutes of Evidence

Appendix 3:

Chairperson’s letter of 5 February 2008 to Dr Andrew McCormick, Accounting Officer,
Department of Health, Social Services and Public Safety

Correspondence of 22 February 2008 from Dr Andrew McCormick, Accounting Officer,
Department of Health, Social Services and Public Safety

Correspondence of 23 January 2008 from United Kingdom Home Care Association.

Appendix 4:

List of Witnesses

List of Abbreviations used in the Report

The Department	Department of Health, Social Services and Public Safety
Trust	Health and Social Care Trust
Board	Health and Social Services Board
C&AG	Comptroller and Auditor General
RQIA	Regulation and Quality Improvement Authority
GB	Great Britain
UKHCA	United Kingdom Home Care Association

Executive Summary

Introduction

1. Since 1990, and the publication of the policy document “People First”, the Department of Health, Social Services and Public Safety (the Department) has sought to transform its care system for older people from one dominated by residential and nursing home provision to one which offers flexibility and sufficient support to allow older people to remain at home for as long as possible. The initiative also sought to draw on voluntary and private sector provision of services as well as those services publicly provided.

The Pattern of Care for Older People

2. Despite the intended shift in care towards a domiciliary setting, the Committee was disappointed to find that significant numbers of older people with care needs continue to be treated in an institutional setting rather than at home. As a consequence, £236.4 million (60%) of the £394 million spent by Trusts on personal social services for older people in 2005-06 was spent on residential or nursing home care. In the Committee’s view, funding levels should better reflect the principle of ensuring that older people are supported in their own homes wherever possible.

3. The Department acknowledged that its domiciliary care services now tend to be targeted towards those with higher levels of need. Consequently, the overall number of people receiving services has reduced and services assisting those with lower levels of need (such as home helps/meals on wheels) have reduced. While the Committee appreciates that spending more on complex services and concentrating on those with the greatest needs, is in line with the principles of People First, it considers that the Department may be adopting a somewhat short-sighted strategy given the preventive significance of low level services in maintaining independence.

4. The discharge of older people from general hospital care often causes problems for the domiciliary care process, principally due to differences of opinion between the individual, professionals, relatives and carers on the appropriateness of returning home. In resolving such conflicts, patients are often unwillingly directed into institutional care. The Committee stressed the importance of more careful planning of discharges to ensure that the appropriate package is available as and when needed.

5. The Committee is surprised that the good practice lessons in handling discharges, emerging from two Trusts (Craigavon and Banbridge Trust and Causeway Trust), were not circulated and mirrored across all Trusts. The Department undertook to advise all Trusts that, in designing their services, they should consider previous successes of other Trusts.

7. The Department’s distribution of funds to each of the Health and Social Services Boards is largely determined by the application of the Capitation Formula. The Formula shares out available resources between Boards based on the size, age and needs of the population. In 2004, a fourth review of the Capitation Formula, to look for evidence of unmet need, was published. However, four years later, the findings of this review have not been implemented. As a result, allocated funding continues to be significantly out of line with current population trends across the Boards.

8. The Committee believes that fairer funding is crucial to meeting the domiciliary care needs of older people and considers it essential that the Department implements the outcome of its review quickly to ensure that there is more consistency in provision. The Committee emphasised that similar considerations apply to the implementation of the fifth review, which is now underway.

Promoting the Improvement of Care Services for Older People

9. Without the contribution of informal carers, the present system of care and support for older people receiving domiciliary care packages would be unsustainable. Good quality, flexible respite care, therefore, is vitally important for informal carers of older people, allowing both parties a short break at a time to suit the carer. Such support can help older people live at home for longer.

10. Older people with intensive needs have to rely on the assessments of multiple service providers. Domiciliary care, therefore, presents a key test of the quality of local joint working. Recognition of this by the Department has led to the long overdue introduction, during 2008-09, of a single assessment tool. The Committee was critical of the length of time it has taken to develop this tool, however, it hopes that this tool will help to improve the integration of health and social services in meeting the needs of older people and ensure consistency of approach and standards. The Committee expects the Department to closely monitor the success of the tool in assessing need and developing joint working arrangements.

11. Direct Payments allow older people to choose how to spend their allocated budgets to meet their care needs. However, at present, uptake on the scheme is low. The Committee was assured by the Department that there is no monetary disadvantage to older people should they opt to purchase their care requirements in this way. The Committee expects the Department to ensure that the burden of operating the arrangements for Direct Payments is kept to a minimum and the availability of suitably skilled and competent care workers - registered with the Northern Ireland Social Care Council and fully regulated.

12. Domiciliary care workers are generally poorly paid and poorly trained. This leads to recruitment and retention difficulties and consequently a high turnover of staff. The resulting lack of continuity can be unsettling and distressing for older people. The Committee welcomes the recognition by the Department that the status and esteem of social care needs to be raised. The introduction of registration and regulation to the sector should, in the long term, help to address this issue and raise standards amongst its workforce.

13. The extensive use of “spot” contracting hampers the ability of independent providers to plan ahead and guarantee hours for employees. In the Committee’s view, this practice threatens the viability of independent sector providers who may be able to provide greater diversity of provision for service users.

14. A key component of the vision of shifting resources and emphasis from institutional care to care in individuals’ own homes has been the intention to utilise the independent sector more effectively. However, the Committee considers that to a large extent the statutory domiciliary care sector has failed to engage constructively with independent care providers in their localities. The Committee reminded the Department that it is the responsibility of Trusts to fully consider all available service provision rather than rely on the availability of in-house services.

Providing Quality Domiciliary Care Services for Older People

15. It is the Committee’s view that the survey commissioned by the C&AG demonstrated that there is scope for the Department to be more proactive in seeking the views of older people so that their needs and wishes can be central to decision making. It is clear to the Committee that as the number of older people in the community continues to grow, the importance of choice and control will become ever more central.

16. The C&AG’s survey of older people’s experiences of domiciliary care showed that the vast majority of those interviewed were immensely appreciative of the services received. However, there were some complaints and criticisms, particularly with regard to the regularity, reliability and flexibility of care and the availability of information on services. As well as helping users to control their care, complaints can also contribute to monitoring and quality assurance processes. Where problems do arise, Trusts need to be responsive to users. Indeed for older service users the Committee feels that this is particularly important.

17. The Committee welcomes the intention to establish a Commissioner for Older People and expects that this will help to ensure that the interests of older people are adequately safeguarded and promoted and that any necessary changes to the domiciliary care process are secured.

18. The Committee welcomes as a step forward the introduction of a set of minimum care standards in 2006 but is disappointed that it has taken such a protracted period of time for these to actually come into effect. The Regulation and Quality Inspection Authority must ensure the quality of domiciliary care services and roll out its inspection process across each Board area without delay.

Summary of Recommendations

The Pattern of Care for Older People

1. The Committee agrees with the Department that care packages must be tailored to meet the individual’s needs. However, the Committee recommends that institutional care should be used only in cases where domiciliary care is not a feasible option. The vast majority of older people want to remain independent, in their own homes and in control of their own lives for as long as possible. If these objectives are to have a significant impact on the future development of care services for older people, the Committee would expect to see a substantial shift in funding from institutional to domiciliary care (see paragraph 14).

2. The Committee recommends that the Department reviews the arrangements for the provision of specialist equipment to ensure that older people receiving care in an institutional or domiciliary setting, either in the public or private sector, have equal access to specialist equipment appropriate to their needs (see paragraph 16).

3. The Committee welcomes the Accounting Officer’s acknowledgement that the targeting of domiciliary care on those older people requiring intensive services means that those with lesser needs may slip through the net. Even if these are lesser needs, they can have a great impact on quality of life. The Committee recommends that the Department and Trusts ensure that the distribution of resources recognises the contribution which meeting relatively lesser care needs can make to preventing more serious and expensive needs in the future (see paragraph 19).

4. The admission of older people to a residential or nursing home setting following a stay in hospital can severely damage their independence. The Committee recommends the development of domiciliary care packages to be considered some time prior to the decision to discharge. This process must be carefully planned, as seamless as possible and offer imaginative solutions (see paragraph 21).

5. The Committee is disappointed that instances of good discharge practice across Trusts in the Southern Health and Social Services Board area have not been translated to other areas and recommends that the Department ensures that any good practice is rolled-out across all Boards and Trusts promptly (see paragraph 22).

6. While recognising that improvements have been made, the Committee recommends that the Department carries out further investigations into the GB system before considering the introduction of penalties on Trusts in cases where discharge is substantially delayed through failure to arrange an appropriate care package (see paragraph 25).

7. While accepting the sensitivities of implementing the review, the Committee considers that the Department should, in the four year period since 2004, have taken steps to alter its budgeting arrangements to more accurately reflect demographic changes across Board areas. Given that the fifth Capitation Formula review is underway, the Committee recommends that the Department moves to implement the fourth review. Further, the Committee does not expect to see such an extended delay in implementing the fifth review (see paragraph 28).

Promoting the Improvement of Care Services for Older People

8. Given the invaluable contribution of informal carers, it is sensible and cost-effective to take full account of their needs for respite care support. The Committee notes existing respite provision within Trusts, but emphasises the need for flexibility in the choice of respite care. For instance, assistance could be made available in people’s own homes through sitting or sleepover services. Given the Department’s policy to ensure older people remain in their own homes, the Committee recommends that wherever possible, respite in an institutional setting should only be offered where it is the preferred option of all parties (see paragraph 30).

9. In the Committee’s view, given that the health and social care sectors have been integrated, the development of the single assessment tool is welcomed, if long overdue. Multidisciplinary assessment is a prerequisite for ensuring that the precise nature of individual needs is addressed before considering the options through which they can be met. The Committee sought assurance from the Department on the practicalities of delivering a holistic care package that meets the needs of the individual and recommends that the operation and outcomes of the assessment tool are closely monitored (see paragraph 33).

10. The Committee emphasises that the use of Direct Payments does not absolve Trusts from their responsibility to ensure the provision of quality domiciliary care. It notes the Department’s assurances that a system of registration will be fully operational within three to four years and recommends that this be supplemented by close monitoring of compliance with regulations and legislation (see paragraph 37).

11. The Committee welcomes the Department’s acknowledgement of the difficulties faced by the independent sector. The Committee recommends that the Department takes steps to raise the status and esteem of the social care profession. The Committee advised that failure to address this issue could lead to a shortfall in the standard and supply of domiciliary care services for older people (see paragraph 40).

12. The Committee recommends that the Department does more to improve links with the private and voluntary sectors. It believes that in order to achieve greater flexibility of supply and value for money in domiciliary care services, the Department needs to put measures in place which will encourage a full range of providers (see paragraph 45).

13. The Committee recognises that cost is not the only consideration in providing services for older people because factors such as safety in the delivery of support also have to be taken into account. However, the Committee is surprised that the Department has failed to properly investigate the variations in cost of in-house provision across Trusts and to compare these against the costs of independent home care providers. The Committee recommends that the Department carries out a rigorous and detailed examination of individual domiciliary care packages so that it can accurately assess the relative cost burden falling to the various agencies (see paragraph 46).

Providing Quality Domiciliary Care Services for Older People

14. The Committee does not share the Department’s view that clients’ concerns would be well known and remains of the opinion that a system of regular, confidential and independent surveys of users would be helpful within the care system to identify any underlying causes of dissatisfaction and to provide assurance that decision making is informed by the views of the users. The Committee recommends that the Department puts measures in place to ensure the flow of regular, high quality feedback from older people and carers (see paragraph 48).

15. The Committee considers that the existing lack of information provided to users and their families is unacceptable. The Committee recommends that the Department now takes steps to ensure that all Trusts are fulfilling their obligation to provide adequate information. In cases where it is identified that this is not happening, action must be taken to remedy the situation (see paragraph 50).

16. In recognition of the importance of complaints in the development of best practice the Committee recommends that the Department completes its review of the complaints process promptly to ensure that lessons are learnt from all complaints lodged. The Committee acknowledges the potential contribution of the proposed Commissioner for Older People to improvement in this area (see paragraph 54).

17. The Committee considers that the Department must be in a position to confirm that care provided to older people at least complies with specified minimum standards. The Committee recommends that the planned RQIA inspections commence as a matter of urgency in order that any problem areas are identified and resolved (see paragraph 56).

Introduction

1. The Public Accounts Committee (the Committee) met on 31 January 2008 for an evidence session with the Department of Health, Social Services and Public Safety. The session related to the Comptroller and Auditor General’s (C&AG’s) report: “Older People and Domiciliary Care”.

2. The witnesses were:

• Dr Andrew McCormick, Accounting Officer, Department of Health, Social Services and Public Safety;
• Mr Andrew Hamilton, Deputy Secretary, Department of Health, Social Services and Public Safety;
• Mr Paul Martin, Chief Social Services Officer, Department of Health, Social Services and Public Safety;
• Mr John Dowdall CB, Comptroller and Auditor General (C&AG); and
• Mr Ciaran Doran, Deputy Treasury Officer of Accounts.

3. Since 1990, and the publication of the policy document “People First”, the Department of Health, Social Services and Public Safety (the Department) has sought to transform its care system for the elderly from one dominated by residential and nursing home provision to one which offers flexibility and sufficient support to allow older people to remain at home for as long as possible.

4. The key to the shift in policy was a realisation of the need to promote independent living, user choice, innovation and cost effectiveness.

5. Despite the intended shift in care towards a domiciliary setting, significant numbers of older people with care needs, continue to be treated in an institutional setting rather than at home. As a consequence, the majority of available funding is diverted to care institutions. The Committee expects that, as progress is made in providing more care in the home, the balance of funding will shift.

6. The Department acknowledged that much has still to be done to speed up the discharge of older people from hospital and accepted that, where good practice is adopted within one Health and Social Care Trust, other Trusts should learn and adopt similar practices.

7. People First also drew attention to the need for greater independent sector involvement in the provision of domiciliary care services. However, the relationship between Trusts and the independent sector has remained weak and needs to be addressed to ensure that the availability and quality of services do not suffer.

8. In relation to the quality of domiciliary care, it became apparent that the Department needs to work more closely with its customers (carers and older people) to seek their views, respond to concerns, provide information on available services and assess the quality of care provided.

9. In taking evidence on the C&AG’s report, the Committee focused on three main issues. These were:

• the pattern of care for older people;
• promoting the improvement of care services for older people; and
• providing quality domiciliary care services for older people.

The Pattern of Care for Older People

10. The publication of “People First” in 1990 was a landmark in the development of public policy on care for older people. Its broad objective was to ensure that older people were enabled to maintain their independence and dignity and live in their own homes for as long as possible. Some 18 years later, the Department told the Committee it considered that the aspirations of the policy remained valid but accepted that some of its aims had not been achieved.

11. Despite the stated intention to provide care in the home, resources remain heavily invested in the institutional sector. In 2005-06, £236.4 million (60%) of the £394 million spent by Trusts on personal social services for older people was spent on residential and nursing home care. The Department told the Committee that, against a background of a growth in population and an increasing requirement for long term care, it considered that it was working against that trend and maintaining a good performance. It pointed to a 32% increase in domiciliary care provision over ten years and stated that increases in nursing care were in line with population increases.

