House of COMMONS

MINUTES OF EVIDENCE

TAKEN BEFORE

HEALTH COMMITTEE

Thursday 22 January 2004

MS ANNE PARKER CBE, DAME DEIRDRE HINE and MS LYNNE BERRY

DR STEPHEN LADYMAN MP, PROFESSOR IAN PHILP and MR RAY WARBURTON

Evidence heard in Public Questions 99 - 211

USE OF THE TRANSCRIPT

Oral Evidence

Taken before the Health Committee

on Thursday 22 January 2004

Members present

Mr David Hinchliffe, in the Chair

Mr David Amess

John Austin

Mr Keith Bradley

Mr Simon Burns

Mr Paul Burstow

Dr Doug Naysmith

Dr Richard Taylor

________________

Witnesses: Ms Anne Parker CBE, Chair, National Care Standards Commission, Dame Deirdre Hine, Chairman, Commission for Health Improvement, and Ms Lynne Berry, Chief Executive, General Social Care Council, examined.

Q99 Chairman: Good morning. May I welcome you to this session of the Committee, and welcome our first group of witnesses. We are very pleased to see you, and can I thank you for your cooperation with our inquiry and for the written evidence that you have already given us. Could I ask you briefly to introduce yourselves to the Committee before we commence.

Ms Parker: I am Anne Parker, and I chair the National Care Standards Commission, which is the regulatory body for service provision in social care and independent health care in England.

Dame Deirdre Hine: I am Deirdre Hine, and I chair the Commission for Health Improvement, which is the regulatory body for the National Health Service in England and Wales.

Ms Berry: I am Lynne Berry. I am the Chief Executive of the General Social Care Council, which is the first regulator of the social care workforce established for England. There are similar regulators now for Wales, Scotland and Northern Ireland.

Q100 Chairman: Can I begin by asking your views on the extent of the problem of elder abuse. You will probably be aware that in our first session before Christmas the general consensus of the witnesses was that at any one time at least half a million elderly people are the subject of some form of abuse. From your various perspectives, do you concur with that estimate, and if you do, on what basis do you concur? What are your views on the fact that we do not appear to have any formal mechanism for recording abuse in a way that gives us accurate figures on the extent of the problem?

Dame Deirdre Hine: You are right, Chairman, we do not, and CHI does not have any accurate figures either about the prevalence of elder abuse. All the evidence that we have and we can put before you is that concerns about services for older people n the NHS are one of the most frequent matters that are brought to our attention. We have found - and I can elaborate on that later if you wish - reasons for concern in many of our clinical governance reviews. We have reviewed every acute hospital trust in England and Wales, and almost every mental health trust, and we are in the process of reviewing primary care trusts, so we do have a fairly wide band of evidence. Of the 11 investigations into serious clinical failure that we have completed and reported on, three of those involved cases of serious abuse of older people. That is our evidence on numbers, and I agree with what you said about the fact that we do not have any statistical evidence to give you.

Q101 Chairman: What you are saying is, from your experience of the way your work has been skewed towards this area, that perhaps indicates a wide ranging concern about the standards of care in some respects.

Dame Deirdre Hine: It does indeed. I would have to qualify that slightly by saying that in the majority of the trusts that we have had reason to review or investigate, we find caring, committed staff, giving sensitive care to older people, so I would not want to give the impression that no older person is safe in the NHS, but we do have reason to believe that there are quite serious concerns about the quality of care.

Ms Parker: I too would concur with the view that we need better evidence and information, and I cannot offer evidence to substantiate the overall figure which you quoted. However, the existence of the National Care Standards Commission and National Minimum Standards and its successor body does mean that, year on year, we are collecting evidence in a way which will enable this Committee and others to have a better handle on some of the issues. For example, we gather information about how National Minimum Standards around medication are playing out. We have identified in our first trawl that 12 per cent of providers fail to meet that standard, and I can give you more detail again if you would like it. Similarly, the standards around abuse, which is not to say failing to meet the standard means that people are abusing people in care, very large numbers of people, but it does mean that the systems to prevent that happening are not sufficiently strong, and again, over half care homes are not meeting that standard. Ten per cent of our complaints, as you are aware, I think, from our evidence, relate directly to abuse, but 51 per cent of them also relate to poor staffing standards and management. So over time - and I know we are all impatient for this data to become stronger year on year - the existence of my Commission and its successor body will certainly produce evidence which will illuminate this area.

Q102 Chairman: Over and above the work that you do - and we appreciate the fact that you have given us some specific figures from the work that you have done - do you have any thoughts on how we might be able to establish a mechanism that gives us a clearer picture, not just in relation to the work that you do but in relation to the work of CHI and the work of Ms Berry's organisation, a wider picture? How might we establish a more coherent and meaningful record?

Ms Parker: There are, of course, a number of sources for this information, and the way in which we analyse our complaints and analyse our standards is becoming more sophisticated. We have recently changed the arrangement so that it reflects the types of category that are set out in the No Secrets guidance, so that again, one would be able to get a more refined picture. Similarly, the work of the No Secrets groups established amongst local authorities would give that information. As domiciliary care rolls into regulation, there will be a better picture, though it could be an improved picture, I think, both of the instances of abuse in relation to service providers, but also instances of abuse that are identified within homes, not directly related to service providers. There is a possibility there. I know that Dame Deirdre has issues about how PCTs and health organisations might contribute to that database.

Dame Deirdre Hine: I would like to mention to you the fact that we have begun within the current Commission for Health Improvement to establish an Office for Health Care Information, and I think that, as that develops within our successor body, the Commission for Health Audit and Inspection, it will be possible to collect stronger data and to relate that to, as Anne said, the data collection within bodies with whom we have memoranda of understanding, because it is important to note that we are not operating totally in isolation from one another. We already have quite a lot of partnership agreements, the most important of which is the memorandum of understanding, which allows us to exchange information between the bodies.

Ms Berry: I wonder if I could say something about the establishment of the Social Care Council, which is called specifically the General Social Care Council, and those of you who were involved in the Care Standards Act will recall that at the time of the legislation there had for many years been a campaign to set up a general social work council, and I think there was a recognition that there needed to be greater regulation of the broader social care workforce instead of just the 60,000 qualified social workers, all of the 1.2-1.4 million people working in social care, that we needed to set up systems which would enable people to be trained, to be regulated and to have known standards for the whole range of social care, because there was indeed considerable uncertainty about just what was the degree of abuse, or indeed the degree of poor practice in the broader social care sector. I think that as we get people on to the register, particularly as we start looking at conduct hearings, which we shall be doing, we will be able to understand a little bit more not only of the extent but of the type of abuse there has been, and we will be able to look at what the remedies might be.

Q103 Chairman: Can I be specific about the area of concern in respect of the approach that has been taken? You will have had this question put to you on many previous occasions. The approach taken by the Commission of tackling qualified social workers first has certainly raised questions as to whether this is the right approach, bearing in mind that certainly some of the evidence that we have had points to the less qualified people, particularly in the residential sector, being in a minority of cases the ones who may be involved in some form of elder abuse. I do not want to overstate the case, but obviously if a person is a qualified social worker, they have had a minimum of two years training, they will have been on placements, they will have been supervised in their practice. How do you justify tackling that group first as opposed to tackling those who, some would argue, needed to be looked at initially, the group that I have mentioned?

Ms Berry: I suppose the short answer is that it was the will of Parliament. The legislation required us to start with social workers.

Q104 Chairman: Can you explain to me why?

Ms Berry: I think the rationale for that was, certainly in the first place, that the campaign to set up a council had been around social work and it was amended to develop a regulatory framework for the entire social care workforce. So I think that historically there had been a lot of interest in how social workers themselves were trained and regulated, and a recognition that, despite the complexity of their tasks, there had been no regulatory framework. That was part of it. The second reason is that social workers are in many ways the gateways to all other provision, and that by concentrating on social workers, we were able to establish standards for those who are already coming into positions not only of direct relationship to service users, but also those who were the gateway to other services. Finally, there was a sense that it was really important to drive up standards through qualification and through training, and as you will know, there are already issues about enabling us to create a properly trained social work work force until we can get the standards of the rest of the workforce, the other million or so of them, to a level which meets the Government's requirements for training and for access through demonstrating good practice through our codes. It will be difficult to get them on to the register in terms of qualifications.

Q105 Chairman: So you basically feel the approach taken by Parliament was correct?

Ms Berry: I think it was right that, in addition to looking at that, what Parliament did do, which should never be forgotten, was that Parliament insisted that we should set up a Code of Practice and a Code of Conduct, and those codes apply to all care workers, whether they are qualified social workers or the rest. The register at this stage is only for qualified social workers, but the codes, which we enforce and are predominantly enforced through the Social Services Inspectorate and the National Care Standards Commission, Parliament did decide were to apply to all care workers, and indeed they do.

Chairman: My recollection is that Paul Burstow served on that Committee.

Q106 Mr Burstow: Certainly, my recollection of the Care Standards legislation going through was that the Act does not have on its face a specific schedule of which type of worker will be registered first with the Council. It sets out the nature of the Council, the work it is to do, and the Code of Practice and who was to be registered first was a matter for ministers dealt with under the regulations that were laid before Parliament. Can you confirm whether or not you have had any further indications from the Department as to its thinking as to which groups might be registered in the next waves of registration, and whether there is a timetable?

Ms Berry: Yes, we are indeed in discussion with the Department and with the Minister about the next stages. You are right that it is for Government to determine which of the groups that it describes as being regulated workers. The first group was qualified social workers. The next two groups will be those who manage care homes, and those who are working with children in care. The next groups, which could well include domiciliary workers, and could include a whole range of others, are for Government to determine. They will do that in part in relation to their own priorities and in part in relation to the advice that we give them, and what we have agreed to do is to go out to consultation in the next months, to get a view on what the next order should be. We have created a matrix of risk in which we are looking at issues like vulnerability and isolation of the service user, the degree to which the staff are people who are going to be working in supervised ways, such as in a residential home or in somebody's own home, and indeed the seniority level of training and so on of those workers. So the next stages are for the Government to determine, but they will do it on a combination of priorities, no doubt the recommendations of this Committee and the recommendations in the Green Paper on children, but in addition our advice, which will come from our consultation exercise, which we are about to begin.

Q107 Mr Burstow: You have said in the next few months; can you give us a slightly clearer timetable on which you will be giving advice to ministers?

Ms Berry: Certainly by Easter.

Q108 Mr Burstow: If ministers are then minded to take that advice and, for example, domiciliary care were to be one of the areas that was in the next wave, that is a substantial workforce with large numbers of part-time workers, a widely spread workforce, are you currently as an organisation tooled up to register that type of workforce? If not, how long would it take you to become tooled up to do so?

Ms Berry: If I may, there are two questions there: one is about the time that it would take us, and the other is what it would take in order for somebody to be registered. I will answer those two separately, if I may. At the moment we are required to put people on to the register who have the appropriate training, can demonstrate that they are of good character and can demonstrate that they have no health problems which would cause difficulties. The real issue in that for domiciliary care workers is being able to demonstrate the appropriate training, and certainly one of the issues about timetable is the requirement for 50 per cent of staff to get NVQ level 2, which will be coming in, I think, in 2005. So we will have to look at whether or not either the expectation that people are qualified before they come on the register will be amended or whether or not we will have to stick to that, because that in itself will have some timetabling issues. In terms of whether we have the capacity to do it, we are at present geared up to deal with about 5,000 applications a month. If we were to take on the whole of the domiciliary care force, then either with the numbers that we have at the moment we can get on with it, or indeed we would have no difficulty at all in moving to a position where we increased the numbers, except that there are obviously some practical and technical difficulties, things like getting licenses to be able to use the IT system etc, but in principle there is no difficulty in doing that.