12. While acknowledging the progress that has been made, the Committee is still of the view that there has been a failure to develop sufficient capacity in the domiciliary care sector to support the objectives of “People First”. The challenge for the Department is to ensure that it continues to respond to the changes in society so that the balance of care for older people is shifted further and more emphatically towards the delivery of domiciliary care provision.

13. The Department assured the Committee that there is no bias in favour of institutional care and that domiciliary care is offered wherever practical. While the Committee agrees that each case must be considered on an individual basis, this must be done within a framework which promotes the provision of domiciliary care for as many people as possible.

Recommendation 1

14. The Committee agrees with the Department that care packages must be tailored to meet the individual’s needs. However, the Committee recommends that institutional care should be used only in cases where domiciliary care is not a feasible option. The vast majority of older people want to remain independent, in their own homes and in control of their own lives for as long as possible. If these objectives are to have a significant impact on the future development of care services for older people, the Committee would expect to see a substantial shift in funding from institutional to domiciliary care.

15. The care needs of older people are individual. In delivering an effective care package, it is often necessary for an older person to have access to specialist equipment. For example, the individual may require a bespoke chair to meet their specific care needs. The Committee is aware of concerns that access to such equipment varies depending on the environment in which care is delivered. Older people receiving care at home are likely to be permanently provided with equipment tailored to their needs, while individuals in institutional care may be required to share equipment or make do with equipment similar to that which meets their needs. The Committee is keen that any disparities in treatment are eliminated.

Recommendation 2

16. The Committee recommends that the Department reviews the arrangements for the provision of specialist equipment to ensure that older people receiving care in an institutional or domiciliary setting, either in the public or private sector, have equal access to specialist equipment appropriate to their needs.

17. “People First” recommended that “services should concentrate on those with the greatest needs”. Implementation of this principle has resulted in services for older people which are often focused on a narrow range of intensive services that support the most vulnerable in times of crisis. The Committee has concerns that, as a consequence of this, older people with lower levels of need receive less help.

18. While recognising the need to address and provide services for those with complex needs, Boards and Trusts should be mindful that failure to address relatively lesser needs may result in a missed opportunity to prevent future crises or deterioration in independence. Minor interventions such as the provision of meals on wheels or day centre access can assist in preventing, or at least delaying, admission to hospital and/or residential/nursing homes. The approach has to be a focus on a range of services and interventions that make the most difference to older people’s well-being, planned and delivered in ways that offer maximum flexibility, choice and control.

Recommendation 3

19. The Committee welcomes the Accounting Officer’s acknowledgement that the targeting of domiciliary care on those older people requiring intensive services means that those with lesser needs may slip through the net. Even if these are lesser needs, they can have a great impact on quality of life. The Committee recommends that the Department and Trusts ensure that the distribution of resources recognises the contribution which meeting relatively lesser care needs can make to preventing more serious and expensive needs in the future.

20. For many older people admitted to hospital, it is essential that a domiciliary care package is agreed and available before any return home can be considered. With significant pressure on Trusts to speed up hospital discharge, the absence of a suitable care package can often mean that the only immediate option is admission to a nursing or residential setting. The Department acknowledged that it has had ongoing concerns about these issues. It also told the Committee of the positive action taken by the Southern Health and Social Services Board and its Trusts. There, interim, step down arrangements had been introduced to phase older people back into their own homes after a hospital admission. A more comprehensive assessment of long term care is then developed when the needs of the older person become clearer. The Department confirmed that this good practice has not been shared and rolled-out across the Trusts.

Recommendation 4

21. The admission of older people to a residential or nursing home setting following a stay in hospital can severely damage their independence. The Committee recommends the development of domiciliary care packages to be considered some time prior to the decision to discharge. This process must be carefully planned, as seamless as possible and offer imaginative solutions.

Recommendation 5

22. The Committee is disappointed that instances of good discharge practice across Trusts in the Southern Health and Social Service Board area have not been translated to other areas and recommends that the Department ensures that any good practice is rolled-out across all Boards and Trusts promptly.

23. The C&AG’s report highlighted the mixed performance of Boards and Trusts in meeting discharge targets. The Committee takes this issue of “bed-blocking” very seriously as delayed discharges not only mean that patients are unable to return to their own homes but also that acute hospital beds are not being used to treat people on waiting lists. Additional information provided to the Committee by the Department after the session, shows that some progress has been made by Trusts in meeting more challenging discharge targets.

24. The Committee is aware that local authorities in England have introduced a system of fines in cases where failure to arrange home care for older people prevents discharge. The Department told the Committee that, in its view, the financial autonomy of local authorities facilitates such arrangements. In Northern Ireland, where Trusts are fully funded from public expenditure, the Department contends that similar arrangements would displace available resources and put Trusts in a difficult financial position. The Committee was not persuaded and sees merit in the Department carrying out further investigations into the GB system before giving consideration to the introduction of some form of financial sanction to support the aim of managing discharges effectively.

Recommendation 6

25. While recognising that improvements have been made, the Committee recommends that the Department carries out further investigations into the GB system before considering the introduction of penalties on Trusts in cases where discharge is substantially delayed through failure to arrange an appropriate care package.

26. The Capitation Formula Review is used to distribute health budgets to the Boards according to the size and the age profile of the population. In 2004, the fourth Capitation Formula review was published. The Committee is alarmed that, four years after its issue, the Department has not used the review as the basis for allocating funds. The implications of failing to implement the review are particularly visible in the Northern Board where the population of elderly people is growing considerably and yet funding is significantly less than that recommended in the 2004 review.

27. The Department confirmed that it is aware that the delay in implementing the fourth Capitation Formula review has had implications, particularly for the Northern Board. It stressed however, that if it “moved too quickly and transferred resources precipitously”, it would cause significant disruption to services in other areas – primarily the Eastern Board area where funding would be reduced. The Department considers that given the sensitivities, it is justified in being “careful and thoughtful in its actions”.

Recommendation 7

28. While accepting the sensitivities of implementing the review, the Committee is of the view that the Department should, in the four year period since 2004, have taken steps to alter its budgeting arrangements to more accurately reflect demographic changes across Board areas. Given that the fifth Capitation Formula review is underway, the Committee recommends that the Department moves to implement the fourth review. Further, the Committee does not expect to see such an extended delay in implementing the fifth review.

Promoting the Improvement of
Care Services for Older People

29. The role played by informal carers (such as family and friends), is critical to providing a quality service. The Department acknowledges the significant impact this has on reducing the numbers of older people requiring care in a residential or nursing setting. Intermittent respite care provided by Trusts, where the older person is temporarily cared for in an institutional setting, can assist in preventing the collapse of long term care offered by family and friends.

Recommendation 8

30. Given the invaluable contribution of informal carers, it is sensible and cost-effective to take full account of their needs for respite care support. The Committee notes existing respite provision within Trusts, but emphasises the need for flexibility in the choice of respite care. For instance, assistance could be made available in people’s own homes through sitting or sleepover services. Given the Department’s policy to ensure older people remain in their own homes, the Committee recommends that wherever possible, respite in an institutional setting should only be offered where it is the preferred option of all parties.

31. Current policy in health and social care emphasises the importance of a comprehensive assessment of people’s needs in order to adequately determine and deliver the most appropriate care and services. A Departmental review of community care in 2002 concluded that the lack of a common approach across Trusts has led to inequality of provision.

32. To address this, the Department employed the University of Ulster to develop a single comprehensive assessment tool for assessing older people’s needs for health and social services. This tool will be unique in the United Kingdom and is expected to be rolled out across Northern Ireland in 2008-09. The Department expects that the tool will ensure integration of the health and social care system and ensure consistency of approach and standards.

Recommendation 9

33. In the Committee’s view, given that the health and social care sectors have been integrated, the development of the single assessment tool is welcomed, if long overdue. Multidisciplinary assessment is a prerequisite for ensuring that the precise nature of individual needs is addressed before considering the options through which they can be met. The Committee sought assurance from the Department on the practicalities of delivering a holistic care package that meets the needs of the individual and recommends that the operation and outcomes of the assessment tool are closely monitored.

34. Direct Payments are cash payments made in lieu of social service provision to individuals who have been assessed as needing care. They were introduced in 1996 as a means of sustaining the contribution made by informal carers. Through direct payments older people have access to funding which they can then use to pay for personal assistants or to purchase goods and services. However, while Direct Payments have the potential to increase choice and independence, the autonomy of the process can create difficulties in assessing the relative quality of care provided. It is, of course, essential to keep the burden of operating these arrangements to a minimum.

35. Uptake of Direct Payments is consistently low and the Department is keen that more use should be made of the facility. The Committee considers that the low uptake may reflect the fact that the amount available under the Direct Payment Scheme is less than the average cost of care. As a result, unless the older person has sufficient income to top-up the payment they may be required to accept lower quality care. The Committee is also concerned that, in many cases, carers employed under the Direct Payment Scheme may be subjected to less regulation.

36. The Department informed the Committee that of the 40,000 people who work in social care in Northern Ireland, 12,000 work in the domiciliary sector. Over the next three to four years this entire workforce will have to register with the Northern Ireland Social Care Council. In addition, the 600 organisations providing care will have to register with the Regulation and Quality Improvement Authority. This, the Department considers, will enable implementation of a programme of regulation to safeguard those who purchase care through the Direct Payments Scheme.

Recommendation 10

37. The Committee emphasises that the use of Direct Payments does not absolve Trusts from their responsibility to ensure the provision of quality domiciliary care. It notes the Department’s assurances that a system of registration will be fully operational within three to four years and recommends that this be supplemented by close monitoring of compliance with regulations and legislation.

38. It can be difficult to employ and retain staff in the domiciliary care sector. In the voluntary sector, the lack of guaranteed hours, the low hourly rates payable and the often poor conditions of employment can affect the morale of staff and hinder recruitment and retention of staff. In a letter from the United Kingdom Home Care Association (UKHCA) to the Committee it stated that it considers that the planned introduction of enhanced regulation, such as compulsory care worker training and fee paying criminal record checks, will pose significant challenges to providers and compound the existing problems.

39. The Department accepts that the challenge of sustaining an appropriate workforce in this area is immense - particularly in light of the rising numbers of older people who need care. It anticipates that the introduction of registration and regulation will raise esteem within the care provision sector and that this should, eventually, ease recruitment and retention difficulties. The Department also pointed to the introduction of a new personal social services training strategy in 2006 which covers both the independent and statutory sectors and its intention to revisit the quality of its social care workforce when the new health and social services structures are in place.

Recommendation 11

40. The Committee welcomes the Department’s acknowledgement of the difficulties faced by the independent sector. The Committee recommends that the Department takes steps to raise the status and esteem of the social care profession. The Committee advised that failure to address this issue could lead to a shortfall in the standard and supply of domiciliary care services for older people.

41. The C&AG’s report suggests that contracting out has yet to be developed to its full potential and that domiciliary care services offered by the independent sector presently complement rather than substitute for those provided by Trusts. Spot contracts with the independent sector are commonly used to “top up” statutorily provided services. The Department told the Committee that there was some evidence of growth in the independent sector and that procuring the most effective services is affected by what is available in various areas.

42. The Committee considers that there is a need for more stability for the independent sector and while it welcomes the Department’s undertaking to create a better platform for providers, it is critical of the time taken to address the problem.

43. In a review of services in 2002, the Department identified that the independent sector considered that it was not involved as an equal partner in the development of community care; that its relationship with the statutory sector had become quite strained; and that contract prices for basic levels of community care needed to be agreed. The Department acknowledged that this is a challenging area and that it must ensure that a system is built that can work in the medium to long term. It pointed out that the reorganisation of the Trusts provides an opportunity to take a different, more standardised and centralised approach to procurement.

44. In its letter, the UKHCA stated that, with an hourly rate of £9.84, it offers more cost-effective care services than those offered by Trusts. The Department told the Committee that the figures quoted were an overstatement. Revised figures submitted to the Committee by the Department show that the actual, hourly cost of in-house services offered by Trusts ranges from £9.74 to £15.42. Nevertheless, the Department acknowledged the considerable variation in rates between Trusts and told the Committee that it expects more uniformity in rates with the operation of the new Trusts since April 2007.

Recommendation 12

45. The Committee recommends that the Department does more to improve links with the private and voluntary sectors. It believes that in order to achieve greater flexibility of supply and value for money in domiciliary care services, the Department needs to put measures in place which will encourage a full range of providers.

Recommendation 13

46. The Committee recognises that cost is not the only consideration in providing services for older people because factors such as safety in the delivery of support also have to be taken into account. However, the Committee is surprised that the Department has failed to properly investigate the variations in cost of in-house provision across Trusts and to compare these against the costs of independent home care providers. The Committee recommends that the Department carries out a rigorous and detailed examination of individual domiciliary care packages so that it can accurately assess the relative cost burden falling to the various agencies.

Providing Quality Domiciliary
Care Services for Older People

47. A survey carried out by the C&AG showed that, while older people were generally satisfied with the support they received, there was an undercurrent of dissatisfaction with issues such as the poor timing of care visits, the flexibility of care staff, their reliability and attitudes. The Committee was concerned that, although the Department had carried out a survey to gauge the views of carers of older people, neither it, nor any Board or Trust, had undertaken such an exercise to assess the views of older people in receipt of care. The Department acknowledged the potential value of a survey but stressed that, in its view, given the involvement and interaction of service providers and users, clients’ concerns would be well known.

Recommendation 14

48. The Committee does not share the Department’s view that clients’ concerns would be well known and remains of the opinion that a system of regular, confidential and independent surveys of users would be helpful within the care system to identify any underlying causes of dissatisfaction and to provide assurance that decision making is informed by the views of the users. The Committee recommends that the Department puts measures in place to ensure the flow of regular, high quality feedback from older people and carers.

49. The C&AG’s survey also showed that 20% of those surveyed believed that their views were not taken into account and over half of those surveyed considered that they did not have enough input into their care. The Committee was also concerned by revelations that “one third of respondents considered they did not have enough information on the services available” and only half had a copy of the relevant documentation. The Committee views these as fundamental weaknesses in the system. The Department acknowledged that the results were worrying and agreed that users and their families should have full information on the services that are available, on their rights and entitlement, and on whom they should contact if something goes wrong.

Recommendation 15

50. The Committee considers that the existing lack of information provided to users and their families is unacceptable. The Committee recommends that the Department now takes steps to ensure that all Trusts are fulfilling their obligation to provide adequate information. In cases where it is identified that this is not happening, action must be taken to remedy the situation.

51. Although the results of the C&AG’s survey were generally positive, one in five respondents has had to make a complaint at one time or another. The ability to learn from complaints can facilitate the improvement of care systems. For this process to be effective, however, controls must be in place to enable providers to learn from mistakes.

52. The Department said that it encourages a culture of learning from mistakes without placing too much emphasis on apportioning blame. The Committee endorses this as good practice. The Department explained that most complaints are resolved simply and monitored at a local level. In cases where resolution cannot be achieved, independent mechanisms exist. Work is being concluded on amending the complaints process to ensure that it is effective, independent and clear and that people have confidence in it.

53. In the Committee’s view, the results of the C&AG’s survey suggest that complaints are not sufficiently used to inform and improve care provision. Although the Department offered assurance that sanctions are in place, for example, where carers fail to turn up, the incidence of dissatisfaction expressed through the survey indicates that much remains to be done. Resolution at local level may not lead to widespread learning across the sector and, as a result, may create anomalies in treatment.

Recommendation 16

54. In recognition of the importance of complaints in the development of best practice, the Committee recommends that the Department completes it review of the complaints process promptly to ensure that that lessons are learnt from all complaints lodged. The Committee acknowledges the potential contribution of the proposed Commissioner for Older People to improvement in this area.

55. Equally important in maintaining standards in domiciliary care will be the role of the new Regulation and Quality Improvement Authority (RQIA). RQIA will conduct inspections to assess the quality of care provision against a set of new minimum care standards issued by the Department in March 2006. The Committee was concerned to learn that these inspections have not yet begun and indeed will not commence until 2008-09. In the interim, the Committee considers that the Department, Trusts and Boards have limited assurance that older people are receiving care equating to even minimum standards.

Recommendation 17

56. The Committee considers that the Department must be in a position to confirm that care provided to older people at least complies with specified minimum standards. The Committee recommends that the planned RQIA inspections commence as a matter of urgency in order that any problem areas are identified and resolved.

Appendix 1

Minutes of Proceedings of the Committee Relating to the Report

Thursday, 31 January 2008
Senate Chamber, Parliament Buildings

Present: Mr John O’Dowd (Chairperson)
Mr Roy Beggs (Deputy Chairperson)
Mr Jonathan Craig
Mr Simon Hamilton
Mr David Hilditch
Mr Trevor Lunn
Mr Ian McCrea
Mr Mitchel McLaughlin
Ms Dawn Purvis

In Attendance: Mrs Debbie Pritchard (Principal Clerk)
Mr Jim Beatty (Assembly Clerk)
Mrs Gillian Lewis (Assistant Assembly Clerk)
Mrs Nicola Shephard (Clerical Supervisor)
Mr Ricky Shek (Clerical Officer)

Apologies: Mr Patsy McGlone

The meeting opened at 2.00pm in public session.

3. The Chairperson welcomed Mr John Dowdall CB, Comptroller and Auditor General (C&AG) and Mr Ciaran Doran, Deputy Treasury Officer of Accounts (Deputy TOA), to the meeting.

4. Evidence on the NIAO Report ‘Older People and Domiciliary Care’.

The Committee took oral evidence on the NIAO report ‘Older People and Domiciliary Care’ from Dr Andrew McCormick, Accounting Officer, Department of Health, Social Services and Public Safety (DHSSPS), Mr Andrew Hamilton, Deputy Secretary, Healthcare Policy Group, DHSSPS, and Mr Paul Martin, Chief Social Services Officer, DHSSPS.

2.09pm Mr McCrea joined the meeting.

The witnesses answered a number of questions put by the Committee.

Members requested that the witnesses should provide additional information on some issues raised during the evidence session to the Clerk.

3.50pm The evidence session finished.

[EXTRACT]

Thursday, 28 February 2008
Room 144, Parliament Buildings

Present: Mr John O’Dowd (Chairperson)
Mr Roy Beggs (Deputy Chairperson)
Mr Jonathan Craig
Mr John Dallat
Mr Simon Hamilton
Mr David Hilditch
Mr Ian McCrea
Mr Mitchel McLaughlin

In Attendance: Mr Jim Beatty (Assembly Clerk)
Mrs Gillian Lewis (Assistant Assembly Clerk)
Mrs Nicola Shephard (Clerical Supervisor)
Mr Ricky Shek (Clerical Officer)

Apologies: Mr Trevor Lunn
Mr Patsy McGlone
Ms Dawn Purvis

The meeting opened at 2.00pm in public session.

2.17pm The meeting went into closed session.

7. Consideration of the Committee’s Draft Report into Older People and Domiciliary Care.

Members considered the draft report paragraph by paragraph. The witnesses attending were Mr John Dowdall CB, C&AG, Mr Sean McKay, Director of Value for Money, Ms Clare Dornan, Audit Manager, and Mr Joe Campbell, Audit Manager, NIAO.

The Committee considered the main body of the report.

Paragraph 1 read and agreed.

Paragraph 2 read, amended and agreed.

Paragraphs 3 - 6 read and agreed.

2.55pm Mr Hamilton joined the meeting.

Paragraphs 7 – 13 read and agreed.

Paragraph 14 read, amended and agreed.

Paragraphs 15 – 21 read and agreed.

Paragraph 22 read, amended and agreed.

Paragraph 23 read and agreed.

Paragraphs 24 and 25 read, amended and agreed.

Paragraphs 26 – 29 read and agreed.

Paragraph 30 read, amended and agreed.

Paragraphs 31 and 32 read and agreed.

Paragraphs 33 – 35 read, amended and agreed.

Paragraph 36 read and agreed.

Paragraph 37 read, amended and agreed.

Paragraph 38 read and agreed.

Paragraphs 39 and 40 read, amended and agreed.

Paragraphs 41 - 45 read and agreed.

Paragraph 46 read, amended and agreed.

Paragraph 47 read and agreed.

Paragraph 48 read, amended and agreed.

Paragraphs 49 – 53 read and agreed.

Paragraph 55 read, amended and agreed.

Paragraph 56 read and agreed.

3.45pm Mr McCrea left the meeting.

Paragraph 54 read, amended and agreed.

The Committee considered the Executive Summary of the report.

Paragraph 1 read, amended and agreed.

Paragraphs 2 - 9 read and agreed.

Paragraphs 10 and 11 read, amended and agreed.

3.52pm Mr McCrea rejoined the meeting.

Paragraph 12 read, amended and agreed.

Paragraphs 13 - 17 read and agreed.

Paragraph 18 read, amended and agreed.

Agreed: Members ordered the report to be printed.

Agreed: Members agreed that the Chairperson’s letter requesting additional information and the response from the Accounting Officer, Department of Health, Social Services and Public Safety, and the letter from the UK Home Care Association Ltd, would be included in the Committee’s report.

Agreed: Members agreed to embargo the report until 00.01am on 10 April 2008, when the report would be officially released.

Agreed: Members agreed that they would not hold a press conference.

[EXTRACT]

Appendix 2

Minutes of Evidence

31 January 2008

Members present for all or part of the proceedings:
Mr John O’Dowd (Chairperson)
Mr Roy Beggs (Deputy Chairperson)
Mr Jonathan Craig
Mr Simon Hamilton
Mr David Hilditch
Mr Trevor Lunn
Mr Ian McCrea
Mr Mitchel McLaughlin
Ms Dawn Purvis

Witnesses:

Mr Andrew Hamilton Dr Andrew McCormick Mr Paul Martin

Department of Health, Social Services and Public Safety

Also in attendance:

Mr John Dowdall CB		Comptroller and Auditor General
Mr Ciaran Doran		Deputy Treasury Officer of Accounts

1. The Chairperson (Mr O’Dowd): I remind members, guests and witnesses that, as evidence is being recorded for use in the Committee’s report, they must turn off their mobile phones; even if they are turned to silent mode, they interfere with the recording equipment.

2. There are two evidence sessions today; the first is on the NIAO’s report, ‘Older People and Domiciliary Care’, and the second will cover the memorandum of response on the use of operating theatres in the Department of Health, Social Services and Public Safety.

3. Appearing today are: Dr Andrew McCormick, accounting officer for the Department of Health, Social Services and Public Safety; Mr Andrew Hamilton, deputy secretary of the healthcare policy group in the Department; and Mr Paul Martin, the chief social services officer in the Department. Thank you all for coming to assist the Committee in the compilation of its report.

4. I will start by asking questions, and then Committee members will question the witnesses. Given that you have been here recently, you know the format.

5. Paragraph 1.4 of the Comptroller and Auditor General’s report states that ‘People First’ is the main policy document on the subject of older people and domiciliary care. That was published in 1990 and seems to have been a landmark publication in the Department’s approach to the issue. Surprisingly, it has not been updated in the past 18 years, and further to that, some of its aims have not been achieved. Do you still see that document as a reflection of the Department’s aspirations for the care of older people?

6. Dr Andrew McCormick (Department of Health, Social Services and Public Safety): Good afternoon. Thank you for giving us the opportunity to give evidence on this subject.

7. Although much has changed in the world since ‘People First’ was published, the broad thrust of the policy remains valid. The direction of the policy is clear — older people want to maintain their independence and dignity and live in their own houses for as long as possible, so since 1990, there has been a consistent pursuit of delivering that change in services. When ‘People First’ was published, it represented a significant change of direction, given that at that time there was exponential growth in nursing-home care.

8. There will always be significant need for nursing-home care; some people, for example, may require a higher level of care, and 24/7 care at home for them is not the best option. One would expect numbers who need a great deal of care to increase, given that more people are living longer: in the past 10 years, there has been a 12% growth in the number of people over 65, and a 25% increase in the over 85s. Over the next 20 years, the number of over 85s is projected to double. Therefore, the need for adequate care provision is increasing, and the objective is to help as many people to maintain their independence for as long as possible. The broad strategy remains the same; we just need to be aware of the many changes that are occurring in wider society, respond accordingly to those, and ensure that the delivery of care is as effective as possible.

9. The Chairperson: Paragraph 2.7 of the Comptroller and Auditor General’s report shows that, although the number of domiciliary-care packages has increased since the mid-1990s, the proportion of older people receiving care in their own homes has remained static. Is there still a bias towards institutional forms of care? In your answer to my first question, you said that caring for people at home is at the core of the Department’s strategy. However, the statistics seem show that the situation has remained the same.

10. Dr McCormick: It is important to look at the full range of statistics, some of which are highlighted in the report. The main point is that there has been a 12% growth in population. Therefore, the 12% growth in the number of people in nursing homes — which is shown in figure 3 of the report — is not surprising and is broadly in line with the population trend. Given that more of those people are very elderly and, as a result, have long-term conditions and diseases that require long-term care, it is a significant achievement that the growth in nursing-home care has only been in line with the total population, instead of rising more rapidly, which was the case before ‘People First’ was published.

11. Figure 3 also shows that there was a 32% growth in domiciliary care over 10 years. That statistic illustrates that the proportion of those in need has been rising. That means that in the past couple of years, growth has been faster in the domiciliary-care sector than in the nursing-home care sector. Therefore, it is important to consider the totality of the numbers that are given in the report and to draw on the full range of evidence.

12. Contrary to what you asked me, the bias, intent and purpose of our policy is to enable people to receive care in their homes when possible. The correct approach is to consider the needs of each individual on a professional basis, but within a policy framework that seeks to provide domiciliary care for as many people as possible. It is important to consider that total picture.

13. The Chairperson: Therefore, following your logic, are you suggesting that because people are living longer, more will move into residential care, rather than stay in their homes?

14. Dr McCormick: That is certainly what will happen if nothing is done. However, the Health Service and the Department are intervening and building up domiciliary care; therefore, we are working against that trend and are maintaining a good performance.

15. The target for 2010 is to provide domiciliary care for 45% of people who require any kind of care. Currently, 41% of elderly people who require care are receiving domiciliary care. Although our figures and those of our counterparts across the water cannot be compared completely on a like-for-like basis, we are in a significantly better position. They have set a target of 34%, and we know that a large number of local authorities are not achieving that target. As I have said, the systems are not precisely like for like, but we are confident that we are doing comparatively well.

16. The policy process and the aims are clear, and there is no bias in favour of institutional care. On the contrary; the clear policy intention is to provide the care that people want. That will be more effective, more dignified, and better for all concerned.

17. The Chairperson: Paragraph 3.5 of the Audit Office report refers to targeting domiciliary care towards those who have intensive needs. Although that may ensure that those who have the most intensive needs are well served, surely the downside is that many older people who have lesser needs will slip through the net, resulting in missed opportunities to prevent crises and promote the well-being of older people living in the community.

18. By setting targets, is there a danger of hiding the fact that many old people who are socially excluded and living on their own no longer have the assistance of home helps? Such people would have called to help with basic needs such as preparing a breakfast or lighting a fire, although I suppose with oil-fired central heating that is no longer an issue. However, there are still instances in which minor interventions would enable older people to stay at home. Are such opportunities being missed?

19. Dr McCormick: I hope that they will not be entirely missed. That issue must be acknowledged, and the report refers to it. Giving necessary priority to meeting highly complex needs has made it more difficult for the statutory sector to provide less complex care. That is why we are so grateful for and acknowledge strongly the wider contributions of carers, the voluntary and community sectors and wider society in helping many individuals.

20. From a policy and operational point of view, it is vital that we support, underpin, acknowledge and strengthen those contributions. Such care provision is difficult to secure, but many people contribute to it by facilitating partnership between the statutory and other sectors. Therefore, as the report makes clear, that is a genuine issue, and we acknowledge that.

21. We are seeking the right balance. Sometimes the kind of care that you have described serves the strategic objective of helping individuals and ensuring that they have quality of life and dignity for as long as possible. That is what we are trying to achieve.

22. We encourage small-scale and informal care where it is effective. However, we must work in partnership and balance the use of resources to meet the highest priority needs. It would be wrong to fail to meet complex needs; sometimes they must be prioritised. Therefore, finding the best way to deal with less complex care is a genuine problem.

23. The Chairperson: No one would argue against people who have complex needs requiring intervention. Although you acknowledge that point, are you saying that your method of tackling the problem is to work in conjunction with the community, voluntary and other sectors? Does a programme or scheme exist to tackle that anomaly?

24. Dr McCormick: The general strategy approach is that everyone in the system knows that that is the right thing to do. How that works in practice often manifests itself best at a local level. Mr Hamilton might perhaps like to add to that point.

25. Mr Andrew Hamilton (Department of Health, Social Services and Public Safety): In addition to the core domiciliary-care packages, a range of activities is aimed at promoting independent living for elderly people. For example, the meals-on-wheels service and day-centre provision have increased significantly over that period.

26. The voluntary sector is very active. Approximately 440 voluntary- and community-sector organisations are involved in the health and social care arena, and their total turnover is about £120 million. Although many of those organisations employ their staff directly, we could not avoid mentioning the 8,000 volunteers who freely give their time. That is all part of the rich pattern of activity that supports our elderly colleagues’ ability to continue living independently in their own homes.

27. Mr Hilditch: Paragraph 2.4 of the report discusses the targets that have been set for the provision of domiciliary care. Given that older people are an important and distinct group, why has the Department not set a separate target for them?

28. Dr McCormick: Our statistics are subdivided in order to monitor trends in such groups. We have set principal targets in order to hold organisations to account and to work effectively with them. However, if there are too many targets, that becomes harder to do and is less effective. We monitor incoming information regularly and closely in order to maintain the clearly stated policy of increasing the number of elderly people who receive domiciliary care.

29. Mr Hilditch: Might that aim change in the future?

30. Dr McCormick: We always keep the targets under review because circumstances move on and contexts change, and it is an ongoing process to ensure that targets match what is most important to society. Ultimately, they are the Minister’s targets, and if the tide of opinion from the Minister or the wider body politic is that a particular issue matters more than it did before, the targets can, and should, change to reflect that. That is how the service is led and driven.