Q109 Chairman: Can I raise a couple of specific questions on the role of the Commission. Obviously, the longer you are in parliament, the more you realise that every time legislation is passed, there are always some bits that are forgotten for various reasons. I have two particular points. One of the issues that is being raised with the Committee is the gap covering care workers involved in direct payments schemes. What are your comments on that? Secondly, what is the position in respect of day care for adults and the role of your Commission, whether that day care may be a separate entity from a care home or where it is actually within a registered care home that is inspected?

Ms Berry: On the first issue of services through direct payments, if the people who are providing the services come from within an agency, then they are covered and the agencies are covered by our codes and by registration requirements. If they are independent, self-employed people, they are not at present covered.

Q110 Chairman: Are steps being taken to look at that point?

Ms Berry: I think that, as we consult on who the next group should be, it will be very important to look at what responses we get in that area. At the moment, the Government has not designated workers through direct payment as one of the groups to be regulated, but if the consultation were to come up with very strong recommendations, I am sure the Government would look at that, but certainly at the moment that is not one of the groups that we are currently looking at as the next stages, because they are not included in the categories, except where they are part of an agency. If they are part of an agency - and indeed, the vast majority are - they are covered within our codes. In terms of day care provided by a local authority, by a voluntary organisation, by a private sector body, they are covered in so far as we shall be covering the whole range of social care workers. So whatever sort of setting they are working in, we do not differentiate between setting in that sense.

Q111 Chairman: I was thinking perhaps more in terms of the inspection regime.

Ms Parker: Chairman, if I might just link our role in response to that question, if inclusion on the Council's register is going to continue to be predicated on a sufficient tranche of the staff being trained, the issue for domiciliary care and the link with our responsibility to inspect to ensure that the codes and requirements are in place, the actual requirement for residential care to achieve the 50 per cent level is not until 2008, so there would be a considerably longer period if the two regimes were to be matched up. Secondly, my Commission and as yet the Commission for Social Care Inspection does not regulate day care, so that would be the other question about rolling out the timetable compatibly.

Q112 Chairman: Why does it not cover that? You will say it is that Parliament determined that it did not, presumably? Do you feel it should do?

Ms Parker: Chairman, this is not my responsibility as the Chair of my organisation.

Q113 Chairman: There are a lot of areas that will not be your responsibility, but we want your thoughts as to what we might say.

Ms Parker: I understand. I just wanted to make it clear. I do not know whether my perception is a feasible one, but I had wondered whether there might be a possibility of an arrangement whereby people would be required to subscribe to the code, but would not be fully registered, and then one might be able to monitor compliance with the code. I am not at all sure whether that is remotely possible.

Ms Berry: Yes, it is, because it is actually a shared responsibility for enforcing the codes, and that includes with employers. Certainly once CSCI is on board and we have new protocols with them, they will be covering a whole range of provision, and therefore there will be an expectation that we have an arrangement with CSCI to look at all areas of work. But, as I  say, quite what the order is going to be we do not know. We will be going out to consultation soon, certainly by Easter, and therefore I hope at the end of that consultation period we will have some more answers to those questions.

Q114 Chairman: You have mentioned the codes on several occasions. What concrete steps have been taken to ensure that the codes are embedded in the day to day practice of social care staff?

Ms Berry: One is to work very closely with NCSC, and we have been involved in the training of NCSC staff in the codes and the implications of the codes. They know what to look out for when they are doing their inspections. We have been involved in giving them information that has informed and is informing the pre-registration questionnaires. That is some very recent work that we have been doing. We have also been doing some work to ensure that as people go out to do inspections, whether it be from NCSC or from the SSI, they are very aware of the protocols and the arrangements between us for passing on information. So we are using at the moment the inspection regimes. What we are also about to issue is some guidance on good practice in embedding those codes because, as you rightly say, the codes relate to the entire workforce, not just those who are registered. So we have been working and we have gone out to consultation and got back some extremely helpful information from man people about what is good practice in embedding the codes. That having been now agreed, we are literally getting that sorted out and hopefully we are going to press on that within the next few weeks. Then we will be doing workshops and that sort of thing with local authorities and with independent providers in the private and voluntary sector.

Dame Deirdre Hine: Chairman, there is another group which is not regulated, which is health care assistants. In the investigation that we undertook into the Bedfordshire and Luton NHS Trust - and this related to learning disability services, not to the elderly, but it is vulnerable people, wherever they are - we recommended that health care assistants within the NHS should also be regulated, and that recommendation is now with the Department of Health.

Q115 Chairman: Would that be UKCC?

Dame Deirdre Hine: Yes.

Ms Parker: I would simply reiterate that the NMS do embody within the inspection regime an approach which requires us to engage with service providers to ensure that they understand their duties and responsibilities within the codes of conduct. To make a separate point, if I may, which I failed to make earlier, the issue about training for domiciliary care staff and indeed day care staff is also one of capacity for the trainers. One of the very good things about the codes and the National Minimum Standards is that these are enthusing the training world, and really there is a lot of extra leverage by having these frameworks to ensure delivery. But there is a question of the capacity of the training world to actually deliver the training in the volumes that will be required.

Ms Berry: I have to say that people have embraced the codes with enormous enthusiasm. We have sent out well over a million so far, in a very short time. I think the fact that the sector is actively looking to these and wanting to use them as a basis for training and so on is very encouraging.

Q116 Mr Bradley: In your collective written evidence you have identified a number of factors which have inhibited progress in tackling abuse, one of which is the delayed implementation of another register, the Protection Of Vulnerable Adults register. How satisfied or reassured are you with the announcement that it will start to be implemented from June of this year, and the process that will be undertaken to do that? What are your views about at that stage excluding NHS staff from that register?

Ms Parker: We certainly welcome the fact that there is progress here. It has been an issue which we have been concerned about, and which providers themselves have been seriously concerned about and have raised with us. So we very much welcome the fact that it is now about to become a reality. The timing and the proposed groups do cover the vast majority of the people for whom my organisation is responsible, so we are pleased about that.

Dame Deirdre Hine: It is not a matter that my Commission has actually considered and therefore I cannot give you the view of the Commission but I can give you my own view, and that is, because so many of the complaints and concerns and the investigations that we have undertaken have concerned vulnerable adults of some sort, whether they are people with a learning disability or elderly people or whatever, I think that it would be important, and I do not personally understand the reason for the exclusion of the NHS from that.

Ms Berry: Our response would be that we very much welcome it. One of the main functions of the General Social Care Council is to ensure that the workforce is one in which the public can have confidence. That does mean absolutely ensuring that there are rigorous checks before people come into that workforce. That, I have to say, is part of the rationale behind the decision to go for training first rather than simply putting everybody on to the register, and it would be fair to say that is a slightly contentious area. Some people believe it is better to get everybody on the register and then deal with issues; others believe it is far more important to work on standards, to get people to a sufficient level of training and then get them on and be able to regulate them, if necessary by removing them. All of this debate is about ensuring that there are effective checks before anyone comes on to the register. We are absolutely delighted that this is coming through, and indeed, will be working to ensure that the rules that relate to POVA will fit in very well with the rules that we have for ensuring checks. So we are very pleased about that and looking forward very much, as a result of this consultation, to seeing how we can, if necessary, amend our working arrangements.

Q117 Mr Bradley: In terms of the timetable, as far as you know, are you satisfied with the implementation or the progress on drawing up the register? Are the administrative parts of that, as far as you are aware, satisfactory to make it effective as quickly as possible?

Ms Berry: Certainly we have in place the necessary administrative procedures to deal with that. There is one issue, which is that nobody really knows how big this entire workforce is. We say 1.2 million, others talk about 1.4 million, some indeed 1.5 million. The social care workforce has never been registered. There has been no complete database, therefore it is not surprising. It is like taking the entire NHS, plus half the teachers in the country and trying to raise their standards, to check them all out and to get them into a regulated workforce all in one go. It is a huge task, one we have very much embraced through our systems, but we cannot know the answers to some of those questions because we do not know how many people there are. We can make best guesses at that, and as far as we have made our best guesses, yes, we are set up to be able to do that.

Q118 Mr Burstow: This is a question really based on some of the evidence from the Care Standards Commission and the fact that you do have systems in place to capture information based on complaints and so on. From that, in 2002-03 you tell us that there were 13,000 complaints, of which one in 10, 1,278, are making specific allegations about abuse. The other complaints tend to be around poor practice or neglect. The thing I wanted to particularly follow up on was that in the written evidence you list in paragraph 3.4 three main forms of abuse: deliberate abuse, spontaneous abuse - which is described as "isolated single incidents can occur for example when a person becomes frustrated with a challenging person in their care and becomes verbally or physically abusive" - and the third is unintentional abuse, and it says "can arise through neglect, poor practice by untrained staff, ignorance or where there are insufficient staff or resources to provide proper care." Surely, unintentional abuse would capture at least the first two or three groups of complaints, which are around inadequate staffing and poor staff training.

Ms Parker: Yes.

Q119 Mr Burstow: So although you have told us in your written evidence that only one in 10 of your complaints is about abuse, is it not far more if you apply your own definitions?

Ms Parker: Yes, Chairman. When I answered the question earlier I drew attention to the fact that whilst 10 per cent were specifically relating to abuse, the 51 per cent undoubtedly had the capacity to indicate at least a possibility of abuse in a number of these cases, and some of them would have been.

Q120 Mr Burstow: I wanted to pick up on something which came up in the opening statements around one form of abuse, one type of restraint in a way, the issue of medication, which appears in both the submissions from the Commission for Care Inspection and also from CHI. What I wanted to pick up on in that regard was particularly in terms of the Care Standards Commission. You refer in the report to there being 40 per cent of care homes that meet the standards for administering and handling medication, and I think you said just now that 12 per cent do not comply. That suggests there is a number that do not seem to fit in either category. What is their problem? Are they not completely in compliance? Where precisely are those other homes?

Ms Parker: Perhaps I can just quickly give you the figures for the four categories, starting with the best. One per cent exceed the standard, which means that they have elements in their practice which are outstanding. I could give you some examples of those if you want. Forty-five per cent meet them, 12 per cent do not, but 42 per cent are in the category which we call category 2, which is "almost meet". We have done quite a lot of analysis on "almost meet" because it clearly is a definitional issue, and one of the concerns for the Commission is to try and ensure that we are consistent in our judgments and our ratings, so we have unpicked this, and half of those are very minor infringements, which means they could be got there quite quickly. One of the encouraging things, I think, about the inspection process and the National Minimum Standards is that year on year people are striving to raise the game, raise their performance. I expect in our second year's analysis to see a significant number of those who almost meet moving into the "meet" category. So I think it is important to see that this is a tool which year on year has some potential for showing improvements - or not, as the case may be.

Q121 Mr Burstow: You mentioned half are almost meeting. What about the other half?

Ms Parker: No. I hope I am right in saying this. I was saying over half failed to meet the abuse standard. The actual figures for medication are one per cent exceed, 45 per cent meet, 42 per cent almost meet and 12 per cent fail to meet. I am happy to put this in writing.

Q122 Mr Burstow: when you were talking about category 2, which I think is the "almost meet", you said half of them were committing minor infringements, but could be improved quickly.

Ms Parker: Yes.

Q123 Mr Burstow: Therefore the other half are doing something else. Are they committing more significant infringements?

Ms Parker: Yes. For instance, if I can just distinguish what you might call something minor, something minor might be a failure to perceive that keeping controlled drugs in a locked cupboard but in a room that was not locked did not meet the standard. So once the awareness of that has been raised, one could expect to see that that would not occur again on the next inspection. If it is something about the training of staff in handling medication, which might take longer to deal with, it might depend on the availability of good quality training locally and the support of others, like pharmacists, you could see that that might take longer to remedy. It is still remediable, but it is not a quick fix. It is that sort of distinction.

Q124 Mr Burstow: Finally on this, there has been quite a lot of focus on the potentially inappropriate use of medication within care homes, and quite a lot of academic research which produces evidence which shows around 24 per cent of people receiving medication, of which 82 per cent might be inappropriate. That is the range of figures I have seen over time. But there are other settings. I would like to bring CHI in as well. The first is domiciliary care and whether or not at this stage you have any view as to whether the extent of inappropriate medication in domiciliary settings is a problem or whether or not you will be specifically looking for that as an issue in inspections. The second is more for CHI: in your submission today you refer to issues of medication as being one of the things that has come out from some of the investigations you have made. Do you think there are robust systems in place, particularly in those institutions where there is long stay care being provided for people with dementia, to adequately safeguard against the inappropriate use of medication?

Ms Parker: Domiciliary care is being registered this year and will at least start to be inspected next year. Some information will be picked up about the way in which the staff engaging in those tasks are involved in the administration of medicine. There will be some information there. What I would hope - and I think this is rather longer term - is that working in partnership with others, we might pick up more information about issues to do with what I know is a particular concern to my staff, depression and how that is or is not treated. We are picking that up at the other end, where people may or may not be inappropriately admitted to care homes because their problems are perceived perhaps as early onset dementia. There is lots of stuff there. The other important thing is that, of course, we are conscious that our remit here is about systems, administration, taking care when you are doing a job on behalf of the prescriber and the individual themselves, so that it has been very encouraging to see the interest - and I am sure this is much more for Dame Deirdre - that some PCTs are taking in actually reviewing the level of medication and the way in which this conforms or does not conform to medicines management. The National Minimum Standards do emphasize the importance of training in the management and administration of drugs, as indeed do the national care homes. They do not tackle the core issue of prescribing levels, just reporting if somebody is worried that something does not look right.

Dame Deirdre Hine: The one specific piece of evidence that we can give you from CHI relates to our investigation into services provided in Gosport Hospital, where we investigated, where there had been allegations that patients had been actually killed by staff. This was an investigation we did really because the police referred to us their concern about prescribing in some wards in that hospital. That concern relates to the quantity, the combination, the lack of review and the lack of recording of medicines, and to what is called "anticipatory prescribing", particularly of sedatives, which I think is a general problem, both in care homes and in perhaps wards caring for older people in hospital, and that is where patients are given sedation to ensure that they have a quiet night and therefore the staff have a quiet night. If we go to the much wider question - and I am speaking now not as Chairman of the Commission for Health Improvement because I do not have any direct evidence there, but as somebody who has worked in geriatric medicine - it is a matter of concern I think to the medical profession and to consultants in geriatric medicine in particular that polypharmacy, the prescribing of large amounts of different drugs, is a matter of poor quality care of patients. It requires more training of doctors, it means that they have to have more acknowledgement of the particular responses of older people as opposed to younger people to drugs, and it above all means that there has to be continued review of the drug regimes. If we go on to the administration of drugs within hospitals, then I think it is a matter as much of supervision of management that the systems which do exist to ensure that these are properly administered are taken. So it is staff knowing what the systems are, but it is equally management continually vigilant to supervise.

Q125 Dr Taylor: I would very much like to follow this up, because I absolutely agree with Dame Deirdre that polypharmacy is desperately dangerous, and it is inappropriate prescribing, I am afraid, by some GPs in the domiciliary set-up that concerns me. The absolute classic example is the treatment of depression with the Prozac type drugs, which it says in the BNF quite clearly should not be given without very careful follow-up to the elderly because of their effect, which can make people appear to be dementing rapidly. CHI has the inspection of PCTs and the grading of PCTs. Do you have any tie-up with the National Patient Safety Agency, which should be picking up these sort of things? How can these sort of inappropriate prescribing gaps be picked up?

Dame Deirdre Hine: We do have a memorandum of understanding with the National Patient Safety Agency. Currently, I am not aware that the NPSA has referred this matter to us as coming up through their studies, but then, of course, they are at the very beginning of attacking a very broad remit that they have, and certainly we have not had reason to refer this matter to them, but it is entirely possible that that will happen with our successor body.

Q126 Dr Taylor: Is that something we should be recommending to your successor organisation that they make sure they pick up?

Dame Deirdre Hine: I think it is. It is difficult for me to speak on behalf of the successor organisation, who will probably be undertaking their work in a slightly different way to the way we have. CHI has been concerned largely with systems and ensuring that systems are in place, and that management and supervision undertake to operate those systems and that staff are aware of the systems, so that specific areas of work, unless they have come up in the course of our review of systems, have not been part of our remit.

Ms Parker: Perhaps I might add something in relation to that question. We have recently undertaken a review of a number of cases of abuse to see whether there are any systemic issues or learning points for ourselves, and one of the issues in relation to our links with the Health Service have been discussions about the way in which we might collate and share information about adverse incident reporting with colleagues in community health and in PCTs, so I think there is an issue there. There is a linked issue, if I may make two points about domiciliary care. The same requirement to report adverse incidents is not contained within the NMS for domiciliary care. I understand some of the reasons why but I think some further thought might be given to that. Secondly, colleagues in the Royal Pharmaceutical Society produce very good information for care homes on these issues, and we have been hoping to encourage them to do a companion piece for domiciliary care.

Q127 Mr Burns: Miss Parker, your Commission uses compliance with the National Minimum Standards as the basis for your inspections and, as you have already told us in your written submissions, your inspectors seek as wide a range of views as possible as they are carrying out their duties, including the important area of actually talking to users of the service and seeking their views. How successful do you think your inspectors are in getting an accurate view from the users? Is there not the possibility that where there might potentially or where there might actually be something wrong, the users will be frightened of speaking their minds and telling the truth because they may then be open to intimidation or abuse?

Ms Parker: I think that certainly is a serious consideration. If I start at the broad brush end and then work back into an individual inspection, if I may, we are conscious that, first of all, people do not know what their rights are; they do not know what the minimum standards are. So we have been mounting a campaign about Your Right to Care, which is quite a user-friendly document, accompanied by a short television clip, which tries to encourage people to understand what their rights are so that they will first of all understand when something is not right and feel able to say, "Should that really be happening to me?" rather than just accept it. There is that broad level. Secondly, in relation to the inspection process, we were very conscious in our first year that the newness of the standards, both for the providers and our own inspectors, meant that it felt much more like an audit year and that staff did not feel that they could engage as much as they would have wished with service users in that first year. This shows in some of the reports. I am pleased to see that in our second year the voice of service users is coming through more clearly. There is still a great deal of work to do and we have a major service user strategy, which is involving service users in talking to us about the way we seek their information. They have made very helpful, constructive suggestions about the comment cards that we leave, which can be returned anonymously, to try to address some of these concerns; about the way in which we write our reports; about helping our inspectors to improve their skills in communicating with both service users, but particularly with service users who have communications problems. So we are on a journey here, and it is a very critically important one.

Q128 Mr Burns: Can I pick up a point? You said, if I heard you correctly, that basically, in your first year it was more of an audit because you were starting out, but subsequently things settled down. Is there a danger then of inspectors going native, or do you have different inspectors visiting different homes the whole time rather than the same inspector visiting the same home?

Ms Parker: There is a delicate balance, because part of the inspection process is about improvement and building relationships that enable you to engage first, to spot things changing over time, to be more alert, but also to have a relationship which means that you can promulgate and pursue issues consistently. But we do have an arrangement whereby we move a proportion of the workload of each inspector on over a three-year cycle so that there is less chance of people going native.

Ms Berry: May I add one comment to that? Returning to the codes of practice, it is very important that these codes - I commend them to you greatly; they even have a pocket version - have an obligation on employers not only to have these given to their staff, but also to service users. We know that one local authority at least has given them to every single service user. They are also obliged to ensure that there are advocacy arrangements in place so that service users can use these codes to challenge the practice and to challenge the conduct of their care worker. So again, I come back to the use of the codes as a mechanism for ensuring that service users are told what their rights are, and they must be given access to some sort of advocacy to enable them to exercise their rights.

Dame Deirdre Hine: Perhaps I could round off that subject by indicating that what the Commission for Health Improvement does when we undertake a review is we invite patients and users to come to talk to us locally, if necessary confidentially. We also invite the staff actually to come and talk confidentially to allow them to point up problems. We have review teams, which are multidisciplinary, which always include a lay person, and we have 450 lay reviewers who are over the age of 50, so they are certainly older people and would have an interest. Also, we have information from our National Patient Survey and we do a lot of work to engage with patients and patients' organisations. I have to say that, as I get older, my standard for what I thought was quality care has moved from the care that I would want my granny to have, to the care that I hope to have myself in the not too distant future.

Q129 Dr Taylor: I am very interested to hear that CHI has a panel of lay reviewers. I was going to ask Ms Parker about the value of lay assessors in your inspection teams, just as ordinary people who might get what the official inspectors would not get.

Ms Parker: Yes. We inherited a situation where we did have what was called a lay assessors' programme. It was completely different around the country. In some places it was excellent; in some places it was awful. Having reviewed that, to roll that out in our first year we felt would not be helpful, so instead we focused as a Board on trying to get better at hearing the voice of service users, and to use the skills of some of the people who had been lay assessors who were very good at that in helping to roll out that programme. The way in which at the moment we are using people who used to be lay assessors is on pre-inspection visits. There are a couple of different pilots for the way of using their skills and helping people to work with us in developing our processes. But that is designed to build the confidence - to come back to Mr Burns' point - of service users in understanding what the inspection is about and being able to get their thoughts together and therefore being able to respond when inspectors who are talking to them directly are asking them questions about their care.

Q130 Dr Taylor: Do you find that these lay people get points that the official inspectors would not get?

Ms Parker: In particular, we find where we are using lay people who have had an experience of the service or a relationship, we do.

Ms Berry: Again, if I may add, the GSCC was set up quite specifically to have a majority of lay people on the Council, on all its committees, and indeed, our Chair is lay. So in all our decision making there is a lay majority, but at the same time, we make sure that it is people who have experience of the services but who nonetheless come in with very much a non-professional approach to the questions.

Dame Deirdre Hine: We are undertaking a study of the national service framework for older people and we are currently piloting that. On our advisory panel 50 per cent are older people. I am not sure how we define that, but it would include me, I think.

Ms Parker: I would want to strengthen the comments made about the value and importance of developing advocacy services, because we are in there twice a year, and having a continuing relationship with someone really frees people up to speak and not to be isolated and suppressed.