31. Mr Hilditch: Paragraph 2.8 shows that, since 2002, the largest increase in care packages for the elderly has been in the nursing-home sector. Despite the Department’s stated policy, is it the case that it is often more cost-effective to purchase 24-hour nursing-home care than to provide an intensive domiciliary-care package for a vulnerable person?

32. Dr McCormick: Funding is not the only consideration. We attempt to ensure that the service that is provided is the most appropriate and helpful to the individual. As I said earlier, packages are put together on a case-by-case basis. The purpose and direction of policy is to ensure that as many people as possible are treated in a domiciliary context, and the longer-term trend, over 10 years, shows that the greatest growth has been in the domiciliary-care sector. The number of people who receive nursing-home care is what it needs to be — or more — and that reflects our clear intention.

33. Mr A Hamilton: The report details changes that have occurred since 2002, but the trend is definitely towards domiciliary care. Since 2001, nursing-home provision has increased by 11% and domiciliary care has increased by 18%. Since 2003, nursing-home provision has increased by 3% and domiciliary care has increased by 11%.

34. Mr Hilditch: The report states:

“that there is also a substantial degree of difference across Trusts in the proportion of older people cared for at home.”

It could be said that those differences reflect the fact that the community-care services are not driven by the vision of giving older people choice, but that managers at local level are struggling to develop services without clear direction. How would you respond to such a view?

35. Dr McCormick: The direction is consistent. Last year’s amalgamation of trusts was an important change. There are now only five fully integrated health and social care trusts. One clear intention behind that is to ensure that there is a stronger regional focus and a standardised provision so that people can expect a high standard of care wherever they are in any given region. As figure 4 shows, different contexts and circumstances mean that it is inevitable that there will be some degree of local variation among the populations served. Undoubtedly, in a complex organisational context, there will be some differences of behaviour and leadership. Family preferences and the supply and availability of different forms of care, such as statutory-sector residential homes or independent domiciliary care, also come into play. There is some scope for variation, and the reorganisation should ensure that the standard of care that is being provided and the access to it are more consistent. That is, potentially, a significant benefit of organisational change.

36. Mr Hilditch: Against the backdrop of increasing growth in numbers of older people, figure 5 illustrates the decline that there has been in interventions such as meals services and home help. Can you explain that?

37. Dr McCormick: Again, it is important to keep that in perspective. The trend figures in the report show significant increases in some aspects of care, such as the meals service, in total care packages. It is a question of finding the right balance of care, as I said to the Chairperson earlier. We must ensure that all aspects of care are properly managed. Meeting the most complex needs is a significant priority, although, as Andrew Hamilton said, other services have grown that complement the main aspects of care that are highlighted in figure 5.

38. Mr Lunn: I have some questions about first, the acute social-care staff shortages that are referred to in the Audit Office report, and secondly, about the paper submitted by the United Kingdom Home Care Association (UKHCA) — I presume that you are familiar with that paper.

39. Paragraph 3.21 of the Audit Office report contends that there are difficulties in recruiting and retaining workers in the domiciliary-care sector. The UKHCA paper warns that the requirements of regulation, care-worker training and the new fee-paying criminal record check will also have a detrimental effect on a sector that is already struggling to recruit and retain staff. It will also have an impact on the morale of independent providers. However, recruitment and retention are vital in order to sustain a service that is of sufficiently high quality for those who need it. How will the sector in general rise to the challenge of recruiting, training and developing domiciliary-care workers?

40. Dr McCormick: That is a very important part of this topic. It is important to consider the UKHCA’s comments. The challenge is immense, because with the rise in numbers of those who need care, it is vital to create a growing esteem for the function and the workload of those who provide social care. It is vital that we recruit and retain workers. That also applies to all the organisations, whether they are in the statutory or independent sectors.

41. Regulation and registration is one way of raising the esteem of the care-provision sector, with the result that its status should increase in the long term. We want to see that important possibility pursued, and the Northern Ireland Social Care Council is also working on that area. It is an important development.

42. That leads us into a discussion about market forces. There is no evidence of a specific recruitment and retention issue, but we are aware of those matters, and we monitor them. It must be taken fully into account when planning and resourcing of the sector is being considered. Rates of payment and other factors must be monitored carefully so that we ensure that there is a viable workforce. It is important that we do not procure merely on the basis of lowest cost. The importance of sustainable and sustained provision of a workforce for the sector needs to be recognised. We need to ensure that the market is built, strengthened and secured so that long-term availability is provided. We all hope that the care sector will be a source of growing employment, because we will all depend on carers —on the kindness of strangers, as it were — in the future.

43. Mr Lunn: The UKHCA paper indicates that boards and trusts also have difficulties in retaining staff. Their difficulties are compounded by the conditions in which workers are obliged to operate when they contract to work for the trusts. Spot contracting and the lack of guaranteed hours mean that the employment that boards and trusts offer is unstable, with the result that the impact on those who need care is doubled. I am heartened to hear you say that we need more stability and a way forward that may provide the UKHCA with a better platform from which to work. However, that has taken some time to be implemented. Does the annual 17·9% turnover of staff alarm you?

44. Dr McCormick: It is not that surprising, given the nature of the work and what would suit the circumstances of many of those who provide the care. There is fluidity in the system: that is how things are. However, we must manage and regulate it carefully.

45. Concerns about security checking were mentioned. In a context where people spend a great deal of time on a one-to-one basis, good regulation must exist and thorough checks must be carried out. That creates cost, but that must be borne by the system. We must have the right balance between adequate provision and provision of the right quality. We must safeguard vulnerable elderly people and the rights of staff in order to ensure that a proper and careful balance can be found.

46. Mr Paul Martin (Department of Health, Social Services and Public Safety): I take the point that many challenges lie ahead. The workforce in question is massive: 40,000 people work in social care in Northern Ireland. Of that, 12,000 work in domiciliary-care services alone, and, of those, over 50% work part time. Those figures reflect the significance of the challenge that we face.

47. Regulation is important. Uniquely, in Northern Ireland, we are moving to regulate the entire workforce. That is for three reasons: first, to bring added protection to the vulnerable people who use social services — including domiciliary-care services — in Northern Ireland; secondly, as Dr McCormick has mentioned, to raise the standards and quality of the services provided; and finally, to raise the status and standing of the social-care workforce in Northern Ireland. The latter point is important in the context of your question about securing the workforce into the future.

48. For the first time, in our personal social services training strategy, which was launched in late 2006, we have embraced not just the statutory and voluntary sectors, but the private sector.

49. When the new health and social services structures are in place we will revisit how we will secure the strategic objectives of a properly trained, properly qualified workforce across social services. We are aware that it is a challenge; therefore we have set in place a strategy to achieve it.

50. Mr Lunn: Paragraph 3.24 states that trusts are still responsible for 65% of spending on domiciliary care provision, although I realise that that figure has changed slightly. In a paper submitted to the Committee, the United Kingdom Home Care Association, on the other hand, expressed its belief that the independent sector is cost-effective and can develop new services to meet the demand for greater user involvement and choice. Why has there not been more success in developing closer links with the private and voluntary sectors to offer those services? Why has the percentage remained so high?

51. Dr McCormick: The approach is to ensure that there is a viable partnership and growth in the independent sector; that is important as there are limits to what the statutory sector can do. All those elements must work together, and there must be no bias. We are looking for a defined way to procure the most effective care services, and that is affected by what is available in various areas. There is no uniformity of supply; it varies from area to area.

52. In the past few years, there has been more growth in the independent sector than in the statutory sector. Between 2003-04 and 2006-07, there was a 2% growth in hours worked in the statutory sector and a 32% growth in the independent sector. However, that sector is starting from a lower base, so I do not want to overstate that figure. Nevertheless, there is growth. From the control and management point of view, it is important to ensure consistency of standards and provision to allow it to develop properly. There is some evidence of growth, and we want to work closely with the umbrella organisations, including the United Kingdom Home Care Association and the Independent Health and Care Providers, to ensure that there is an understanding of the issues that they face so that the necessary response can be provided in the community.

53. Mr Lunn: The United Kingdom Home Care Association claims to be more cost-effective and, judging by the figures provided in its paper, it would be hard to argue with that. The PricewaterhouseCoopers report in 2005 gave detail on the independent sector rates, but why did that report not cover the in-house sector as well? What is the point in doing a report on one third of the industry?

54. Mr A Hamilton: The focus and objective of that work was primarily to reach agreement on a reasonable and fair rate of remuneration for the independent sector; it was not a comparison between the statutory sector and the independent sector.

55. Our analysis suggests that cost differences between the independent sector and the statutory sector are not as great as suggested in the United Kingdom Home Care Association report: the average cost of care in the statutory sector is between £11 and £12, and it is just over £11 in the independent sector. Indeed, if you had to procure one additional hour of care, it would be cheaper to employ someone directly for an additional hour rather than buy one additional hour from the independent sector. There is a marginal cost issue here as well, so it is quite complicated.

56. The matter is not as simple as projected in the response from the UKHCA.

57. Mr Lunn: I am sure that it is never simple. The problem seems to be getting accurate figures for the cost of in-house care. The UKHCA figures show that the cost of services ranged from £9·74 an hour to £21·74 an hour, against a price of £9·84 an hour. Can the Department not supply accurate figures for its own costs?

58. Dr McCormick: There is a specific outlier in those figures, and it might be helpful if we provided the Committee with a note of our assessment of them. I will explain them very briefly now. The rate of £21·74 an hour is at the high end of the range. That figure in paragraph 14 of the UKHCA paper is an outlier — it may even be a wrong figure from a particular trust. We received the paper only a few days ago, and the range that we have been able to validate in that time is, we think, £9·74 to £13·94, which is a smaller range. That gives the average that Andrew has just explained, and it is closer to the range quoted for the independent sector as well. Given the limited time that we have had to study the paper, it might be more orderly if we provide the Committee with a written assessment of it. Would that be helpful, Chairman?

59. The Chairperson: Yes.

60. Mr Lunn: Paragraph 3.28 deals with the concerns of the independent sector about its ability to compete with statutory providers. Indeed, the UKHCA paper expressed surprise that no action has been taken by the Department to compare the cost effectiveness of in-house provision against independent home care. Paragraph 3.28 states:

“The Department’s 2002 Review noted the concerns of the independent sector: that it has not been fully involved as an equal partner in the development of community care; that its relationship with the statutory sector had become quite strained; and that contract prices for basic levels of community care needed to be agreed. The Review also noted the view held in the independent sector, that the contract culture had significantly damaged relationships and has resulted in less partnership working and joint planning.”

61. Has anything changed since then?

62. Dr McCormick: It is important to note the reorganisation of the trusts, which provides an opportunity to take a different, more standardised and centralised approach to procurement. The intention is partly to ensure that there is a clearer standardisation of those issues and that the right balance is struck between protecting the taxpayer’s interest by securing care at a good cost and adopting good practice by working in partnership with the umbrella organisations and the major providers. In that way, the Department can be sensitive to their concerns and the issues that they have highlighted in the paper and in our dialogue with them. This is such a challenging area, and we must ensure that we build a system that can work in the medium to long term.

63. Mr I McCrea: Paragraph 2.16 points out that the pressure to speed up the discharge of older people from hospital can lead to their being placed in a residential or nursing home. If levels of domiciliary care are insufficient to prevent such placements, is there not a risk that such decisions, once taken, will never be changed? Even if the older person initially could return home, once in institutional care most people do not leave.

64. Dr McCormick: The Department has been concerned about that issue. It is important that we promote and share good practice. The Southern Health and Social Services Board and its trusts have developed a clear procedure and system for patients leaving hospital, whereby long-term decisions are not taken while that individual is experiencing the stresses and uncertainties of the acute setting. Rather, an interim, step-down arrangement is put in place and the long-term decision is made sometime afterwards when a better view can be taken of how matters will evolve and of what would be possible through family and carer support.

65. That is established and is working in the southern area. It came up in the performance management discussions that the Department had with all the trusts during the past few weeks. It encourages the trusts to adopt that as good practice.

66. As you said, there is a major risk that, through wrong decisions, someone could become more dependent than they need to be, and the Department entirely takes the point that that is a hazard. Therefore it hopes to share its evidence of good practice in order to ensure that it works throughout the system.

67. Mr I McCrea: I assume that it will be monitored.

68. Dr McCormick: Indeed. Through the Department’s monitoring of targets and practice, it is important that it does not simply hold people to account over numbers, but that it wants to see the development and extent of reform and modernisation in a deeper sense. That is extremely important.

69. Mr I McCrea: Paragraph 2.19 tells us that a significant number of older people must wait in hospital because of inadequate domiciliary care support; such bed-blocking is not an effective use of resources. The average cost of a hospital bed must far outweigh the cost of an average domiciliary care package. The Department developed a target that 95% of all people who are assessed as medically fit for discharge should wait no longer than seven weeks. That does not appear to be particularly challenging. Can more flexibility not be introduced into the service in order to reduce that time lag?

70. Dr McCormick: Yes. The target of seven weeks to which paragraph 2.20 refers was for March 2006. Targets have changed and are now significantly more ambitious. The targets for March 2008 are to have all simple discharges carried out within six hours and all complex discharges within 72 hours. There has been major progress towards those targets among all trusts. The latest available figures show that 77% of complex discharges are carried out within the 72-hour target.

71. The Department is conscious that the right options must be available in practice. As you say, delays can occur because domiciliary care packages are not available; however, there can be other reasons for delay. By working closely with all trusts, the Department aims to find the underlying reasons for delay and help them to resolve those problems. That is part of the Department’s approach; it requires trusts to do that. They are generally doing well and are making significant progress towards achieving those targets.

72. I have referred to discharges from an acute setting. Of course, it is important to emphasise that the issue is not just that the practice has incurred the Department expenditure that could have been avoided; it is about ensuring that money is used in the most effective way possible, and that people are in the appropriate setting for their needs. It is fair to say that the Department’s challenges in that area relate to targets and to making progress until discharge times compare favourably with those in other parts of the UK. Significant progress has been shown during the past year or so, when targets have featured strongly towards making a difference.

73. Mr I McCrea: Paragraph 2.25 talks about the Department’s drive to reduce delayed discharges. When does discharge planning begin? If it does not occur already, is there not a case for it to happen at the point of admission?

74. Dr McCormick: That is exactly right. The Department encourages that and seeks to ensure that that is what happens: from the point of admission onwards, thought is given and plans are made so that there is the best possible response when someone is declared fit for discharge so that it can take place quickly and straightforwardly.

75. That is the sort of good practice that we want to encourage and promote, and it is being taken up in many settings.

76. Mr McLaughlin: Thank you, gentlemen. I am reassured that there has been continuous review and that changes have been made since the report was date-stamped. It is important to acknowledge and welcome that.

77. Paragraph 3.17 discusses direct-payment issues in the context of the trend towards the increased take-up of that option. It also recognises that although direct payments offer independence, flexibility and choice, there are associated risks to quality. What is the Department doing to assess those risks, and how does it check whether care purchased through direct payments is cost-effective and quality-proofed in comparison to care that is commissioned by the trusts?