Q131 Chairman: Can I ask Ms Parker a question? One of the interests I have had for a long time is why we have a statutory system of reviewing children in care and we do not have a similar system for older people in care, looking at their medical condition. I had a case in my constituency some time ago where several older ladies had scabies, and it was not picked up at all. In fact, the home eventually closed, and a good thing too. But there was no review mechanism. I was concerned about the medical monitoring of the circumstances. Arguably, many elderly people are perhaps less able to voice their concerns than youngsters in the care system, for a variety of reasons. What are your views on whether there ought to be some form of formal mechanism for reviewing, particularly as we now have within Dame Deirdre's arena the delayed discharge legislation that reviews the circumstances of people in NHS beds?

Ms Parker: If you look at almost any piece of legislation, any piece of policy, any piece of guidance and compare the way it applies to services for children, and the way it applies to services for older people, there is a light touch when it comes to services for older people. You make the point about the No Secrets guidance being guidance as opposed to the child protection guidance. I made the point earlier about the differential approach on domiciliary care, adverse reporting, remedies - legal remedies are weaker in many respects when you are trying to take cases of abuse of older people through the system. One can categorise a whole range, and I think there is a general issue about public perceptions of the rights, dignity and respect which should be afforded to us all, which we somehow do not see in the same way when people are older. We will certainly see it when we become older.

Q132 Chairman: A specific question: should we have, without being totally bureaucratic about it, some form of reviewing mechanism in place for vulnerable adults who are in a care setting, a nursing home, residential care, which we do not have at the present time?

Ms Parker: Yes. I think that has much to commend it. My Board has not commented on it, but it seems to me to have legs.

Dame Deirdre Hine: This is not CHI, but again relates to my own personal experience. When I was medical advisor to a social services committee of a county council - many years ago, I have to say - I arranged for consultant geriatricians to go into care homes to assess all the residents there, because we felt that there was a rehabilitation opportunity being missed. This is a matter of utilitarian as much as humanitarian concern, that in fact patients who could be made more autonomous for their own benefit and for the reduction of costs in looking after them are overlooked often because there is insufficient attention to the possibility that they are developing conditions that could be rehabilitated. That is one thing I would say. The other is that following the Victoria Climbie case my Commission has been undertaking a lot of work on the improvement of child protection arrangements within the NHS, and we have produced a self-assessment tool for organisations to look at to see whether their arrangements are meeting the needs of children. We would suggest that there may be quite a good case for such a self-assessment tool to be devised, maybe by our successor organisation - I could not say - for older people, so that the NHS is continually reassessing the way in which it meets the needs of older people. The same thing might occur in Anne's field.

Q133 Chairman: So there is some degree of agreement on the need to look at this review mechanism. I had some experience in the authority I worked for, for not quite the same reasons, where the public health doctor was wheeled in to Part 3 accommodation to argue the case that residents should be moved into the NHS at less cost to the local authority. But there we are. I was interested in your experience, because it is more positive.

Dame Deirdre Hine: The geriatrician did find substantial numbers of patients who required a reassessment of their care as a result of this review.

Chairman: Perhaps if the Royal Commission's recommendation on free personal care had been adopted, we may have had a system in place to review that care.

Q134 Mr Burstow: That is a very good idea. Moving back to the earlier question about medical review, the one area where the national service framework already has potentially some attraction on that is in respect of medication reviews. In terms of the National Care Standards Commission's inspections and the work you are doing around medication and compliance with the standards and the work that the Commission has been doing in terms of its inspections of primary care trusts, I wonder whether you have any fix on the extent to which medication reviews are now happening to the level that is required within the National Service Framework and whether that level itself is adequate in the first place?

Ms Parker: I cannot say nationally because we have not collected that data, but I have seen some excellent examples of proactive work by pharmacy advisers to PCTs, visiting homes, working with prescribers to look at the regime, finding problems and rectifying them. Undoubtedly, if that were to role out more right across the country - and I am not conscious that it is - that would be immensely helpful.

Dame Deirdre Hine: We cannot give you the answer to that question at the moment but when the study of the NSF is completed, which will probably be next year rather than this year, we should be able to tell you the answer to that as to many of the standards in the NSF.

Q135 Mr Burstow: It is worth noting that MORI was commissioned by the Department last year to do some research on medication review and they found that just under one in five patients taking more than one prescription medicine had had a medicines review in the last 12 months. That is for the whole population. In terms of poly-pharmacy, that is really an issue for this age group that we are talking about today. More frequent reviews are very important. You do not know whether or not the frequency of review is currently hitting the National Service Framework standard. That will be picked up?

Dame Deirdre Hine: It will be.

Ms Parker: One of my aspirations when I took this job on was that the networking between my organisation, NSF, NICE - and we already work with colleagues here - would be that perhaps year on year a key question might be identified, perhaps a policy question, which could be incorporated into our inspections when we are out there, over and above the NMS. It seemed to me, because we have the legs out there to gather the information, that would have been potentially extremely helpful.

Q136 Dr Naysmith: I had been going to ask Dame Deirdre about the implication of the National Service Framework but given her reply to that question we will wait to find out.

Dame Deirdre Hine: I do not think we can anticipate the answer.

Q137 Dr Naysmith: What do you feel about the treatment of older people in the National Health Service, things like resources, management priorities and so on? We are talking about a light touch in terms of regulation. A light touch can mean not very much touch. Is that the same sort of thing?

Dame Deirdre Hine: That is true also. Services for older people do not necessarily achieve the priority that they required within the National Health Service. There are particular concerns that staffing levels are poor, that there is a high use of agency and bank nursing staff, for instance. Because, very often, of the very high pressure of work, the development of staff is neglected and their further training is neglected. The environment within which older people are treated in the NHS is in general less good than that under which patients in general are treated. There is a lack of specialist services for them, for instance, in stroke care, where all stroke patients should be treated in a stroke unit. There is very good evidence for improved response to that. There are the problems that we have already alluded to of inappropriate medication and sedation, even within the NHS. What we are concerned about is that some of these factors, when they are combined with isolation of a unit where there have been changes and a unit is isolated geographically, where there is lack of clinical leadership within the team looking after them, where there is a lack of focus on services for older people by senior management, or where there are poor relationships within the teams looking after older people, these are the circumstance in which we have found that abuse is very likely to take place. That is not to say - and I would reiterate my caveat - that this is throughout the service. We have been sufficiently concerned. Our very first investigation in 2000, the first day we were operational, was into care of the elderly. More recently, in Rowan Ward in Manchester, we have found exactly the same problems. The NHS is not learning.

Q138 Dr Naysmith: We were together in a meeting not long ago about strokes and it is clear that if the proper facilities are put in there very quickly after an incident, people can be rehabilitated or helped. We know that and yet there is tremendous variation up and down the country. What is inhibiting that?

Dame Deirdre Hine: Shortage of staff.

Q139 Dr Naysmith: There is a real shortage of staff?

Dame Deirdre Hine: Yes, but there is an increasing will to do it because the clinical staff particularly recognise the benefit.

Q140 Mr Burns: Given that the population is living longer and there are more people needing either domiciliary care or residential home care and given that more and more elderly people are suffering from dementia in one form or another, do you think that it is right that staff looking after these patients should have training in the care of patients with dementia so that they specifically have knowledge of dementia and the way to care for those patients, rather than what is happening at present?

Dame Deirdre Hine: Absolutely. The complexity of care of the elderly has been undersold time and time again, whether it is for patients with dementia or patients with physical conditions. It is a highly sophisticated business. I am sorry to say that I think the medical profession has given far too little attention to the sophistication and complexity of this as compared to some other parts of the service.

Q141 Mr Burstow: Can I go on to a question about how organisations learn, remember and are capable of retaining their learning? It has come up in some of the evidence we have heard already this morning. I wanted to pick up on the written evidence from the National Care Standards Commission where they talk about loss of memory, knowledge and experience within organisations and agencies that allows patterns of abuse to go undetected. Clearly, that is a cause for concern. There are two questions I wanted to ask. One is obviously in the context of some of the events that allowed the murders to take place in Soham but also I think there is the issue of how we manage institutional changes so at a national level, for example, there is a lot of change going on at the moment in terms of the inspectorates. What steps are both the National Care Standards Commission and existing CHI taking to safeguard and ensure that the corporate knowledge that they have acquired during their existence will be passed on and not lost? I will evidence that by one or two points very quickly. One is the very useful adult protection protocol which is attached to the National Care Standards Commission evidence and I think the other is this reference, for example, to the self-assessment tool for elderly people. It is a very good idea which hopefully this Committee takes on, but how do you as two organisations that will cease to exist on 31 March ensure that your inheritance is taken on by the new bodies?

Dame Deirdre Hine: The whole of my organisation is going into the new body, not just part of it. I am very pleased to say that 100 per cent of our staff, other than our directors, are going to be part of the new body. Together with the fact that we have been working with the people who are going to run new CHAI over the past year, we have tried to ensure that we have inserted our DNA, if you like, into the new body.

Ms Parker: I am pleased also to say that we have had excellent working relationships with new CHAI, because our independent health care responsibilities move to them and all our inspectors move across. There has been real evidence of an openness to acknowledging the work that is done and stabilising it in this transition year for the independent health care sector. Similarly with CSCI, we seem to have done endless papers about lessons we have learned, things we would not do the same way, but we have also had many opportunities to present the policies, the issues, the work that has been done. There are not only issues about policies and protocols but also the very positive working groups that our staff, particularly in this field, have developed with service providers and service users, advocacy groups and reference groups, so that they are well aware of all of those networks as well as policies. Most critically important is that all our inspectors go forward as does our legislation. The point we were making is that on the ground, particularly around elder abuse where one is networking, we have found as a feature people have overcome it quite rapidly. The new organisations, PCTs, SHAs and ourselves -- in some cases, it is only a local authority and not always a local authority that is still in the same structure - and that sort of turbulence does require particular attention being given to making sure that very quickly, where there are systems and networks involved, they are re-established.

Q142 Mr Burstow: Yet, in the case of the CHI findings, we have had organisations that have had long periods of stability in terms of the delivery of the service they are providing to individuals - Rowan Ward, for example.

Dame Deirdre Hine: No. Rowan Ward had not. It was a newly merged trust.

Q143 Mr Burstow: The trust had been integrated but had the service management team and people providing the service changed?

Dame Deirdre Hine: At the top level, yes, they had. It is significant that two of our investigations, North Leighton Trust and Rowan Ward, were in trusts where there had been mergers and a disturbance of the management system. We think that throughout the NHS that is a cause for concern.

Q144 Chairman: Ms Parker, one of the issues that we have had raised with us has been the death certification procedures within care and nursing homes. I certainly had cause to talk to some MPs in my part of the UK over quite a lot of publicised concern about a particular care home in Yorkshire that you may be aware of. Questions were certainly raised with me about the processes that applied in respect of death certificates for people who had died within the care homes. My understanding was that care homes have to notify your organisation of all deaths in their care. What happens on receipt of this notification? What are the triggers which would cause you to follow up such notifications and how significant have such follow-ups been? What are the circumstances that have prevailed in these particular cases? Maybe you would wish to come back to us with more information.

Ms Parker: Indeed. We have submitted evidence to Tom Luce's inquiry. I can give you a short briefing note about when we receive this information. Essentially, it forms part of a database that informs the intelligence for the next event. This is one of the areas we have discussed with public health colleagues about sharing that information with them. It has been discussed at least twice on the board about whether one could or could not have standardised death rates and it is a very complex area. I would be very happy to produce a short paper if that would assist the Committee.