78. Dr McCormick: That is a very important part of the process of managing the system and dealing with the trusts’ continuing responsibility for clients, even those who have chosen to adopt the direct-payment methodology. Direct payments offer more choice, freedom and opportunity for the individual, but that does not relieve the trust of the responsibility to be aware of what is going on, to keep in touch, to safeguard the client and to ensure that risk is managed. It means that trusts have less direct involvement, but, by keeping in touch and paying the right attention, it is possible to find the right balance. We want the growth of direct payment to continue, as it gives more choice and independence to the individual, and that is important.

79. Mr McLaughlin: Paragraph 4.21 continues the discussion on the quality of care and minimum care standards. It refers to standards that were issued by the Department in March 2006 to provide a basis for the inspection of domiciliary-care services by the Regulation and Quality Improvement Authority. Have those inspections begun yet, and, if so, what have been the outcomes?

80. Dr McCormick: The standards will be finalised and formalised during the course of this year. They are not yet in place, and therefore there is no formal basis for inspection and regulation. However, we are seeking to develop and implement the standards as quickly as possible.

81. Mr A Hamilton: Under The Domiciliary Care Agencies Regulations (Northern Ireland) 2007, domiciliary-care providers must register, and that process is ongoing. The inspection will start in 2008-09.

82. Mr McLaughlin: What is causing the delay?

83. Dr McCormick: It has been a matter of developing and finalising the standards and making sure that they are fully appropriate, fully endorsed and fully supported. That has been an important process to go through to show that they are fully effective.

84. Mr McLaughlin: Nevertheless, they have taken more than a year to develop.

85. Mr Martin: To give the Committee a sense of the scale of the problem, I understand that more than 600 care providers are seeking to be registered across the entire provision of domiciliary and day care. Therefore, 209 — I hope that that figure is correct — domiciliary-care agencies have applied for registration. Interviewing the most senior responsible person for each of those agencies will take place in the next two to three months, and inspection will follow thereafter.

86. The development of standards for domiciliary-care agencies is part of a suite of standards that has been developed since the establishment of the Regulation and Quality Improvement Authority.

87. It is also fair to acknowledge that the Regulation and Quality Improvement Authority came into existence only in 2005. There has been a significant programme of regulation and inspection of residential and nursing-home care, children’s homes and other aspects of care. That is being extended to domiciliary care and day care.

88. Mr McLaughlin: In the meantime, is there an information gap? How do trusts, boards and the Department ensure that the minimum standards — and improvements in them — are being delivered as the result of interactive feedback and monitoring? What do we do in the meantime?

89. Mr Martin: It is a dynamic process. When someone receives a package of care, they remain care-managed. It falls to the lead professional from social services to continue to visit the home of the older person to ensure that quality service is being provided and that the feedback that comes directly from older people is taken seriously. That ensures that the provider delivers the required service and that the older person is satisfied with the quality of the service that they receive. It will be monitored by the care manager from social services. When the care package being provided is no longer appropriate, it is amended and changed; it is an ongoing, dynamic process. Importantly, it is carried out at the frontline at the home of the older person who is receiving the care.

90. Mr McLaughlin: Paragraph 4.24 discusses the domiciliary care agency standards, about which we have already had feedback. Have those standards been introduced in their entirety and how long have they been in preparation? Are further developments expected?

91. Mr Martin: They are at different draft stages of development, but many of them that relate to residential and nursing homes have been approved and agreed and are being applied. As the regulation and inspection responsibilities expand into domiciliary and day-care services, the standards, which are in final draft, should be in place early in the next financial year. Developing standards is an interactive process: it involves the service providers but it must also engage those who use services. Their views are sought on the services that will be provided. There has been an extensive programme of engagement across Northern Ireland in a raft of care areas, from residential nursing homes to day-care and domiciliary services.

92. Mr McLaughlin: It appears that all of that is funnelled through the social case work.

93. Mr Martin: Quality is also the responsibility of the case manager. It is not that nothing is happening to safeguard older people who receive a package of care; those responsible for caring for older people work to the standards in the form of a clearly expressed care plan. That identifies what care will be provided and the timing of that care. It is monitored regularly, not only to assess quality but to seek assurances that the package as agreed continues to meet the changing needs of an older person.

94. Mr McLaughlin: I will not go into the individual details, but I am aware of a case in which a care package was in place for an adult dependant with profound difficulties. That person’s mother died.

95. It took an inordinate time — and in difficult circumstances — to have the care package reviewed and reassessed, despite an urgent requirement to do so. The people with whom I was in contact were hard-working, and their professionalism and commitment was unquestionable. Nevertheless, it took a long time to get a decision on that care package. It seemed to me that part of the communication system was constipated. It was difficult to get a decision. That is a situation with which I have dealt. Are there similar problems elsewhere?

96. Dr McCormick: I am sorry to hear of that case; it is always disappointing when the service does not meet our reasonable expectations. Although there are many demands on the domiciliary care service, we should respond promptly and effectively to changing circumstances and need. That is one reason why it is important that our assessment approach is developed, although, generally speaking, the service is in good shape.

97. However, the development of the single-assessment tool should provide a means of securing stronger uniformity of standards and it should also ensure that stronger, clearer approaches are taken across the entire system. It should help to ensure that people know what is expected of them and that they can respond to those demands so that the wider system supports the front-line individuals who are at times working with a major caseload. I recognise the point that you are making.

98. Mr McLaughlin: I welcome and endorse the raft of assessment tools that is being developed. In compiling his report, the Comptroller and Auditor General found it useful to conduct a survey, and he found that not one trust, board or Department found it necessary to conduct a survey. Are you satisfied that you have the best-quality feedback from older people who are the direct users of the service? Would a survey improve the quality of understanding and feedback?

99. Dr McCormick: I recognise the potential value of a survey. We should examine the matter carefully to determine whether regular surveys would benefit the service. Such is the involvement and interaction that organisations would expect to be well aware of their clients’ concerns.

100. It is important that communication is strengthened by means that are confidential and independent of the system, especially if there are major causes of dissatisfaction and complaint. We must take that into account when considering organisational change in the system and the Minister’s review of the review of public administration’s decisions. It is important that we have that clear communication.

101. A recent report by Paul’s team emphasised the need for improvements in communication with carers. That is another way of ensuring that the message about what the system does for individuals is clear and that there is strong, reflective feedback. That will ensure that issues come to light and are addressed. That is the ethos and approach that we want to see, and surveys can play an important part in that.

102. Mr McLaughlin: The Comptroller and Auditor General’s survey found that older people were very satisfied with the service. There was good quality feedback about the difficulties or deficiencies, and that can only help. The message was that people recognised that a quality service was being delivered, albeit with some problems. Feedback would be valuable to the Department.

103. Ms Purvis: The Comptroller and Auditor General’s statistics in paragraph 3.15 show that the take-up of the direct payment scheme has been a low 3·3%.

104. What is your understanding of why that is the case?

105. Dr McCormick: The direct-payment scheme is relatively new, and how an individual perceives what is in their interests can be hard for them to overcome. However, we are trying to ensure that the organisations promote and explain what the scheme means. The system does not leave them to make decisions on their own; the objective is to give the individual more choice and an opportunity to consider what suits them so that care can be arranged around their needs and circumstances, rather than being provided through the limited options that the statutory sector offers. However, there is room for the scheme to be developed further. We have seen a six-fold increase in take-up over three years, but the total number is still smaller than we would like it to be. However, there is a good, rising trend, which we are trying to encourage and develop.

106. Ms Purvis: Could the reluctance be because an older person is concerned about the cost of buying care?

107. Dr McCormick: The amounts that are involved are monitored carefully. Although they vary a little between areas, they are in line with what is seen to be necessary to provide a reasonable care package.

108. Ms Purvis: Can I quote some figures?

109. Dr McCormick: Sure.

110. Ms Purvis: You said earlier that the average cost for statutory care was £11 to £12 an hour, and in the independent sector it is just over £11 an hour. The UKHCA referred to a 2007 report that states that the average payment that an older person in Northern Ireland receives to buy care is £7.76. Unless they have sufficient income to top that up, the poorer elderly are no better off if they buy their care through direct payments.

111. Dr McCormick: The figures quoted in the UKHCA paper are based on the rates in 2002-03. Direct payments currently range from £8 to £10. Direct payment gives the client an opportunity to employ an individual, with the result that there are fewer overheads. Therefore, the amount that is effectively available for direct employment of care is not far away from being in line — or broadly in line — with the cost of care and is comparable to the hours that a carer works.

112. Mr A Hamilton: The purpose behind the scheme is not to constrain but to enhance choice, and the rate that is made available is sufficient to employ a carer directly and meet the average cost. It should also provide for some flexibility in the care package. Money is not the constraining factor in the lack of take-up of the direct-payment scheme. In the past, there may have been professional scepticism about whether such a scheme was in the best interests of the elderly.

113. The Department of Health, Social Services and Public Safety has been promoting the direct-payment scheme, and it has turned a corner. Professionals have been really impressed by the testimonies of the individuals who have benefited from the new approaches — they have actually changed lives. I am aware of several cases in which the flexibility that has been offered as a result of the direct-payment scheme has transformed a person’s quality of life.

114. The other constraining factor may be that for an individual bureaucracy requires them to become an employer and pay tax and ensure that the procedures that are involved with that are followed correctly. We are working to streamline that process, and we are financing the voluntary bodies in order that they can work with the individuals concerned so that the burden can be removed and the approach is made easier.

115. Ms Purvis: I accept that, but if choice is enhanced, quality might be compromised. You talked about raising standards. I am a parent, and I would not leave my children with just anyone, and the same applies to an elderly loved one. Therefore, I would expect that the person who is appointed to look after my elderly relative would be properly qualified and regulated. If a direct-payment user chooses to employ a personal assistant or carer at a much reduced rate — they may be in the £8 to £10 range that you mentioned — that person will not have been regulated by the Regulation Quality Improvement Authority (RQIA), and will not have been required to register. Is that correct?

116. Mr Martin: The RQIA regulates the service, and the Northern Ireland Social Care Council (NISCC) regulates the employees. All individuals who are registered with the NISCC will eventually be bound by codes of practice and conduct, and I have already spelt out the scale and size of the workforce in Northern Ireland. They will be charged with re-registering every three to five years: registration will not be a one-off event. At the time of re-registering, the individual will have to demonstrate his or her continuing competence to continue being part of that workforce.

117. Ms Purvis: When will that be implemented?

118. Mr Martin: It has started already. The first stage of the implementation of the new requirements began with professional social workers and the heads of homes. They are all now registered and regulated. Over the next one to three years, the programme will be rolled out to include the rest of the workforce. I anticipate that in the next three to four years, the entire workforce in Northern Ireland will be registered. That will provide the required assurances about the quality of individuals, including those who provide direct care to people in their own homes. One might argue that people who receive such a service are more vulnerable to such dangers as exploitation than those who are being cared for in residential and nursing homes. The workforce is so large that it will take a while to complete the process.

119. Ms Purvis: There are two downsides to the direct-payment scheme. First, there is a reduced rate for claiming for direct care, and secondly, the carers are subjected to less regulation. Those downsides will deter people from taking up direct payments.

120. Dr McCormick: We have only just received the UKHCA document, so we will provide written evidence about the levels of payments that are made under the direct-payment scheme and how they relate to the costs in the statutory and independent sector, where care is provided through organisations rather than individuals. I do not think that we can demonstrate now how the rates compare, but the comparisons should not be a problem — there should be enough empowerment through the direct-payment system to secure a valid and viable service for the individual.

121. We recognise your points about regulations and safeguards. Mr Martin’s description of how the programme on regulations and registration will be implemented is correct. The best way to approach the registration and regulation of individuals who take up a caring role through the direct-payment scheme must also be addressed. We will have to consider whether the Northern Ireland Social Care Council should be given a role where those individuals are concerned.

122. There are different ways for clients to secure the service that they need. The direct employment of an individual is one way, or clients may choose to use agencies. We must develop the different approaches effectively and strike the right balance. It is difficult to find a balance between first, the independence of choice that people want to an extent and secondly, safeguarding, which, as has been emphasised, is extremely important.

123. Ms Purvis: The Northern Ireland Childminding Association has a simple solution: childminders register with the association, and clients have access to that register and, therefore, can make a choice. I will leave that example with you.

124. Dr McCormick: Yes, that system is sound.

125. Ms Purvis: Paragraph 3.4 of the report refers to the important role that family carers play. I note that you said in your introduction that it is vital to support and underpin care for the elderly. Paragraph 3.4 states that respite breaks are a:

“valuable preventive measure in avoiding the breakdown of care arrangements at home for family and friends who provide long-term care.”

126. The cost of caring for individuals — and not only to the taxpayer — is well known. Do you agree that it is highly cost-effective to have good respite care available?

127. Dr McCormick: It is an important aspect of the care strategy. It is not always possible to deliver everything that we aspire to deliver, but respite breaks are recognised as a significant dimension of providing the best possible quality care.

128. Ms Purvis: What are you doing to ensure the sufficient availability and appropriate targeting of respite care?

129. Dr McCormick: I will ask Paul to say a bit more about the carers’ strategy in a moment.

130. In planning for the rising numbers of elderly people, we must provide the trusts with sufficient resources to supply direct-care packages. As a vital part of the overall plan, allowances for the resources must be available for, and targeted on, providing respite. To pretend otherwise would mean that the provision of respite would not be sustainable.

131. Mr Martin: I want to reinforce that last point. Through the carers’ strategy, carers in Northern Ireland are now entitled to their own assessment of need. Also, every trust in Northern Ireland has a carers’ liaison officer to ensure that the needs of carers are at the heart of service delivery, planning and review.

132. The significance of the role that carers play and the sheer volume of caring that they provide in Northern Ireland cannot be overstated. There are an estimated 185,000 carers. I cannot break that figure down into how many care for elderly people, but it is a significant proportion of that number. Therefore, it is extremely important to support those carers.

133. The Department also has a central carers’ strategy implementation group. That is important in that we did not simply issue a strategy and let the trusts get on with it — we monitor their performance. Carers and service providers are involved in the group to ensure that the trusts are delivering on their responsibilities. That is an extremely important part of our agenda.

134. Ms Purvis: Is there flexibility in the choice of respite care? Paragraph 3.4 of the report refers to respite in an “institutional setting”. We have been discussing domiciliary care and the importance of elderly people remaining in their own homes. If, for example, the carer is going on holiday, can the elderly person remain in his or her own home rather than being placed in residential care?

135. Mr A Hamilton: Yes, there should be flexibility. Options that the trusts offer range from a week’s respite in a nursing home, to allow the family to go on holiday, to a night sitting or sleepover service. All that is available and can be applied throughout Northern Ireland.

136. The Budget agreement has provided for an additional 2,000 respite units to be made available by 2011. Those units could represent a week’s respite in a nursing home or support at home during the week.

137. Ms Purvis: I would like to ask a couple more questions.

138. The Chairperson: We are beginning to wind down; I can come back to you at the end of the session.

139. Ms Purvis: I would like to ask about the single-assessment tool, but I will ask them at the end.

140. Mr Beggs: Paragraph 2·21 refers to the mixed performance in meeting discharge targets. That is a significant area, bearing in mind that delayed discharges mean that patients are unable to return to their homes, or to anywhere that is close to their homes, and that acute beds are not being used to treat people who remain on waiting lists. Is it correct that local authorities in England that have responsibility for reducing delayed discharge can be fined if they fail to arrange home-care placements for older people? Is the Department giving any consideration to introducing inducements or fines?