Chairman: We would appreciate that. On behalf of the Committee, can I thank our witnesses. It has been a very valuable session and we are most grateful to all of you.

Witnesses: Dr Stephen Ladyman, a Member of the House, Parliamentary Under-Secretary of State, Professor Ian Philp, National Director, Older People's Services, and Mr Ray Warburton, Head, Elder Abuse and Social Care Access, Department of Health, examined.

Q145 Chairman: Good morning. Can I welcome our second group of witnesses? The first session was extremely useful to the Committee and I apologise for keeping you waiting. Can I ask each of you to briefly introduce yourselves?

Dr Ladyman: I am Steve Ladyman. I am the Minister for Community at the Department of Health.

Mr Warburton: Ray Warburton, a civil servant at the Department of Health. I advise the Minister on things such as assessment of care management and abuse.

Professor Philp: I am Ian Philp. I am professor of health care for older people at the University of Sheffield and I am on an 80 per cent secondment as national clinical director to the Department of Health, responsible for implementing the National Service Framework.

Q146 Chairman: Can I thank you also for the written evidence? Can I ask about the extent of the problem? I am sure you will be aware that in the first of the two sessions we have done on this issue we were advised that at any one time there are around half a million elderly people who are subject to some form of abuse. The group of witnesses we have just had did not disagree with that assessment. We obviously have a concern for the extent of the problem. What is your view as to whether that is an accurate figure and can you say why it would appear that you do not have any formal mechanism for recording cases where elderly people are abused?

Dr Ladyman: We probably have a dispute over the number. I do not dispute that it is a very significant problem and that there is a very significant number of elderly people who are abused. The figure of 500,000, as I understand it, is an extrapolation from work done in 1992 by Ogg and Bennett. They used a very broad definition of abuse and perhaps we can talk about that because I am not entirely sure that such a broad definition is helpful. The figure of 500,000, because it is an extrapolation of 1992's figures, assumes nothing has been done since 1992 to improve the situation. I would suggest the figure is probably lower than 500,000 but I do not dispute that it is a very significant problem. In terms of formal mechanisms for getting at the issue, one of the difficulties is that we know that it is usually family and friends who are the abusers. It is very difficult to come up with satisfactory figures for what family and friends are doing in private settings. Abuse does not always happen in care homes. It can happen in people's own homes. It is a very complex picture and it is very difficult to get firm figures, but we do have some initiatives under way that we think are going to help us get more accurate figures. Ian will comment on the work that is going to be done under the National Service Framework but we have the possibility of using the National Service Framework survey to get more data. The work that the SSI is looking at doing will help us to produce more data. We have the Action on Elder Abuse help line which allows us to get a feel for the situation. Action on Elder Abuse have applied for a section 64 grant to do some much better work in this area. Unfortunately, I am not in a position to tell you whether that grant has been accepted or not yet, because we will be making that announcement in the next week or two. Suffice it to say that it is a very interesting proposal and perhaps I can tell the Committee something about it before the Committee writes its report.

Q147 Chairman: The picture you have given us is that you raised questions about the manner in which the estimate has been arrived at but you would not dispute the fact that all our witnesses up to the stage of you arriving seem to have concurred that this is a very significant problem and have not raised any real questions about the elderly.

Dr Ladyman: I do not demur from the idea that it is a very significant problem. I just think that the figure of 500,000 is probably not reliable.

Q148 Mr Bradley: Accepting it is a significant number, one of the delays has been in the implementation of the Protection of Vulnerable Adults register. Given the importance of this issue, could you explain some of the reasons for the delays and give us assurances over its implementation and its administration from June?

Dr Ladyman: There have been considerable, practical difficulties that have to be overcome before we could implement POVA. The Criminal Records Bureau, who are going to implement it, have only been in operation since April 2002. They have not been in post for very long and we know that they have had an awful lot of work to do in that time. It was important to us that we did not impose POVA onto that system until we were sure the system could cope with it. We are now sure that the system can cope with it, so we have made the announcement that we will begin the formal consultation with a view to introducing POVA from June. Would I have liked to have done it earlier? Of course I would, but it is better that we do it when it is going to work than we do it and the system breaks down.

Mr Warburton: In addition to the capacity of the CRB, there were some technical issues about the application of POVA, particularly with regard to trainees. In the NHS there is a huge number of trainees, both doctors and nurses. The way the Act is drafted means that each time you go for a new training post you would have to have a new POVA check. Weighing that up in terms of the implications of that for training and how smoothly that would run, let alone the cost issues, it was felt that that was too disruptive of general patient care which may suffer as a result. We are exploring how best to address those matters and probably will require regulations to make it run a little bit more smoothly so that, for example, for a training course you have one POVA check either at the start of the course or maybe every 12 or 18 months, just to make sure it runs smoothly. Within social care, you do not find that level of problem because the numbers of trainees, who are social work trainees, are far smaller.

Q149 Mr Bradley: Within the overall taking on of people, the NHS is initially excluded. In the light of the evidence from the inquiries there have been into abuse, a lot centring on NHS establishments, Rowan Ward in my constituency being the most recent, how do you explain that exclusion? If you are really serious about tackling the problem, what are you going to do about it to ensure that those people are included?

Dr Ladyman: Let me emphasise we are not excluding the NHS indefinitely. We are excluding the NHS until such time as we can bring forward the appropriate regulations to be able to include the NHS.

Q150 Mr Bradley: When do you hope to do that?

Dr Ladyman: It is very difficult to give you an accurate estimate but I would hope certainly by the end of the year. We are not talking about a huge delay in implementing POVA in the NHS, but it will need some easements to the regulations.

Q151 Mr Bradley: And implementation after you have put forward the regulations?

Dr Ladyman: As soon as possible after that. Early next year I think is reasonable.

Q152 Mr Burns: In your introductory comments, Minister, I think probably not unreasonably you suggested that the half million figure that is bandied around is 12 years out of date and may not be an accurate figure for what is happening now. Unless I misunderstood you, you suggested that you might have had some question marks over some of the definitions of elder abuse that contributed to that half million figure. You said we could discuss it. Could you tell us what your concerns are about what the definition is and do you have any guesstimate of your own or the Department of what the level of abuse might be at the moment?

Dr Ladyman: The concern I have about those earlier definitions is that they include things that can be as innocuous as raised voices. There is a difference, in my view, between a raised voice when somebody loses their temper under stress and immediately apologises, realising they have done thing and the apology is accepted. That should not be counted as abuse, in my view, unless it is happening every day in a systematic way. Those broad definitions, in terms of the realities of providing care to people, are not helpful.

Q153 Mr Burns: What are the definitions you are unhappy about?

Dr Ladyman: In No Secrets we published our definitions of what really constitutes abuse.

Q154 Mr Burns: Which are?

Dr Ladyman: They are extensive, but they include physical, sexual, financial and verbal abuse, where it leads to loss of self esteem.

Q155 Mr Burns: What other abuses are there in the half million figure that are not in your No Secrets definitions that give you concern?

Dr Ladyman: Around personal relationships, arguments, raised voices. Those are the sorts of areas that give me some concern that Ogg and Bennett perhaps defined abuse too broadly.

Q156 Mr Burns: You have also said that you raised the point about how do you know that innocuous instances do not go on to become more serious levels of abuse.

Dr Ladyman: Yes. You are absolutely right. That is where we come to some problems in terms of collecting data as to what we define as abuse. If I can refer you to No Secrets, if we were writing No Secrets today and it was put in front of me - I think No Secrets is an absolutely excellent document; I am not criticising my colleagues who were in the department when it was written - the one bit of it that I feel needs some tightening up is the paragraphs on when we should intervene. The definition of abuse where we should intervene basically says when it starts to do harm. In other words, it defines abuse according to the outcome rather than according to the action. I can imagine a situation where somebody who went into a care setting, for example, with a very high level of self esteem started to be subjected to verbal abuse. Initially, it would not affect that self esteem but over a period of time it would. I think it is wrong to say that the abuse only starts therefore once the person is depressed and has now low self esteem. The abuse really started initially. There are great complexities about how we define abuse and how we define the point where we should intervene, how we should define where harm starts. I am not suggesting that we have all the answers to that but if we are going to have systematic data collection we are going to have to have an answer to that. For the time being, we are working with the No Secrets definition.

Q157 Mr Burns: Do you have any guesstimate in the department for what level the abuse might be at?

Dr Ladyman: No.

Q158 Mr Burstow: You were saying that if we are to have systematic data protection we might want to revisit the No Secrets definition. Are you planning to have systematic data collection? If so, what is your timescale? The other part of the question relates to what you were saying also about the question of at what point abuse takes place. Is it the act or is it the consequence? Is that something you are minded to review and change in any further guidance issue around No Secrets? Finally, this is to do with No Secrets itself. The guidance was published in 2000. There has been a review by the department of the codes that have been produced by local authorities as part of that. Has there been any subsequent work done or planned to evaluate how the codes have affected practice on the ground?

Dr Ladyman: Is it appropriate for Professor Philp to say what the National Service Framework survey amounted to?

Q159 Chairman: Can we leave that until later?

Dr Ladyman: The work that the SSI are looking into that will be taken up by CSCI is going to be very important in providing that date because for the first time CSCI will be regulating both providers and commissioners of service. That is going to be important in improving the data collection. The intention is that we will have a range of initiatives to try and improve this data, one of which is this proposal from Action on Elder Abuse. I am not in a position to confirm or deny today whether it is going to go ahead but certainly it is a very interesting proposal.

Q160 Mr Burstow: If that piece of work were to be successful, hypothetically of course at this moment, would that provide the department and the public with a basis of information that we are currently not able to have?

Dr Ladyman: I believe so.

Q161 Mr Burstow: Is the NSF review the only vehicle by which the department is getting a clear picture of how the guidance on No Secrets is being implemented?

Dr Ladyman: No, it is not. We are also looking at indicators within the performance assessment framework to see how it is being implemented across councils.

Q162 Dr Naysmith: In your memorandum you talk about raising standards generally and trying to deal with the question of elder abuse. It becomes incredibly difficult to define elder abuse. Some people define it as meaning if you know, say, in stroke services there are things you can do to improve the situation of people who have had a stroke and then you do not allow everyone access to the service. That is a form of abuse. I want to know whether elder abuse is part of an integrated strategy for care of the elderly.

Dr Ladyman: Absolutely. Elder abuse is something that I personally am committed to ensuring that we have a systematic panoply of measures to address. I cannot say to you that the solution to elder abuse is going to be one piece of legislation or another. It is going to be a range of activities implemented through different pieces of legislation. The charge is often put to us that we have not moved forward on elder abuse and I just remind the Committee that besides the Human Rights Act in 1998 we have had the Care Standards Act, the creation of NCSC, the POVA legislation, the National Service Framework for older people and the No Secrets document. Remember the No Secrets document is enforceable. It is a section seven document which means that unless there are very serious reasons why it should not be implemented it is a duty on councils to implement No Secrets. We have had a range of initiatives to try and tackle elder abuse. Do I think that they will all have had the impact that we want them to have yet? Absolutely not. We would not be here discussing it. Mr Bradley mentioned Rowan Ward. What a horrifying reminder of what can happen that was to us. We have a range of initiatives going on and we have to see them as a whole part of our approach to trying to tackle this.

Q163 Mr Burstow: It has been put to me and others who are concerned about issues around elder abuse, particularly in residential care settings, that the writ of the Human Rights Act does not directly apply. It has to be applied through the local authority as the contracting body but the individual within the home cannot enforce the Human Rights Act against the individual home. Is that the case? Is that something that the government is looking at?

Dr Ladyman: There are legal issues about the rights of people living in care homes under the Human Rights Act. You are absolutely right. It is something that requires further study. The Human Rights Act is applicable, at least to this extent: out of the Human Rights Act and our work on the Human Rights Act, we introduced our guidance on whistle blowing, for example, in order to ensure that people now have the right to expose abuse when they see it going on and not be punished for it. Also, it was out of our general work on human rights that led us down the road ultimately to POVA. One other piece of legislation that I ought to have mentioned which the Committee should be aware of is the forthcoming legislation from the Home Office on domestic violence victims in crime, which is going to include an offence of familial homicide. That will also be significant in helping us address elder abuse.

Q164 Chairman: In the previous session I raised with the General Social Care Council, Lynne Berry, the issue of the approach they have taken to registration. You will be familiar with some concerns that the approach means they are looking at qualified social workers who have had at least two years' training, supervised placements, a fair degree of monitoring in the work they have done prior to far less qualified social care workers in residential care. Her answer to me was that the approach had been determined by ministers and Parliament. How do you justify that approach when it would appear that there is more abuse - I am not saying all - amongst those groups that they are looking at later rather than earlier?

Dr Ladyman: I would slightly take issue with the view that it was determined by ministers and Parliament.

Q165 Chairman: We need to check the record but that was the impression I had.

Dr Ladyman: It was a position taken with ministers and Parliament. I have no doubt about that. There are practical issues that have to be overcome in doing any registration process: the numbers of people involved; the time it is going to take the body that has to register, the number of people they have working for them and the time it will take to do registrations. All of those things have to be taken into account and these bodies have to make recommendations to ministers about what is practical. They get discussed together and then we work out, given the practicalities, what our priorities are going to be. I do not demur from the idea that it was appropriate to start with social workers. I think it is important to start with a layer that has an overview of the system and then to move quickly as possible to getting everybody else registered as well. I certainly want to see the social care workforce being registered as soon as possible and that should be the next on our list, but I think it was appropriate given the practicalities of setting up a brand new registration system that we started with the people who have an overview, who are the qualified social workers.

Q166 Dr Taylor: I am sure you are aware that as a Committee in one of our previous inquiries we were not entirely happy with the delayed discharges legislation.

Dr Ladyman: It proves that you do not get everything right.

Q167 Dr Taylor: One of the worries is that this obviously puts tremendous pressure on hospitals and social services for rapid discharge. Is this a potential for abuse when poor practices come in? Have you any arrangements to spot this if it is happening and to control it?

Dr Ladyman: I do not see the relationship between the Delayed Discharges Act and abuse. If we are taking the very broad definitions of abuse that Dr Naysmith was suggesting, leaving people in an inappropriate care setting when they should be discharged from an acute bed might be counted as a form of abuse. We can have our dispute over whether the Delayed Discharges Act was a good thing or not but I am sure that what we would not disagree on is the need to move as efficiently and as rapidly as possible to get people into the right care setting. Part of that is the single assessment process where we look at people's individual and specific, detailed needs and design a care package that meets those needs. Part of the Delayed Discharges Act of course says that discharge cannot happen until that single assessment process is complete. For the first time, we will have a view of exactly what an individual's needs are. We will expect those needs to be met in the care environment that they move into.

Q168 Dr Taylor: I think we are thinking of premature discharge to the wrong place because there is nowhere else. For instance, sending people miles away to care homes.

Dr Ladyman: I do not believe that that will happen.

Q169 Mr Burstow: At all?

Dr Ladyman: Given that we discharge hundreds of thousands of people from hospital every day, do I think it is possible that one or two may end up in that sort of environment for an interim period? I suppose it is possible. I think it is not going to be a thing that happens on a routine basis. I do not think it will happen routinely in any particular area. I think social workers and clinicians will be absolutely determined to ensure that it does not happen and I do not think there is any reason under the Act why it should happen. Will it happen once? It might.

Q170 Mr Burstow: One of the things I am interested in is an answer you have given recently in a couple of written answers to myself and Sandra Gidley concerning the data collection in respect of both emergency readmission and delayed discharge. Data collection changed from 1 April last year from something based on a definition of those over the age of 75 to something that is now all ages. The explanation was that it was felt it was ageist to collect the data on an age specific basis. Two questions arise from that. One, why is it felt inappropriate to collect age related data in order to understand how the NHS is behaving and acting in respect of older people? Two, if it is felt to be ageist to collect such data, would that not be an argument for not collecting other sorts of data that would enable the department to understand if there were differences of approach on the basis of age as to the way the service is being provided?

Professor Philp: To some extent I am responsible for that shift. It was a campaign that I took on early on to remove a performance measure that might have resulted in older people being discriminated against. The basis of moving to an all age indicator in these key targets was that it would be a benefit to all adults to not be exposed to delayed discharge and for readmission rates and emergency rates to be appropriate. What we have kept in the data analytic function is the capacity to analyse these data by age groups. We can nevertheless explore differences and similarities across the age range and we can look at the impact specifically on older people.

Q171 Mr Burstow: If a Member were to table a written question to solicit that information on that basis, it would be provided in a written answer?

Dr Ladyman: It would depend upon the availability of the data at the particular time the question is answered but I do not have any particular objection to the data being put in the public domain, so long as it is available and we can collect it at any particular time without too great a cost.

Q172 Mr Burns: I share Mr Burstow's concern that the government has changed the goal posts and the rules and has stopped collecting and publishing this data, particularly in line with your policy on fining social service departments over delayed discharge and particularly given the record of this government in its management of the news. You will know as well as I do that the emergency readmission rates within 28 days of discharge do not reflect well on the government. It does seem quite extraordinary, if you are monitoring this problem in a realistic way, that you should all of a sudden cease to produce those figures in the way that you have in the past.

Dr Ladyman: There is a difference between the collection of data as part of a set of indicators that are used for the purpose of gathering a hospital star rating -- that has an impact on the overall funding and the management of the hospital - and the collection of data for analytical purposes. All we have said is that we do not want to create an ageist indicator that impacts on the management of the hospital but we do need the data in order to help the hospital manage the process of delayed discharges. I take issue with the terminology you use and indeed that the Committee has used on the subject of delayed discharges. Social services are not fined. They simply reimburse the National Health Service for the cost of keeping people in beds.

Q173 Dr Naysmith: The National Service Framework is the main way of raising standards for the care of elderly people. Can you say if it is working and can you give us some sort of idea about how it is going?

Dr Ladyman: It is working. I think we are making very significant progress. Remember, we are only part of the way through its implementation. I am going to ask Professor Philp to give you an indication of where we have got to because I believe you may not have been given a very clear idea of the progress that we have made. I will also ask him to comment on the National Service Framework survey which has a big impact on the possible ability for gathering data.

Q174 Dr Naysmith: Standards and milestones?

Professor Philp: Yes. Specifically on standards and milestones, I cannot give you all the information that I am aware of because some of the information is soft information and anecdotal. I would not want to put on the record impressionistic or anecdotal data. What we do know is that for the key milestones which are coming up in April of this year and April of next year health and social care communities are on target, in the vast majority of cases, to meet these key milestones. These relate to stroke services, fall services, implementation of common assessment systems within health and social care and the development of protocols for the care of older people with mental health problems. We also know that in relation to intermediate care services we are providing services which are benefiting more older people than we had originally intended. There has been particularly a growth of domiciliary, home based forms of intermediate care, as opposed to bed based intermediate care services. It is not to say that we are in any way complacent about progress with the National Service Framework for older people's services because it is an extraordinarily bold and ambitious document that attempts to redesign an awful lot of our NHS and social care system with older people's needs in mind. It is part of a ten year programme. We are looking at not just using our target measures for the NHS and councils but also other means of building on the progress that we make. I know earlier you mentioned stroke services and concerns there. For example, the National Service Framework targets are around having organised stroke services present in general hospitals to care for people who have strokes. We are more or less on target to meet what we set out to do there.

Q175 Dr Naysmith: There is a lot more in that area on rehabilitation. If you start rehabilitation early, it can make a fantastic difference to people's recovery. I know that is variable over the country.

Professor Philp: Absolutely. It is a building block to having service but it is going beyond that to benefiting the majority of people who should receive that service. You can look at any of the National Service Framework standards from that point of view but could I mention those perhaps which relate most to the issue that we are discussing?

Q176 Dr Naysmith: The next question will be that there really are not any specific mentions of standards of management or allegations of abuse, as far as I am aware. You have this survey going on. Is there any possibility that that is something you are looking at and there may be better guidelines coming out from this survey?

Professor Philp: Thank you for that question. I think it is really pertinent. When we developed the National Service Framework we created a framework for change that emphasised treating old people with dignity and respect. We do not have a large number of specific levers within the National Service Framework to target elder abuse but we have the capacity from the NSF review, which has been undertaken jointly by CHI, SSI and the Audit Commission, to build on particularly implementation of the single assessment process. Although this is quite a complex change which involves systematic assessment of older people's needs proportionate to their level of need, it does include key domains around safety and relationships. As we are progressing the implementation of the single assessment process, we have been able to build in a very specific inquiry into the possibility of there being abuse or neglect, from both the point of view of the older person who is assessed and the professional who can make a judgment. I have recently met with Debra Clay who is leading the NSF review and she has said that in the review, in view of the public interest in tackling elder abuse, she will look at the extent to which the single assessment process is being first of all systematically implemented ----

Q177 Dr Naysmith: That is meant to start in April this year, is it not?

Professor Philp: Yes. There is a key milestone in April. To what extent is it being systematically implemented and targeted on vulnerable older people? Second, to what extent during assessment is inquiry being made into the possibility or the actuality of abuse taking place? Third, if older people are identified as being potentially or actually abused, what follow-up through the case management and the review process is being undertaken? We have within the single assessment process for the first time the possibility of systematically and proactively identifying and managing older people at risk of or receiving abuse. The review is a representative survey in 15 health and social care communities and therefore it will give us a national picture. The key to translating the national picture into action that will tackle abuse is the extent to which the findings of the review can feed into future star ratings for councils and for the National Health Service inspection system. It is the intention from the review process to identify the methodologies through which we can systematise that.

Q178 Chairman: On the single assessment process, one of the issues I raised with the previous group of witnesses was the inconsistency between the traditional ways we have treated children who are in care and vulnerable adults in care. With children we have had in statute, at least since 1948, a clear requirement to review their circumstances on a regular basis, including medical reviews. Will this new assessment process impact in any way in respect of people who are in care homes and nursing homes who may well not need to be there, particularly on their medical circumstances? It does seem to me somewhat inconsistent that the government have introduced the delayed discharges mechanism which involves a review of the circumstances of a person in hospital and they may be discharged somewhere or other as a consequence of that review and yet we have a significant number, I suspect, of elderly people who are in care settings that are probably completely inappropriate for them. Nobody seems to be challenging the appropriateness of that placement.

Professor Philp: The full implementation of the National Service Framework will ensure that that does not take place.

Q179 Chairman: Who will do the reviewing?