141. Dr McCormick: You are correct in saying that that is the case in England. One major distinction, however, is that that happens in a local authority context — those authorities have their own sources of revenue. They are more financially autonomous than the health and social care trusts in Northern Ireland, which are grant-aided and funded fully from public expenditure. A fine on a health and social care trust would displace the resources that are available, and it would therefore put the trusts in a different financial position. Therefore, we must find smarter and more effective ways to manage delayed discharge.

142. Mr Beggs: Do you accept that if fines were introduced, trusts would ensure that delayed discharges did not occur, with the result that their priorities would increase?

143. Mr A Hamilton: We have considered that issue. The difficulty is that we would be asking an organisation to fine itself. The problem lies in the relationship between the hospital and the community sectors; both are managed by single organisations, now that we have five integrated trusts. We have found success in setting ambitious targets and working with the service to ensure that they are delivered both through improved performance-management arrangements and changes in approach.

144. Reference was made earlier about starting the discharge planning from the date of admission — having an early estimated discharge date, not looking at the long-term requirements in the hospital sector, and having some sort of temporary arrangement. That has all freed up the system, with the result that performance has significantly improved over the past year or so.

145. Dr McCormick: It is worth reconsidering the performance standards that I referred to earlier — 77% of complex discharges from an acute setting happen within only 72 hours. Therefore, the degree of difficulty that is referred to in paragraph 2·21 is less than it was. We are making significant progress, and the advantages of having formed five new integrated trusts have resulted in those trusts achieving a considerable amount. That reorganisation has allowed them to secure significant performance improvement.

146. Mr Beggs: I note that paragraph 2.21 states that boards and trusts said that:

“the main reason for the delay was budget-limited resources”.

147. I will come back to that point later.

148. Paragraph 2.24 indicates that the northern trust was responsible for almost half of the delayed discharges, but it also reports that the systems that are in place in Craigavon and Banbridge for discharging patients appear to be working. Why have the processes and systems that operate in those areas not been implemented more widely across the sector?

149. Dr McCormick: As I said earlier, it is important that that implementation should happen. My message to the chief executives is that evidence-based good practice should be adopted. Indeed, it is being adopted. The approach that was taken in Craigavon and Banbridge Community Health and Social Services Trust, which is now part of the Southern Trust area and which was described earlier, is a good practice that should be adopted.

150. It is important to recognise that circumstances and availability vary. Some delayed discharges will be due to limitations on the availability of nursing-home places, and that problem should be addressed by the market. Nursing-home care is governed 100% by the independent sector. If that sector does not provide a place in a nursing home, a problem arises. The trust must try then to resolve that in a different way.

151. Although one must recognise that the contexts and challenges that face the different organisations vary, they should be aware of what works and of good practice elsewhere. That knowledge should then enable them to work as effectively as possible. I am convinced that that is happening and that the service is performing better. Our delayed discharges standards are much higher than they were even a year ago.

152. Mr Beggs: Paragraph 2.28 states that the Causeway Trust has the highest number of older people waiting for care packages in the community, and appendix 2 shows that both the Causeway and Homefirst Trusts, both of which are in the Northern Board area, have significant numbers of older people waiting for packages. Why is that the case, and what action has the Department taken to improve the performance of those trusts?

153. Dr McCormick: My colleague will deal with the specifics of that. However, we have a general and clear approach to seeking secure and sustainable improvements in performance. We have set targets and standards that are being applied robustly to community waiting times throughout the region. We aim for assessment to take eight weeks and delivery of the main elements of a package of care should take 12 weeks. Where there is urgent need, we expect elements of the package to be implemented more quickly. Those, too, are monitored regularly, as we seek to deliver reductions in waiting times. The balance has shifted significantly, even from the position that is shown in figure 9 of the report. The ratio of those waiting less than 12 weeks to those waiting more than 12 weeks is now 70:30, as opposed to 53:47, as is shown in the right-hand column of the table. Therefore, progress is being made.

154. Mr A Hamilton: The latest figures from the Northern Health and Social Care Trust show that, as of December, 68% of complex discharges from the acute sector happened within 72 hours. That figure rose to 75% in January. The December and January figures for non-complex discharges both show a discharge rate of 97% within six hours.

155. Mr Beggs: That is welcome news: perhaps you will provide us with overall figures.

156. In 2004, the fourth capitation formula review was published. That distributes the health budget to the boards according to the size of population and the age profile of that population. It is now four years since that happened. If you look at figure 1 of the report, the capitation formula review indicated that the Northern Board should have received £8·4 million more this year than it has currently been allocated. Figure 1 shows that, of all the boards, the Northern Board has the highest percentage increase of elderly population. To recap: in 2004, a capitation formula review was held to distribute money, and the situation has worsened since than, in that there is an even higher percentage of elderly in the Northern Board area. That will therefore contribute to the problem. I refer to what the trust stated in the report: the problem occurred because of a lack of resources. Given that the fifth capitation formula review process began this year, when will the fourth capitation formula review be implemented?

157. Dr McCormick: It is important to keep capitation under review, because it determines the availability of resources in all parts of the region. The principles are very clear: we must have an evidence-based approach to distributing resources. It is important that that is handled meaningfully.

158. If you talk to any of my colleagues who work in any part of the service, each one will have opinions on what should — or should not — be done about the implementation of the fourth capitation formula review. If we moved too suddenly and transferred resources precipitously, there would be significant disruption to services in those areas that would be likely to lose resources. That effectively means those services that are in the Eastern Board area. That is a very sensitive issue, and it is important that the Department is careful and thoughtful in its actions.

159. The principle is clear: we must treat all parts of the region fairly, which is what the capitation formula is about. The Department is committed to doing that as early as is feasibly possible so that any damage that will be caused by moving too quickly will be avoided. A balance must be found — fair treatment is the guiding principle, but we must be aware of all the circumstances and the implications of that to ensure that we act sensibly and thoughtfully.

160. Mr Beggs: I appreciate that a balance must be struck. However, I am simply pointing out that four years have already elapsed and that the increasing health demands of the growing elderly population mean that there is a growing disparity between the Northern Board area and the rest of Northern Ireland.

161. Dr McCormick: We are aware of that problem, and we are wrestling with it.

162. Mr Craig: I want to bring the discussion back to talking about the most important people — the customers — and what they think about domiciliary care. Paragraph 4.16 of the report states that:

“one third of respondents considered that they did not have enough information on the services available”.

163. Worse still, only half said that they had a copy of the relevant documentation. That is surprising, given that trusts are required to provide a copy of the care plan to its users and carers. What is the reason for that situation, and what will the Department do to address it?

164. Dr McCormick: We acknowledge the problem, and we agree that clients and families should have full information on the services that are available, on their rights and entitlements, and, as the report states, on who they should contact if something goes wrong. That is good practice, and the service should be delivering that consistently through interaction between care managers and clients.

165. I stated earlier that, last December, the Social Services Inspectorate report made recommendations for the development and provision of clear information to carers and their families. The Department feels that that should be happening, and the report’s findings on that matter are a cause for concern.

166. Mr Craig: Does the Department have any recommendations on how to force the trusts to fulfil their obligations? It is strange that patients, and their families, do not have copies of the information that they should have.

167. Dr McCormick: I recognise your concern. An appropriate way to address that may be to write directly to the trusts asking them to confirm that they are fulfilling their obligation to provide that information and that sensitive communication with their clients is being maintained.

168. Mr Craig: Paragraph 4.18 presents another conundrum, describing the opinions of elderly people about the domiciliary services that have been on offer for years. The survey reveals that respondents do not feel that they have enough say in how the services are run.

169. In fact, 20% of those who were surveyed believe that their views are not taken into account at all. Worse still, 7% to 13% said that they had not been consulted by their local trust in the past 12 months about the care that they were getting, and half those surveyed say that they do not have enough input into that care. It is hard to say that an effective service is being provided if the customers do not believe that they are being consulted about their needs. What are your views on that issue and how can it be dealt with?

170. Dr McCormick: I accept the thrust of what you say. There is room for improvement, and we will encourage trusts and management teams to ensure that they work better and that there is improved involvement and engagement. Direct payment is one mechanism by which the position can be turned around completely, as the power over what is in a care package is transferred to the autonomy of the client. That is one reason for promoting that course of action. However, even if a client does not avail of direct payment, there should be discussion and involvement, and the family of the client should have an influence. It would be wrong to say that it will always be possible to respond exactly to the aspirations of the client; in a resource-limited service that is not possible. Nevertheless, everyone should be doing their best to respond and be sensitive to individual needs. We must take that on board and give the right messages to the trusts and all providers, and we will be happy to do that following this meeting.

171. Mr Craig: Is there a communications problem?

172. Dr McCormick: Yes.

173. Mr Craig: I would like to play devil’s advocate. The Audit Office report contends that the balance of expenditure on the care of older people is still in favour of the institutional sector — almost a 60/40 split. Is there a perverse incentive to move older people into residential and nursing-care settings in which the elderly are charged for their care, unlike the domiciliary sector where care is free?

174. Dr McCormick: It is important to look at the full range of evidence in the Audit Office report because the trend points to a 36% increase in spending on domiciliary care, whereas spending on institutional care went up by 20%. It is important to recognise that the cost of institutional care has been rising above the rate of inflation for other parts of the service. The rates paid in nursing home care, for example, rose by 18·6% in the three-year period to March 2006. There is a cost driver in the nursing home sector; extra costs have arisen. As the report shows, the trend of numbers has been broadly in line with population, which indicates that cost is not rising significantly. However, there is evidence that expenditure on domiciliary has risen more rapidly.

175. Mr A Hamilton: Those are the figures, but the motivational factor that drives the placements is a professional assessment of need. The perverse incentive that Mr Craig mentioned would not really apply because even taking account of the average contribution towards a nursing-home package, the net cost of such care would still be about £400 a week, which is probably higher than the cost of a domiciliary-care package. However, a professionally driven needs assessment is the motivating factor. The emphasis is on trying to maintain the person in their own home, and that involves an assessment of the risks involved. It is the risk assessment that will trigger the decision to place someone in a home because, even with significant domiciliary-care assistance, the risks may be such that the individuals could damage themselves or fall. Thus the real motivation is assessment of risk.

176. Mr S Hamilton: Part 4 of the report details the results of the user survey that the Audit Office commissioned. I think that it was Mitchel who said earlier that the user response was, by and large, very positive; however, as was also mentioned, some concerns and criticisms of the system were highlighted. I want to pick up on a few of those concerns because constituents have raised them with me. I am sure that other members have heard similar complaints.

177. The survey showed that the overall impression of the system was overwhelmingly positive, but there were some concerns about the number of complaints. The survey showed that one in five respondents has had to make a complaint at one time or another for a variety of reasons, and that finding was backed up by work that the Department had carried out.

178. Such feedback is important in shaping how a system operates. How are complaints responded to, and what systems are in place to enable organisations to learn from mistakes?

179. Dr McCormick: That is an important dimension of the Department’s work. In its general approach to health and social care governance, the Department encourages a culture of learning from mistakes. That means being clear that people will be held to account but avoiding placing too much emphasis on apportioning blame. If there is too much emphasis on blame, people become defensive and the complaints process will not work. It is important that there is positive feedback so that the organisations can learn from mistakes.

180. Most complaints are resolved simply and with the direct involvement of the organisation in question — they are resolved at a local level, if you like. It is important that each organisation monitors the complaints process and the volume and nature of the complaints. It must ensure that a regular review is carried out to pick up on any patterns and recurring issues so that it can intervene and adjust its approach accordingly. That is part of the formal system.

181. Where the process does not lead to satisfactory resolution, it is vital to have independent mechanisms in place. We are concluding work on amendments to the complaints process to ensure that it is effective, independent and clear, and that people can have confidence in it. I am aware from cases that come to my attention that some individuals have had a bad experience of the complaints process. It is important that we take account of those experiences and ensure that the process is fair, reasonable, proportionate and effective. That is a vital part of the Department’s work.

182. Mr S Hamilton: I want to get a feel for how the complaints procedure is monitored. Not every complaint sparks a major investigation, but how regularly do trusts group complaints into different types and examine them?

183. Mr A Hamilton: I am aware that they are regularly referred to a trust’s board. From memory, it is on a quarterly basis, but we will confirm that.

184. Mr S Hamilton: One area of complaint that the survey showed was the reliability of the service. If people are to be cared for in their homes, it is essential that they get a reliable service; if they do not, it can have a severe effect on their lifestyle: they do not get fed at the right time, they do not get washed or dressed, and their daily routine is a mess.

185. The survey shows some concerning results: more than a third of those surveyed reported that their carer did not even turn up on one or more occasions during the past year; some 14% said that that had happened on at least three occasions, which is worrying.

186. What sanctions are in place for those operators — whether in the statutory system or the independent sector — who continually breach their contract? How are such sanctions imposed? Is performance monitored?

187. Dr McCormick: Performance monitoring is important, whether it is monitoring an employee’s performance or monitoring the contract performance of an independent-sector provider. It is important to ensure that individuals are empowered to monitor the performances of any of their employees.

188. All performance monitoring needs to be regulated and have thresholds whereby the appropriate intervention is made and corrective action taken. It is vital to have clear triggers for intervention so that people can be held to account if there is a pattern of recurring failure to deliver on a person’s care package.

189. Mr Martin: That is the case. Part of the responsibility falls to the individual care manager. Immediate actions have to be taken where there is persistent failure, whether it is a home help or other care workers not turning up to perform important tasks that enable people to live in their own homes. Such failures are unacceptable. Ultimately, the sanction is that the person is either sacked or their services are not used again. If such failures involve an independent-sector provider, ultimately, the sanction is that their contract can be brought to an end.

190. Mr S Hamilton: Therefore you can terminate a provider’s contract for such breaches.

191. Dr McCormick: Yes, if that is the proportionate response.

192. Mr A Hamilton: It is more likely that the person being looked after or their family would make a complaint. The timing of visits is important so that family members can go about their normal duties in the knowledge that their mother or father is being properly looked after. If there is a problem with timing, families would make the point that that is unacceptable and they would demand a different care worker.

193. Mr S Hamilton: Although the survey found that in virtually all cases care workers were respectful and courteous to those in their care, some concern was expressed about whether workers had sufficient skill. Some 55% of those surveyed believed that some of the care was being delivered by carers who were not adequately trained; less than half expressed the view that their home carers were “always” trained to do the job. That is worrying. I do not suggest that they are not trained or do not have basics skills; however, perception is important. How can you assure the Committee that carers possess the required competency?

194. Do you believe that adequate resources and training are in place across the sector?

195. Dr McCormick: It should be at the heart of provision in the statutory sector, where direct responsibility for the training and development of staff is with the employer or as a part of contract management. Training and developing the workforce has an important dimension in ensuring that it is esteemed, secure and sustainable for the long term. That includes a major emphasis on skills and training to ensure that that is part of the future regulation and registration process. It is the responsibility of either the employer or the contract manager to ensure that the people who discharge their duties have the appropriate skills and to ensure that if that is not the case, action is taken to resolve it.