Professor Philp: It will happen both before and during.

Q180 Chairman: For existing people in care or a nursing home, what will the mechanism be? Who will do it?

Professor Philp: Any suitably trained and qualified person from the National Health Service or social care. It is most likely to be a nurse or a social worker, but it could be a therapist, a doctor or even a pharmacist, according to what the particular needs of the older person most predominantly are. It is a shared assessment system, but I would like to point out that the National Service Framework states that nobody should be placed in a care home without having received comprehensive assessment through the single assessment process, which is the most detailed form of assessment which includes multidisciplinary review by a range of people including doctors, nurses, therapists and social workers. With the full implementation of the National Service Framework, older people will have that comprehensive assessment and built into that is a review process, depending on how needs are identified. Of course, people in care homes are people with particularly high levels of need, on the whole.

Q181 Chairman: What timescale are we talking about before we can expect to ensure that anybody who is in a care home or a nursing home has this independent review?

Professor Philp: The National Service Framework is a ten year programme. We only have milestones which take us through the first four years so there is still the possibility of setting milestones and targets for the second half of the programme.

Q182 Chairman: Why is it that we have legislation that has gone through to ensure people in the NHS who may be inappropriately placed have this process where they are, after a period of time, moved into another placement and yet we have potentially thousands of people in the care and nursing home sector who also may be completely inappropriately placed and may well have the potential for rehabilitation and yet there is no mechanism at the same time to review their circumstances? Is it a relevant factor that a number of people are paying for their own care, as opposed to NHS treatment which is free?

Mr Warburton: The 1990 NHS Community Care Act introduced assessment and care planning in social care. From April 1993, councils had a duty to assess and then reassess all the needs of individuals they supported.

Q183 Chairman: Are you telling me that they are medically examined to see whether they are appropriately placed, because I am sorry; I do not accept that.

Mr Warburton: I am just talking about councils' functions.

Q184 Chairman: I know. I certainly talk to people who advise me that there are significant numbers of people who are placed, having had the assessment that you describe under the 1990 legislation, who remain in care or nursing homes, who may be more appropriately placed elsewhere, particularly from a medical perspective.

Mr Warburton: Councils have been reviewing people's cases. We are improving that from April 2004 with the single assessment process which requires a review including issues to do with clinical diagnosis, medication, people's rehabilitation needs, issues to do with safety, abuse, neglect, relationships and a whole range of matters. People's needs should be reviewed within three months of being placed in a care home or receiving a service in their own home, and then at least annually thereafter. We would expect, because people in care homes have significant needs, that their reviews would not be 12-monthly but they probably should be more frequent.

Professor Philp: I just wanted to bring in the medicines management aspect, because I think that is the most important quality issue and one which the Committee has already, I think, discussed. There is a range of measures that are intended to strengthen greatly medicines management, and in many cases particularly for people in the care home setting. I think the Committee need to be aware that we should not necessarily adopt a view that it is only doctors who can undertake aspects of medical review.

Q185 Chairman: No, I was not suggesting that. Having had personal experience of certain cases, I do feel there is insufficient medical surveillance of some people in care in the nursing home sector.

Professor Philp: Yes. Thank you. Could I mention on medicines management that we are progressing with a number of measures to strengthen medicines review. We do not have data to update on the survey which was undertaken that showed only one in five people were getting their medicines review within the year that was intended (although these data related to some two years ago), but we have made progress through a medicines management collaborative, which covers one-third of this country, where there has been a dramatic increase in the role of clinical pharmacists in reviewing medicines of older people, particularly in the care home setting, with data suggesting not just benefits to the older person but also reducing, for example, hospital emergency admissions for that group from the care home setting. We have within the new GMS contract for primary care a quality standard by which GPs will get paid for ensuring there is a medicines review at least every 15 months for people aged 75 and above on four or more medications, and we have the NSF standard as well. So there is a lot of activity there and I am working actively with the pharmacy community and with doctors and nurses to ensure that we can get partnerships in place locally so we can determine who would be best placed to undertake these reviews which are so critical.

Q186 Mr Burstow: Just following up on this point about medicines management - and you are absolutely right it is a very key part of this and certainly a concern of this Inquiry - the medicines management collaborative you were talking about just now, do you currently have any data to give us an indication to what numbers of people over the age of 75 are now enjoying the benefit of medicines review up to the standard that was put forward in 2002 as a milestone? How many people in this country are now benefiting from that? How many should be benefiting from that?

Professor Philp: I cannot give you absolutely accurate data, but my discussions with the people leading the medicines management collaborative is that those participating sites, which is one-third of primary care trusts in this country, are hitting and exceeding the standards set in the National Service Framework for medicines review in the vast majority of cases. I am also informed that sites which are not involved in the collaborative in some cases are making progress where there are local champions that are pushing this. I think the picture is different from the picture that we had in 2002, but there is still a lot of work to do to systematise this into every health and social care system in the country.

Q187 Mr Burstow: When you say they are performing better, does that mean that medicines review is taking place more frequently than is set out in the milestone?

Professor Philp: In some cases more frequently; in other cases it is about including people who do not fit the requirement (for example, people below the age of 75).

Q188 Mr Burstow: Will the survey you are about to conduct enable us to have comprehensive data for the first time from which we can then extrapolate the numbers of people who are currently receiving medicine review?

Professor Philp: The NSF review will give us a handle, through taking a representative health and social care community including people in care homes, on the extent to which medicines management is being undertaken to the NSF standard, yes.

Q189 Dr Taylor: While I agree that it does not have to be a doctor who reviews all aspects of care, Dame Deidre in the first part of our session raised the question of the possibility of consultant geriatricians going into care homes more regularly than they do and even taking responsibility for patients there. Is that actually happening anywhere? Is that a possibility?

Professor Philp: When the care home movement developed in this country in big numbers in the 1980s, the British Geriatric Society, the specialist society of doctors caring for older people, took a collective view that it would be beyond their capacity to provide that support to care homes and it became a de facto GP responsibility. Geriatricians at that time concentrated on ensuring that older people in acute hospitals received best care and whether that was taken as a strategic decision or it was just what happened, I am not sure, but that is what happened. In the current situation, where there are many people in care home settings and in domiciliary settings who have quite complex needs and where it is appropriate to receive specialist care, I think we do need to encourage not only geriatricians but also old-age psychiatrists and some general practitioners who would wish to develop special interest in the care of older people, jointly to address the needs of people who have these needs.

Q190 Dr Taylor: There is a very small number, so far as I am aware, of consultant geriatricians in rural areas who do not actually have hospital beds. Do they play a much more active part in going into care homes in their areas? Just as we have community paediatricians, is there a possibility for a career type, a community geriatrician?

Professor Philp: There is. It exists but it is not popular.

Q191 Mr Burstow: Why is it not popular?

Professor Philp: Amongst geriatricians it is not popular career path at present, although there are some extraordinary individual geriatricians who have championed a community role for the speciality. I could name some. There are some who are doing as you say, but it is not mainstream practice. That is the point I am trying to make. My personal view, and where I am concentrating energy, is on whether we could grow the proportion of general practitioners who have a special interest role, if we could grow the proportion to develop the interest in older people. Fifteen per cent of GP time is spent in special interest role but only a tiny fraction is involved in the care of older people. Recently I have brokered the discussions between the specialist societies and the GP societies to agree a common framework of competencies which would be acceptable to both branches of the profession about what a GP with a special interest could do, and I am in discussions with the national primary care team to look at the way in which we can make sure we get accreditation and remuneration which would support that and encourage the growth of the GP with a special interest.

Q192 Dr Taylor: Is thee anything in the GP contract that supports this?

Professor Philp: The GP contract includes quality indicators on medicines management and stroke, but there is nothing specifically about GPs with special interests. It would be for a primary care trust to commission that service from GPs with special interest if they thought that was of benefit to their local population.

Q193 Dr Taylor: But it is something that a recommendation from us would support.

Professor Philp: That would be very welcome.

Q194 Dr Naysmith: It is a very interesting area but of course for most general practitioners their case load will be 50 or 60 per cent elderly people in any case.

Professor Philp: Yes.

Q195 Dr Naysmith: It would have to be much more tightly defined than just an interest in elderly people.

Professor Philp: That is correct, which is why it was important first to agree what would be those skills and competencies that a GP with a special interest in older people should have and upon which their training and accreditation would be based.

Q196 John Austin: May I apologise to the Minister and his colleagues for not being here for the earlier part of this session.

Dr Ladyman: That is all right.

Q197 John Austin: I had an important constituency engagement - and I am sure the Minister will appreciate the importance of that. In previous evidence some of the witnesses have expressed concern about the division of care regulation between the provision for social care inspection and the Commission. What overview will you exercise or what review will you do to ensure that they do collaborate and ensure adequate regulation of elderly people in the social care setting?

Dr Ladyman: First of all, let me make it clear, when you ask me what control I will exercise over them, they are both independent organisations, so the control I can impose on them is extremely limited. However, in the recently passed act, both bodies have not a power to cooperate but a duty to cooperate and I will certainly expect them to honour that duty to cooperate. They also have the power to inspect on each other's part when necessary, so it will not always be necessary for CSCI to go in one day and CHAI to go in the next day: they can come to a decision that it is better for one or the other to look at a particular institution at a particular time and they can then exercise their duties on behalf of the other. So they have both the powers and the duties they need to cooperate and I will certainly be expecting them to honour those duties.

Q198 John Austin: Is there any planned review after the new system is bedded in?

Dr Ladyman: There will certainly be reviews of the way it is going. Since they do not even come into action until April, it is a bit premature to talk about reviews of how it is working, but certainly there will be reviews.

Q199 Chairman: Could I ask a couple of practical questions I raised in the previous session to do with the certification of deaths in care and nursing homes and whether you are satisfied with the current procedures. I know the Shipman review will bring forward certain suggestions of changes in the broader area of this, but it has certainly been put to me in respect of individual cases in my own area that there are some questions about the way in which we check on the circumstances of deaths of people in care. In some instances where people have been expected to die, questions have been raised as to whether the death actually related to the longer term problem or to some incident that occurred prior to death. Are you satisfied with the current arrangements? If not, do you have any thoughts on how things might be changed?

Dr Ladyman: One of the benefits of having to appear before the select committee is the swotting up that you have to do before you get here. I freely confess that I had not focused on the issuing of death certificates and I was a bit surprised to discover that the guidance is that, if the GP has been treating somebody and he thinks they may have died from the illness for which he was treating them, he does not even have to look at the body. That is a concern to me. I cannot say I have any firm ideas as to how it should be addressed at this point, but you have served the purpose of flagging that in my mind as an issue that does have to be thought about to see whether we are doing that appropriately. At the moment we have the BMA's guidance and all the other guidance in place, but, as we have seen from Shipman .....

Q200 Chairman: You understand the problem.

Dr Ladyman: Absolutely.

Q201 Mr Burstow: One of the things we have been told in the written evidence from the National Care Standards Commission is that the scope for use in a domiciliary care setting is probably greater than it is even in a residential care setting. On the process that is currently in hand to register domiciliary care agencies, in some written answers over the last few weeks you have indicated that 243 of the 4,322 domiciliary care providers have so far been registered (I think is the right word), but in another answer you indicate that whilst none have been rejected only two applications have been registered with conditions. I wonder if you could (a) unpack some of the figures so we can understand what the state of play is and (b) move us on to the question, which I think is even more important: Just when will we have care standards that will in fact really bite and deliver change for domiciliary care?