196. Mr S Hamilton: Do you have any benchmarks for training? Is there a basic skill level or level of experience that someone who works in the sector must have to secure a job?

197. Mr Martin: The social services training strategy, which I referred to earlier, sets targets for the workforce. The strategy focuses on many aspects of training needs, beginning with induction training, which is vital for the domiciliary care workforce. We have targets for development and training plans, from basic training that must be provided for staff who are starting in the social services workforce to more specialist expertise. We will have targets against which we measure the workforce. Many of those targets are qualifications-driven, including those for the domiciliary care workforce; clear targets are to be achieved by 2010 for qualifications of at least NVQ level 2. That target will be the basis for registration with the Northern Ireland Social Care Council. I do not dispute for one moment that we have some way to go, but at least we now have a strategic direction to follow and targets to achieve across the workforce. That will be the basis on which the Social Care Council will measure the degree to which we are achieving the qualifications and standards that we require of our workforce.

198. Ms Purvis: Given that the health and social care sectors have been integrated, I am sure that you would acknowledge that the single assessment tool is long overdue. How confident are you that the single assessment tool will be in operation next year?

199. Dr McCormick: I am very confident; it is well advanced and is nearly ready to roll out. It has been important to develop it in conjunction with full professional input, which is vital. If we had imposed something off the peg, there would have been much less likelihood of its being fully used and effective. The value of the single assessment tool is in its use by the professional teams across the range of organisations. We are confident in the value of the tool, which will be unique in the UK. Having an integrated health and social care system is a significant benefit, and being able to operate in a relatively small economy in health and social care will help to ensure consistency of approach and standards and strong professional commitment. Although it has taken longer than we had hoped, we are pleased with our progress, and the effect will be worthwhile.

200. Ms Purvis: In recent years, an elderly person who was assessed for a care package would possibly have been assessed by a consultant, a nursing care team, a social worker or hospital social worker, a physiotherapist, an occupational therapist, a psychotherapist or a speech therapist. That raises doubts about connectedness in delivering an holistic care package that meets the needs of the individual. What assurances have you had that the domiciliary needs of elderly people have been identified and consistently and equitably met across Northern Ireland?

201. Dr McCormick: To date, the assessment processes have been good, and there has been much good practice. As Ms Purvis said, there is room for more harmonisation. That is why we have invested time and energy in drawing together the single assessment tool to ensure that it is person-centred and focuses on the full range of needs and avoids repetition or duplication. It is focused on what suits the individual, and it is in the interests of the client. That is the benefit of that approach, and the Department is confident that it is the way forward.

202. Mr Martin: Importantly, going back to Ms Purvis’s earlier question, the additional benefit of the single assessment tool is that it will also embrace the assessment of the carer’s needs. The avoidance of repetition is a big step forward, particularly for those who are on the receiving end of the assessment process.

203. The Chairperson: Our evidence session has been useful. It has presented a mixed bag of results across the sector, and the Committee will study the transcript with interest to assess progress in ensuring that as many older people as possible are cared for properly in their homes.

204. During sessions such as this, it is difficult to judge how the system is working simply by looking at facts and figures. For instance, I am not sure to what extent meals-on-wheels qualifies as domiciliary home care. A rap on the window and a meal left on a windowsill is anything but domiciliary home care. Therefore, we must examine all the evidence.

205. The RQIA will become involved, through the Northern Ireland Social Care Council, in the regulation of services. Regulation is important, but how it is implemented is far more important. In recent cases, regulations have not been properly implemented. I have no doubt that the Committee will return to that subject even after it has made its initial report. Thank you for your evidence.

Appendix 3

Correspondence

Chairperson’s letter of 5 February 2008

Public Accounts Committee
Parliament Buildings
Room 371
Stormont Estate
BELFAST
BT4 3XX

Tel: (028) 9052 1208
Fax: (028) 9052 0366
Email: jim.beattie@niassembly.gov.uk

Dr Andrew McCormick
Accounting Officer
Department of Health, Social Services & Public Safety
Room C5.11
Castle Buildings
Stormont
Belfast
BT4 3SQ

Date: 5 February 2008

Dear Andrew

Re: Public Accounts Committee Evidence Session on 31 January 2008

Further to the evidence session at the Public Accounts Committee meeting yesterday, please provide the following additional information which members requested at the meeting:

NIAO report ‘Older People and Domiciliary Care’

1 In the briefing from UKHCA, it states “some initial data supplied recently on request by UKHCA from DHSSPS indicates Trusts costs vary greatly, and in-house services ranged from £9.74 to £21.74 an hour in 2005/2006”. Please provide the Department’s assessment of these figures.

2 The fact that there has been such a slow shift in the balance of expenditure between institutional and domiciliary care as reflected in paragraph 2.11 raises the question as to how flexible budgets for the two elements are within Trusts. Is it the case that the numbers who stay at home and the numbers who go into institutional care are actually predetermined in the budget allocation?

3 How satisfied are you that differences in the range and level of services available across Trusts shown in Figure 7 at paragraph 2.11 can be explained by local need? Are different priorities and eligibility criteria leading to older people in different Trust areas experiencing inequalities in provision?

4 The Committee asked about the number of older people waiting for a care package in the community – paragraph 2.24 refers. Please provide overall figures for all delayed discharges from each of the Trusts.

5 The Committee would like details of the frequency with which the Trust Boards are informed of complaints.

I should be obliged for a response by Monday, 18 February 2008.

Yours sincerely

John O’Dowd

Chairperson
Public Accounts Committee

Correspondence of 22 February 2008
from Dr Andrew McCormick

Re: Public Accounts Committee Evidence Session on 31 January 2008

Further to the evidence session at the Public Accounts Committee meeting yesterday, please provide the following additional information which members requested at the meeting:

NIAO report ‘Older People and Domiciliary Care’

1. In the briefing from UKHCA, it states “some initial data supplied recently on request by UKHCA from DHSSPS indicates Trusts costs vary greatly, and in-house services ranged from £9.74 to £21.74 an hour in 2005/2006”. Please provide the Department’s assessment of these figures.

DHSSPS Response: As stated in my evidence to the Committee, we believe the £21.74 figure to be an overstatement that arose in one of the former Trusts. Former Trust staff have been asked to review the cost information for 2005/06. I am advised that, having checked the calculation of hours as per the applicable costing guidance, the original number of hours worked was incorrectly reported. The corrected number of in-house hours in the Trust concerned was 336,867 for 2005/06, rather than the previously reported 239,006. This revises the hourly rate to £15.42 for this Trust in 2005/06, from the previously reported £21.74. I have been assured that the Trust will undertake a review of all the information flows associated with this activity and ensure that the correct figures are used in future.

This therefore means that the average hourly costs in 2005/06 actually ranged from £9.74 to £15.42. This is still a considerable variation and I shall expect it to reduce markedly across the new Trusts that came into operation in April 2007.

2. The fact that there has been such a slow shift in the balance of expenditure between institutional and domiciliary care as reflected in paragraph 2.11 raises the question as to how flexible budgets for the two elements are within Trusts. Is it the case that the numbers who stay at home and the numbers who go into institutional care are actually predetermined in the budget allocation?

DHSSPS Response: It is not the case that numbers who stay at home and the numbers who go into institutional care are predetermined in the budget allocation. The Department does not allocate resources on the basis of care settings. Resources are linked to outcomes such as waiting times for care and the proportion of people supported at home. There are clear incentives for Trusts to promote and support independent living so that the maximum number of people can be supported at home. This provides both for efficient use of resources and for meeting the target for supporting people at home. As stated in my evidence to the Committee, this is reflected in the NIAO Report which shows that the 12% growth in nursing home placements was far outstripped by a 32% growth in domiciliary care placements over the same period. In this case, funding is following the policy and practice initiatives on the ground.

3. How satisfied are you that differences in the range and level of services available across Trusts shown in Figure 7 at paragraph 2.11 can be explained by local need? Are different priorities and eligibility criteria leading to older people in different Trust areas experiencing inequalities in provision?

DHSSPS Response: The Department is confident that there are no major differences in terms of access to services. Although Boards have traditionally set their own access criteria to match local need to resources, there is a high degree of similarity in approaches. Nonetheless, in reflection of the new structures already in place and those now proposed a decision has already been taken to introduce regional access criteria for domiciliary care. Much work on this has already been done and we expect the regional criteria to come into force during this calendar year.

4. The Committee asked about the number of older people waiting for a care package in the community – paragraph 2.24 refers. Please provide overall figures for all delayed discharges from each of the Trusts.

DHSSPS Response: The overall figures for delayed discharges from each of the Trusts are provided in the following tables. The figures are for the most recent full month – January 2008. They are separately recorded for “complex” and “non-complex” discharges[1] since it is not meaningful to amalgamate these figures. The Department considers complex discharges to be delayed when they occur more than 72 hours after the patient is declared medically fit for discharge; in the case of non-complex discharges this is 6 hours.

Complex Discharges by Trust – January 2008

Trust	Total Complex Discharges in Month	Less Than 72 hrs	More Than 72 hrs	% < 72 hrs
Belfast	360	288	72	80%
Northern	105	62	43	59%
South Eastern	222	156	66	70%
Southern	77	70	7	91%
Western	235	190	45	81%
Total	999	766	233	77%

Non - Complex Discharges by Trust – January 2008

Trust	Total Non- Complex Discharges in Month	Less Than 6 hrs	More Than 6 hrs	% < 6 hrs
Belfast	5,315	5,117	198	96%
Northern	2,682	2,601	81	97%
South Eastern	2,199	2,092	107	95%
Southern	2,597	2,478	119	95%
Western	3,483	3,307	176	95%
Total	16,276	15,595	681	96%

5. The Committee would like details of the frequency with which the Trust Boards are informed of complaints.

DHSSPS Response: The frequency with which Trust boards are informed of complaints varies across the region. The Southern, Northern and Western Trust report on a quarterly basis, the Belfast Trust every four months and the South Eastern Trust annually. All Trusts have a complaints committee within their governance structures which meet quarterly and in the Belfast Trust on a four monthly basis.

[1] A discharge is regarded as complex when it can only take place following the implementation of a significant home based or other (including residential or nursing home) community service. All other discharges that do not meet this definition are classed as non-complex.

Correspondence of 23 January 2008 from United Kingdom Home Care Association

Cathie White
Committee Clerk
Room 371
Parliament Buildings
Stormont
Belfast
BT4 3XX

23rd January 2008

Dear Ms White,

Northern Ireland Audit Office report: Older People and Domiciliary Care

I enclose written evidence prepared for the Public Accounts Committee evidence session on the above report on Older People and Domiciliary Care. I hope it will be of interest to the Committee. We would be delighted to amplify any particular points in our submission should the Committee require any further written evidence.

As the evidence session on 31st January is to be held in public, our UKHCA board member in Northern Ireland, Colum Conway, is planning to attend and observe proceedings.

Yours sincerely,

Colin Angel

Head of Policy and Communication
[Dictated by Colin Angel and signed in his absence with a digital image]

Direct line: 020 8288 5297
E-mail: colin.angel@ukhca.co.uk

Alternative formats: If you would prefer to receive this letter in another accessible format,
including e-text, ‘clear print’, large print or audio cassette, please contact us 020 8288 5294 or
donna.obrien@ukhca.co.uk.

Older People and Domiciliary Care: Evidence from United Kingdom Homecare Association

1. United Kingdom Homecare Association (UKHCA) is a professional association of homecare providers from the private, voluntary, not-for-profit and statutory sectors. Our Association represents over 1,600 homecare providers across the United Kingdom and includes 27 member organisations in Northern Ireland.

2. We aspire to the development of a thriving independent sector alongside those services provided by the Health and Social Care Trusts and believe that the independent sector is cost-effective and able to develop new services to meet demand for greater user involvement and choice.

3. UKHCA has warmly welcomed the publication of the NIAO report Older People and Domiciliary Care (hereafter referred to as the “NIAO report”) which identified a high level of general satisfaction with homecare by older people (paragraph 4.9). However the report also identified concerns from older people with aspects of homecare, and issues which are limiting the development of sustainable homecare provision in Northern Ireland.

4. Our evidence explores in greater detail the problems that the independent sector is experiencing in meeting the demand for domiciliary care. Many of these issues are cited in the NIAO report, and have been discussed in Department of Health, Social Services and Public Safety (DHSSPS) commissioned research Cost of Independent Domiciliary Care Provision in Northern Ireland.[1] However there are other areas where fuller evidence is needed and which merit attention by the Committee.

Relationship with commissioning bodies

5. We are concerned by the NIAO report’s findings that despite policy aspirations to encourage a flourishing independent sector, there is very low morale amongst independent sector providers (paragraph 3.29). The relationship with commissioning bodies is in our view a contributory factor.

6. Research by UKHCA in 2002, commissioned by the Northern Ireland Social Care Council, indicated that many homecare providers contract with only one Health and Social Care Trust[2], a position likely to have increased following the recent merger of Trusts, and meaning that independent homecare agencies carry significant risk at the hands of their “monopsony” customer.

7. Feedback from our members indicates that the Health and Social Care Trusts are failing to engage strategically with the sector as an equal partner, despite the NIAO report identifying that over one third of publicly funded homecare is now being delivered by independent providers (paragraph 3.24). This lack of engagement limits the ability of the sector to contribute to policy imperatives identified in the NIAO report, such as reducing delayed discharges from hospital, or developing preventative, enabling services for those with “lower level” needs (paragraphs 2.23 and 3.5).

8. Moreover, as the dominant purchasers, the Trusts are able to exert a downward pressure on prices and use contracting practices that may save money in the short term, but damage the capacity of the sector to plan ahead and invest in services. As identified in the NIAO report, “spot” contracts contain no obligation for commissioners to purchase the service, and other forms of contract hinder providers being able to build up the infrastructure and staffing required to support public homecare delivery (Figure 9, Page 27).

Recent costs of statutory requirements not recognised in contracts

9. The first half of a phased increase in statutory minimum holiday allowance brought entitlements to 24 days in October 2007. A further increase to 28 days comes into effect in April 2009. National minimum wage uplifts come into force every October. It is also worth noting that there are 10 permanent bank and public holidays in Northern Ireland, two more than Great Britain.

10. UKHCA recently undertook a survey of Health and Social Care Trusts to identify whether contract price increases recognise statutory requirements such as the new increase in holiday entitlement (which we estimate to increase wage bills by 2% alone) and the national minimum wage. In our survey of September 2007, with the new requirements imminent, we received no response from the Trusts other than the Southern Health and Social Care Trust which had not made a decision on uplifts.

11. UKHCA was interested to read in the NIAO report that the DHSSPS has invested an additional £24.5 million above the rate of inflation in uplifts to independent sector care rates (paragraph 3.31). As far as we are aware the Department did not officially announce that monies were being released for this specific reason. The NIAO report did not identify the source of this information and the Committee may be interested to explore how this figure was derived and how distribution of the uplift funding by the Trusts is being monitored by DHSSPS. The UKHCA survey signals to us that the Department’s investment is not being delivered at a local level to independent providers.