Dr Ladyman: I think you have absolutely come to the nub of where we need to put a lot of effort now. To unpack it for you, as you have requested, there are three processes: application, validation and registration. Application is when a domiciliary care provider fills in the forms and sends off the money and asks to be registered. There is then a process that has to be gone through to make sure they have provided all the information that needs to be provided, all the forms have been filled in correctly, and the registration process can then begin. That is the process of validation. Although offhand I think we have had something like 4,500 applications, I think we have had about 4,000 now or a little bit less than 4,000 that have been validated. The process of registration is when the Commission has looked at those validated applications and decided that they fulfil the requirements for registration. Now the law requires regulations to be fulfilled. National minimum standards in fact are not regulations. They are not legally enforceable. They have to be taken account of to decide whether the regulations have been fulfilled and certain of the key standards are part of the regulations. Were we to insist - and this was something I was talking to Sandra Gidley about in the recent opposition day debate on care homes - on complete compliance with all the national minimum standards, I doubt whether there would be very many domiciliary care agencies who would comply with those national minimum standards at the moment. However, if what we ask is that they meet the key standards, therefore they are providing a safe system, they meet the regulations, which is the legal requirement, and they are working towards meeting the rest of the national minimum standards, then I think a very high proportion of them will ultimately be registerable, and it is the intention of NCSC to get as many of them as possible registered by April when CSCI takes over.

Q202 Mr Burstow: Just to understand the process a little bit further, where has it been published and set out clearly which aspects of the regulations will be, if you like, the red lines when it comes to whether or not an agency does or does not pass the registration standard but with conditions? Has that been published or is this something that is entirely case by case? Because whilst on the one hand case-by-case might seem sensible, it then could give cause for concern that there were things being accepted as acceptable practice which really ought not to be.

Dr Ladyman: The key standards are not going to be done on a case-by-case basis. I think we are just about to publish them in detail.

Mr Warburton: Apparently the National Care Standards Commission has issued guidance on this matter to inspectors and did so on 18 December last year.

Q203 Mr Burstow: Is that something that could be sent to the Committee?

Mr Warburton: Yes, absolutely.

Q204 Mr Burstow: That guidance is being used by the inspectors consistently across the country to determine whether or not an agency does or does not ----

Dr Ladyman: That is absolutely the intention: that it is going to be consistently applied everywhere. I am just about to write a letter to the chairman of the NCSC on this subject making clear the Government's view of their position. That will be a public letter, but I will make sure you have a copy of that as well.

Q205 Mr Burstow: There are certain standards within domiciliary care standards to do with training. We heard in earlier evidence, and in varying respects on the possibility of domiciliary care staff being on the registers in respect of the General Social Care Council, that training would be a key trip-wire or trigger for their entry to the lists. Is training one of the red lines in respect of the registration of domiciliary care agencies?

Dr Ladyman: I will reflect on that for a moment and give you an answer, but let me just say that one of the different aspects where training comes into this is that you will be aware, I am sure, from your constituency mail bags, that we had the issue of Criminal Records Bureau checks before domiciliary care workers could actually take up their appointment. I did say at the time that I would look at the regulations to see whether they could be made more flexible. Because, if we insist on the Criminal Records Bureau check being in place, then people cannot start work for at least four weeks after they have applied for a job and that makes it very difficult for domiciliary care agencies to work. We have had an informal consultation with the centre and we have now come up with a proposal on which we will go to formal consultation for changing that regulation. That formal consultation actually would require three days' induction training before an individual could start providing domiciliary care services on their own. So there is a training element going to be built into that, subject to what the consultation advises us is the right way to adjust things.

Mr Warburton: Yes, we have reflected! In response to your question: yes, appropriate training for the job is included in regulations, so they will have to be satisfied.

Q206 Mr Burstow: Okay. The other point I wanted to pick up on was to do with No Secrets. It was flagged that it would be dealt with in the context of the NSF survey. Clearly that will deal with the Single Assessment Process. I am not clear whether or not the Department has any other plans to satisfy itself that local authorities have gone beyond simply the publication of codes of practice and actually put into place practices which are influencing the way in which their staff are carrying out their duties and, indeed, now using their contracting powers to ensure that No Secrets also applies to those from whom they purchase services.

Dr Ladyman: We are looking at ways in which we can put an add-all protection indicator in the performance assessment framework. That is the answer to your question.

Q207 Mr Burstow: Will it be a single indicator or a cluster? If it is a single indicator, it will be very hard to pick up on those things I have asked about.

Dr Ladyman: I imagine it will be a number of pieces of data that have to be collected. That may get resolved into a single indicator, but there will be more than one item of information collected as part of that process. But that will be published as soon as we can do it.

Q208 Chairman: May I conclude by asking a wider philosophical question. I was encouraged by your comments in the debate last week which indicated some agreement with my own view that the models of care that we currently offer for large numbers of older people in terms of care and nursing home provision may be somewhat outdated and we need to revisit and maybe to move away from them. I wonder what your thoughts were as to why, in a period of time when we have moved away from institutional models of care for children and the mentally ill, we have gone along with what Professor Philp calls the care movement and in a big way expanded that model of care. To me there appears to be some diminution of the rights of a person who is eventually accommodated in that kind of communal environment. This is a personal view. I know that others do not agree. I have certainly had several abusive letters following that debate - and some of them have been abusive about you, Minister! It strikes me that on this general issue the models of care we offer do reflect a wider societal view of the value of older people. How can we challenge that?

Dr Ladyman: I think we have reached the position we are in today, first of all, because of a number of perverse incentives that were put in place legislatively over a long period of time - and I am not just blaming the previous Government; I think this is an attitude that probably started in the 1960s and was going on for a very long time. There are a lot of people now in care homes who probably never needed to go into care homes if they had had alternative options available to them. There are some who probably went into care homes before they needed to and who now are frail enough that they probably do require to be in care homes. But, if we draw a line under what has happened in the past, we need now to be asking ourselves where we go for the future. The problem we have within this whole debate - and which I hope we would use that opposition day debate as a means of moving forwards - is that it is a lack of imagination about what is possible and what we ought to be trying to achieve. As I have gone round the country - particularly when I have visited extra care facilities - I have met people with severe dependencies and yet they are able to live in their own private accommodation in an extra care facility. I have met people with dementia, I have been to extra care facilities for people with dementia, with all of the people living in those homes living in their own accommodation. I have met people with physical disabilities. In a previous debate I used the example of a lady I met in Coventry, who is in a wheelchair, doubly incontinent, peg-fed and blind, and living in her own flat in an extra care facility. The independent type of living that we can offer through using our imaginations, I think, is immense. At the moment, those extra care facilities are starting to spring up in the public sector and I am working very hard now to try to encourage the private sector to get into them. For people who have their own family home at the moment which is too big for them - we all have constituents who are very worried about losing their home, they want to lock some equity away - we need to have extra care facilities in which they can buy their accommodation and lock their equity into that accommodation. Of course then they will be assessed for their care charges on the basis of domiciliary care rather than residential care, so the value of their home will not be taken into account. For all sorts of people, this is a model of care that I think could be a dramatic improvement and a significant extra choice in the spectrum of choices. I personally believe - I certainly hope - that by the time I am needing to make these choices, probably in about 20 years time, that extra care will be the dominant model of care.

Chairman: I am very encouraged by your comments.

Q209 Mr Burstow: What the Minister has just said is excellent. I entirely support what he has said in terms of developing extra care. It is definitely an option that needs to be developed in the future. I just want to ask the Minister, as you have widened this discussion ever so slightly, about something that has always puzzled me about the exchanges we have on the floor of the House around the development of services not for the person that you described just now, Minister, who is being peg-fed at home, highly dependent, but the person who is at home and possibly on the verge of moving down the slope to a greater level of dependency and the extent to which the service that is available to them has changed and, certainly on the basis of the statistical evidence that appears to be available from departmental sources, diminished. I do not understand how that could have been allowed to diminish. Perhaps from your trips around the country you could give us one example of where that sort of early intervention - not dealing with the most dependent but those who would benefit from a little bit of help early - could avoid some greater dependency later.

Dr Ladyman: I think you are referring here to the fact that the total number of people receiving home care through the local council has gone down. That is as a result of a deliberate decision to try to encourage councils to focus their resources on providing intensive care. The one-hour-a-week popping in just to see if you are all right was a relatively inefficient way of using council's resources, whereas concentrating it on actually keeping people who would otherwise have to go into residential care at home was a much better way of using their resources. In terms of the numbers of people receiving those sorts of intensive home care packages - of whom we can say absolutely they would be in residential care now if it was not for this intensive care package - that number of people has increased by about 30 per cent since 1988. There are 81,400 of them on the 2002/3 figures now who are at home rather than in residential care. That I believe is a significant improvement. I believe we need to be looking at the way we encourage councils to work with the voluntary sector, which I think might have a role in providing some of those less intensive services that might just make life easier for older people. We have to look at the way the attendance allowance is being taken up: there is a very large number of people out there who I think may well be entitled to an attendance allowance who are not claiming. And then there is the whole issue of at what point does intensive home care kick in and the way in which councils set their eligibility criteria at the moment. As I go round the country talking to councils, I remind them of two things. First of all, the Government does not set eligibility criteria for social care. We set rules that say this is the guidance that would indicate what fair policy is, but it is for councils themselves to determine their own eligibility criteria against the needs of their population and their local resources. If councillors are finding that people cannot access social care in their areas because those eligibility criteria are too tight, they need to be thinking about how they can relax them in their area. Secondly, we do not require councils to charge for social care services in their own home. All we say is, if you are going to charge, you have to have a fair charging policy. In other words, it has to be comprehensive; it cannot use flat rates; it cannot take into account people's homes. It has to leave people with a certain proportion of income relative to income support. We set guidance as to what is a fair policy but we do not stop councils, if they want to, waiving charges or subsidising those charges. If councils do not want to, we do not require them recovering the full cost of social care. I think councillors need to start being a lot more proactive in challenging eligibility criteria and local charging policies because I suspect most of them inherited those policies from previous administrations and have never bothered to review them in the light of current local need.

Q210 Mr Burstow: That may be true. I want to come back to my original question which was about early intervention and prevention and ask you again: Do you think - from you answers it would seem to be the case - that early prevention and preventative initiatives are something that is now the realm of the voluntary sector?

Dr Ladyman: No, no.

Q211 Mr Burstow: Because that is what I could have taken from what you have said.

Dr Ladyman: If you are asking do I think that low intensity home care is appropriate, no I do not think low intensity home care is an appropriate function for local councils. If you are asking should local councils be engaging with other partners in initiatives that prevent admissions to hospital, that deals with the issues that Professor Philp is covering in terms of the local full service. How can we be proactive about putting services in place for older people? I absolutely do believe that is a role of local councils, and the Government has done a number of things in some pilot areas. The Ever Care model of care is being piloted and some other initiatives that are looking at preventative activities. My own local council, Kent County Council, is the lead council in the Office of the Deputy Prime Minister's Innovation Forum, which is looking at ways they can reduce hospital admissions in Kent - by 32 per cent, I think, is their target. So I absolutely do believe that councils should be engaged in those sorts of initiatives across the board, which is why we have given the councils the money they need actually to get involved in those sorts of initiatives.