Lack of data to compare independent/in-house costs

12. There is evidence that statutory purchasers of care across the UK pay independent sector providers significantly less per unit of care than they pay for an equivalent service from their own in-house teams. As an example, in England, where 75% of publicly funded homecare is delivered by the independent sector, local authorities must identify the unit costs per hour of homecare supplied by in-house/independent sector services in annual returns to government. The average price paid in 2005-6 by a local authority to an independent sector provider was £10.50 an hour, while a similar service provided in-house by local authorities is estimated to cost £20.90 an hour.[3]

13. Data is much less readily available in Northern Ireland but indications are Trusts pay a lower unit price to providers than expended on their own in-house services. Anecdotal evidence provided to UKHCA by one provider forum is that Trusts in one area (in 2005, before reorganisation) were costing in-house homecare at £17.26 an hour.

14. A PricewaterhouseCoopers report commissioned by DHSSPS in 2005 provided more detail on independent sector rates, but contained no data on in-house costs.[4] Some initial data supplied recently on request by UKHCA from DHSSPS indicates Trusts costs vary greatly, and in-house services ranged from £9.74 to £21.74 an hour in 2005/2006.[5] With Agenda for Change reforms introducing standardised pay rates in the Trusts, such variation is hard to decipher and it is clear that further analysis is needed as to what costs are apportioned within these figures.

15. The DHSSPS supplied figures also show average level of payment of £9.84 per hour to the independent sector in 2005/2006 across Trusts before reorganisation, but again with significant variation. Further analysis is needed as to what costs are apportioned within these figures. The figure shows a level of consistency with the average rate calculated in the PricewaterhouseCoopers report using figures provided by the Trusts.[6], [7] Meanwhile, more work is needed to identify provider experiences of rates paid.

16. There is also some evidence from members that within the same Trust provider rates can vary for the same provision of care, as rates have been “carried over” from the old 18 Trust boundaries. Although attempts have been made to “even out” rates paid, providers within the same Trust should not be penalised because of their historical location.

17. A £9.84 rate for care will cover the minimum wage, national insurance and travel costs but little else such as training, holiday pay, office overheads, pensions, mobile phone calls etc. James Churchill, Chief Executive of the UK’s umbrella body for learning disability service providers, the Association for Real Change, has drawn attention to the real costs of care in The Guardian national newspaper, and estimates that at least £12.36 an hour is needed before capital charges or provider’s profit are added, while in some areas of the UK even £15 an hour would not be sufficient to sustain a business.[8]

18. Northern Ireland utilises in-house services to a much greater degree than other UK administrations, with two thirds of homecare (65%) still provided by the Trusts, compared to 25% in England, 47% in Wales and 53% in Scotland provided by the equivalent statutory services.[9] It is therefore surprising that a comparison of unit cost between in-house and independent sector homecare has not been made more explicit in statistical returns. The Committee may wish to investigate why data is not more readily available to compare the cost-effectiveness of such a high percentage of in-house provision, particularly in the light of public sector efficiency programmes.

19. Meanwhile, data from the first UK wide survey of direct payment rates has found that average rates across the UK are well below the “going rate” for contracted care. The average payment an older person in Northern Ireland receives for buying care is £7.76 an hour.[10] If a direct payment user chooses to employ a personal assistant (these individuals are not regulated by RQIA) then they would be able to pay around £6 an hour after tax and other deductions. The report is the clearest indication yet that the direct payment system is limiting service user choice, particularly if people are being precluded from buying services from a vetted, regulated agency unless they are prepared to top up with their own funds.

Staff recruitment and retention

20. As noted in the NIAO report there are acute recruitment and retention problems in domiciliary care (paragraphs 3.19-3.22). A fluid workforce destabilises continuity of care and satisfaction with the service provided. There is discussion of the reasons for recruitment difficulties (paragraph 3.21) and recognition in the NIAO report that staff shortages need to be addressed as soon as possible, which is very welcome (see recommendation 12, page 9).

21. Urgent attention should be paid to gathering data on the characteristics of the homecare workforce as it is recognised there is very little current information.[11] The 2002 UKHCA survey, funded with the assistance of the Northern Ireland Social Care Council, identified some of the issues and at that time found a 17.9% turnover rate in the sector.[12] Despite this and the Review of Workforce Planning in 2006, which contained recommendations to carry out more detailed research of the workforce[13], there is no readily available current data on turnover in the independent sector, vacancy rates, pay rates, rewards for training, hours of work, motivations and attitudes to training and qualifications. “Live” issues such as the impact and reliance on migrant workers from the EU accession countries is unknown.

22. The NIAO report surveyed older people’s experiences of domiciliary care and identified concerns amongst older people with reliability and continuity of care with over half believing that at least some of their care is being delivered by workers who are not adequately trained (paragraphs 4.5 - 4.15).

23. What is known is that commissioning practice commonly exacerbates these issues and low pay in the sector by using contract terms and conditions that prevent providers from:

• Making proper payment of travel time between visits, an entitlement enjoyed by in-house teams. Trust contracts may pay for “contact time” only;
• Providing a flexible service for older people, rather than limiting care workers to time-orientated, task-driven care. An example is the commissioning of fifteen minute episodes of personal care – leaving both the service user and carer feeling rushed, a practice severely criticised in England.[14]
• Paying workers for undertaking induction training. In UKHCA’s 2002 survey there was strong disagreement from providers that the Trusts take account of costs of training in their contracts and as many as a fifth of agencies were asking careworkers to contribute towards their initial training.[15]
• Offering enhanced pay rates for staff holding vocational qualifications and reducing the migration of careworkers to the more favourable terms of the statutory sector (which has implemented the new NHS pay system under the “Agenda for Change” reforms).

24. Also required is a more joined-up approach from policy makers across departments – we know that the independent sector does not have the same level of access to public training money as the statutory sector[16] despite delivering now a third of publicly funded care. It will also be bound by forthcoming requirements for regulation and registration of the workforce, where the homecare workforce will be set targets to attain NVQ level 2 health and social care by DHSSPS.[17] It is not clear if the Department for Employment and Learning are planning to release monies to providers in recognition of these new statutory obligations.

25. Concerns have been expressed by our members that the new targets to train staff towards NVQ level 2 in health and social care, although welcome in principle, will lead to further retention challenges in the independent sector. Anecdotal evidence from our members is that once NVQ level 2 is acquired care staff in the independent sector move to the in-house domiciliary care services advertised by the Health and Social Care Trusts. In-house terms and conditions under the “Agenda for Change” reforms are more attractive for those with a level 2 qualification than the independent sector could hope to provide under current commissioning arrangements.

26. Recruitment and retention issues are also exacerbated by criminal record checks, which delay entry into the sector and lead to loss of potential applicants to other sectors, such as retail during the 4-6 week wait for a check. In 2007, a surge of demand for checks was created by the implementation of Article 46 of the Protection of Vulnerable Adults and Children (NI) Order 2003[18] which led to delays of up to 16 weeks in the checking service and severe loss of potential recruits to the sector as well as delays in care packages. While the backlog has now been dealt with, it is unacceptable that a policy change implemented by the DHSSPS could have such consequences for an already fragile workforce.

Future costs and system changes

27. In 2008 independent sector providers face a series of costs from new statutory obligations and changes to systems in Northern Ireland.

28. In May 2008 a new regulatory regime of inspection and reporting begins by the Regulation and Quality Improvement Authority. The NIAO report identifies the significant challenges that this may pose to smaller independent sector providers (paragraph 3.21). While UKHCA members welcome regulation, the registration and regulation process will inevitably have cost implications which will include new training requirements and the incorporation of new administrative systems. Business planning for the new system has been hampered by the delays in the publication of the national minimum standards at DHSSPS. Until the standards are published (the last draft supplied to UKHCA was dated April 2005 and may have been changed significantly since then), providers cannot plan with certainty for inspections.

29. Not identified in the NIAO report is the forthcoming “Access NI” system which will introduce an obligation to pay for a criminal record disclosure for each new careworker, which has so far been free. Costs will be £26-£30 depending on the type of disclosure required. Employer registration with the service will cost £150. The “Access NI” system will commence in full on 1 April 2008.

30. Furthermore a “vetting and barring” scheme will operate across England, Wales and Northern Ireland from Autumn 2008 that will require careworkers to be members of the new Independent Safeguarding Authority. No details have been released as to the membership costs of this new scheme.

31. Future proposals to require the registration of the domiciliary care workforce with the Northern Ireland Social Care Council between 2008-2010 carries a further potential cost. We anticipate that providers will pay their workers’ registration fees to remain competitive and reduce the negative impact on recruitment that registration fees are likely to produce.

32. Given our evidence that Health and Social Care Trusts have not reflected the additional costs of holiday entitlement and national minimum wage in contract price increases, UKHCA is pessimistic that the new statutory requirements of regulation, criminal record disclosures and registration of the workforce will be reflected in prices paid for care in 2008. This will inevitably have a further detrimental impact on a sector already struggling to recruit and retain staff and independent provider morale.

Solutions

33. We urge the Committee to consider the following solutions to the issues identified in the NIAO report and in our evidence:

a. The Department of Health, Social Services and Public Safety, and Health and Social Care Trusts to work closely with the independent sector, develop an understanding of its capacity and involve it in the long term planning and commissioning of services in each community. While the NIAO report has noted ongoing work by DHSSPS to engage with the independent sector, this work needs to be disseminated to a much wider audience of homecare providers and UKHCA would welcome better engagement with the Department.

b. National policy directive to ensure the Health and Social Care Trusts pay a fair price and purchase homecare services under reasonable contract terms that focus on quality and outcomes for service users, rather than lowest price possible. This echoes the call by the Low Pay Commission on government to monitor the link between low pay in the homecare sector and commissioning practices across the UK, and to make it clear that commissioning policies should reflect the costs of care provision.[19]

c. Contract uplifts to reflect the many additional costs which are forthcoming in 2008, including the requirements of regulation, careworker training for NVQ level 2 and the new fee-paying criminal record system. Any investment by DHSSPS enabling Trusts to uplift prices paid for care in 2008 must be monitored to ensure that it reaches the independent sector and its workforce.

d. A full analysis of the unit costs of homecare in order to evidence the cost effectiveness of a high percentage of use of in-house homecare services in Northern Ireland. Cost analysis should also consider the limitations of direct payment rates to service users and whether direct payment users are being precluded from buying care from regulated agencies.

e. An urgent data gathering exercise on the homecare workforce (both in-house and independent) to determine the differences between pay and conditions in both sectors, to add to the recommendation for more data by the Review of Workforce Planning for Social Services. This will inform the NIAO report’s call that DHSSPS develop a strategy for improving recruitment and retention in the sector. RQIA and NISCC should be involved in discussions in data collection as the regulation and registration of the workforce offers opportunities to collect information – however, data collection should not cause undue burden to providers as it has in England.

f. As part of the Personal Social Services Development and Training Strategy, authorisation by the Department of Education and Learning to provide training funding to the independent sector in recognition of statutory requirements from 2008 for staff to train towards NVQ level 2 in health and social care.

g. The DHSSPS to ensure that the final National Minimum Standards for domiciliary care are issued urgently – providers need to adapt their businesses to recognise the new standards and cannot do so until the final version is released.

h. A proportionate approach to regulation by RQIA and collaborative work between RQIA and the Health and Social Care Trusts to ensure that the monitoring of the independent sector is not being duplicated through the contract monitoring requirements of the Trusts and RQIA’s new inspection regime. Avoiding duplication of regulation is a principle of Better Regulation under the UK’s Regulatory Reform programme.

i. RQIA to use its role in inspecting and holding data on both the in-house and independent homecare sector to take an overview role as to what is happening across the sector. This is the current role of the social care regulator in England (Commission for Social Care Inspection).

j. Attention to be paid to the proposals to rationalise the back office functions of the Health and Social Care Trusts into one Shared Services Organisation. This raises risks of further damage to the homecare sector if procurement and credit control functions are consolidated into one “arms length” body that may have a distant relationship or understanding of homecare provision.

Conclusion

34. We hope that our evidence provides a clear indication of the interrelationship between how care is funded and commissioned and the subsequence performance of the sector and incentives to make homecare a career. The goal of achieving high quality and high satisfaction with homecare services cannot be achieved without public sector investment in the services that the independent sector provides on its behalf and recognition of the skills and valuable service that homecare workers provide.

[1] PricewaterhouseCoopers LLP. Cost of Independent Domiciliary Care Provision in Northern Ireland (2005). Research commissioned by DHSSPS(NI).

[2] UKHCA and Northern Ireland Social Care Council. Independent Sector Home Care Provision in Northern Ireland: Workforce and Training Issues (2002). Research commissioned by Northern Ireland Social Care Council. Page 15.

[3] Personal Social Services Expenditure and Unit Costs 2005-2006, NHS Health and Social Care Information Centre (2007).

[4] Page 11, Executive Summary. Cost of Independent Domiciliary Care Provision in Northern Ireland (2005). PricewaterhouseCoopers on behalf of DHSSPS(NI)

[5] Information supplied by email from Economics Branch, DHSSPS to UKHCA, 21st January 2008.

[6] Ibid.

[7] Information supplied by email from Economics Branch, DHSSPS to UKHCA, 21st January 2008.

[8] “Worth their weighting”, The Guardian, 21 November 2007.

[9] Overview of the domiciliary care sector. UKHCA (2008).

[10] Direct Payments: A National Survey of Policy and Practice. Personal Social Services Research Unit (2007). Page 57.

[11] Review of Workforce Planning for Social Services. Final Report. (2006) DHSSPS. Paragraph 2.4, Page 15.

[12] UKHCA. Independent Sector Home Care Provision in Northern Ireland: Workforce and Training Issues (2002). Research commissioned by Northern Ireland Social Care Council. Page 19

[13] Review of Workforce Planning for Social Services. Final Report. (2006) DHSSPS. Recommendations Paragraph 8.2, Page 72.

[14] Commission for Social Care Inspection, Time to Care (2006). CSCI.

[15] UKHCA. Independent Sector Home Care Provision in Northern Ireland: Workforce and Training Issues (2002). Research commissioned by Northern Ireland Social Care Council. Page 25.

[16] Ibid. Page 27.

[17] Domiciliary Care Agencies Minimum Standards (Draft). Unpublished. DHSSPS.

[18] See DHSSPS press release: www.northernireland.gov.uk/news/news-dhssps/news-dhssps-230707-further-protection-of.htm.

[19] Low Pay Commission. National Minimum Wage. Low Pay Commission (2007).

Appendix 4

List of Witnesses
who Gave Oral Evidence
to the Committee

List of Witnesses who Gave
Oral Evidence to the Committee

1. Dr Andrew McCormick, Accounting Officer, Department of Health, Social Services and Public Safety.

2. Mr Andrew Hamilton, Deputy Secretary, Department of Health, Social Services and Public Safety.

3. Mr Paul Martin, Chief Social Services Officer, Department of Health, Social Services and Public Safety.

4. Mr John Dowdall CB, Comptroller and Auditor General, Northern Ireland Audit Office.

5. Mr Ciaran Doran, Deputy Treasury Officer of Accounts, Department of Finance and Personnel.