MONDAY 12 NOVEMBER 2007

MR IVAN LEWIS AND MRS ANNE MCGUIRE

  Q160  Earl of Onslow: You have overpaid my daughter! She gets terribly angry when I say that.

  Mr Lewis: I shall send her a transcript of your comments! There are two issues. Clearly if we are going to get very much further on the question of a focus on the needs of people with learning disabilities we are going to have to include that in a number of different ways, first of all in negotiations we have with GPs once the contract negotiations are resumed, so that is something that is going to have to be done, and secondly there is the whole question of what chief executives of NHS provider organisations regard as being important, and if it is not one of their priorities then, frankly, they are not going to treat people with learning disabilities anywhere near as seriously as they ought to. Thirdly, there is the whole question of the relationship between the NHS and local government and, indeed, the voluntary sector, private sector, in local communities. We talk a lot about integration but for many of the groups of people, particularly this group of people, that whole relationship between social care so-called and the NHS is absolutely crucial. My answer to your question would be that, first of all, I think GPs have to consider what is best practice sometimes and make sure they do that best practice without a view to exactly how much in the QOF formula they are going to get as a consequence of it. Some of it is just best practice and the best GPs want to give equal access to their patients and recognise that some of their patients will need more attention and more time than others. You used the five minute argument, and I have not got the detail in front of me, I may want to challenge that, but, of course, there are other patients that GPs are dealing with who need far less time than the median. The best GPs are willing to recognise that different patients have different needs for different reasons, and inevitably some people will need more attention. I wish I felt the biggest single issue here was to do with a lack of time. I think there is a lack of knowledge and expertise, and I am not saying in relation to your daughter but amongst GPs generally.

  Q161  Earl of Onslow: I asked this because it came up.

  Mr Lewis: Also, I think there are certain things which are expected of GPs that I regard as being about best professional practice, not about whether you are going to be incentivised through contractual negotiations to do it or not. We need to be frank about that. Carers, by the way, are another area and we should remember that many adults with learning disabilities are still predominantly supported by carers or family members and there is a whole debate to be had about the relationship between GPs and carers.

  Q162  Chairman: If we are looking at the issue of health, and I think you are right to look more strategically than just at the GP time taken, although that is important, we saw the DRC on an inquiry on health inequalities and they came to a pretty robust conclusion and said: "The term `institutional discrimination' does not seem too strong to describe what is happening in some quarters", and I suspect from what you are saying that whilst you may not formally agree with those words you would understand perhaps where they are coming from. What would you say you are going to try and do to address that? I know you have got your independent investigation into some of these issues now but how can you respond to comments like that from the DRC?

  Mr Lewis: The answer is there are a number of ways and I have tried to identify some of them. There are the contractual negotiations with GPs and their representatives. There is an understanding of what best practice is and spreading that best practice. There is the training of doctors and nurses, and we should remember that primary healthcare is not just about GPs, it is about a whole range of professionals. It is about senior managers in the NHS knowing that a part of the way they are going to judge but also incentivise in terms of their responsibilities are the experiences of people with learning disabilities. Frankly, there is also the fact that when appalling neglect, institutional or otherwise, takes place there are the consequences, because I never want it to be said, "That person had a dreadful experience in terms of their healthcare but the mitigating factor is the person had a learning disability". That is a complete anathema and unacceptable to me. The other issue is commissioning. The other question that has to be asked alongside that is that when there have been these abuses, mainly in specialist services, there have not been very many prosecutions stemming from those abuses. There is a whole variety of factors at play here and it would be very disingenuous to say one more than the other would make the difference. It is really about the Department of Health, and the NHS consequently, taking the needs of people with learning disabilities seriously and giving them a higher status in the future and, whether you are a GP or a senior manager, knowing that people with learning disabilities require a specific and distinct response and they have the same rights in terms of access to mainstream healthcare as any other citizen, and in terms of the provision of specialist services this notion that we have got to move away from the medical model, other than in circumstances where people have an illness or a health condition.

  Mrs McGuire: That is where the Disability Equality Duty is also key, because it is about charging public authorities in the widest sense not just to look at their practice but to start to raise the issues of disability equality as part of the way in which they deliver services, and that covers the NHS as much as it covers police authorities and educational establishments.

  Q163  Chairman: I think that is something we will want to come back to again. The answer you gave there, Ivan, was not very dissimilar from the answer you gave us when we were looking at this issue in relation to the treatment of the elderly within the hospital and care home system. That links through to me to the main thrust of what we were talking about then, which was the use of human rights as a lever to improve services. Do you see the Human Rights Act and human rights principles as a lever here to improve services and, if so, how are you using it in your negotiations with your colleagues across departments to help people with learning disabilities? Perhaps you can give us an example, if possible.

  Mr Lewis: Obviously part of the new Valuing People focus that we will be publishing in the near future will be the whole reminder to people that this is about human rights legislation and the Disability Discrimination Act, and some of this is grounded very clearly in law. It is not just about doing the right thing, it is not just about best practice, it is also about fulfilling statutory obligations. As I said to you the last time I appeared, I also have a concern that ministers are very clear that in the same way as just announcing a policy or an initiative does not change anything for people on the ground, simply having law does not always change people's experiences on the ground either. As long as we get the message right in terms of that combination of factors I think you are right. Mersey Care, and they have appeared here, have a very impressive approach and a significant part of that approach is based around starting off from the perspective of fundamental human rights. The new approach to Valuing People, the next stage of Valuing People, needs to emphasise to the deliverers as well as the policy-makers that much of this is grounded in the law.

  Q164  Lord Plant of Highfield: Your answer there really brings me on to my first question. Many of the witnesses have said in the context that you are producing a further version of Valuing People that what is needed is not so much more policy or an elaboration of policy, they are strongly supportive of the policy and think you have got the policy right, the problem is implementation, persuading people on the ground, as you put it a minute ago. What sort of levers can you pull? How do you go from a widely supported policy to actually getting the implementation on the ground?

  Mr Lewis: I will deal with that and then Anne might want to come in. There are a number of things. First of all, we now have substantive legislation that was not there previously. You have got to align the message you send to your regulators, whether it be CSCI or the Healthcare Commission, in terms of how they are judging public sector provision, so regulation, making sure that is consistent, understanding that if you are a senior person in an organisation part of the way that organisation will be judged is the way you treat people with learning disabilities, in this case. The fact that we have proxy targets for the first time around social exclusion which are about people with learning disabilities are a major step forward. In addition to that, empowering people and family members to know what their rights are and supporting them to develop the skills and confidence to challenge the system when the system is not delivering is crucial, whether it be forums or things like personal budgets and direct payments, so recalibrating the power in the system so you give a lot more power to people and their families who use services is another important way of changing things. We set up the Learning Disability Partnership Boards, which the Committee has heard a little of, and of course the view is they are incredibly patchy in their effectiveness and some local authorities are going through the motions. They have not disbanded them but they have very little influence over the development of either policy or delivery at a local level, so one of the things we have got to look at is what we can do in terms of the Learning Disability Partnership Boards. The new version of Valuing People is no change of policy whatsoever, and this is the whole point, we will be saying very clearly the policy was right and is still right, the consensus is still there. It is how do we use the levers that we have available to us at a national level to secure better delivery locally. The final point I would make is this whole debate around devolution and localism. If you look at the latest Comprehensive Spending Review settlement, the new arrangements between central and local government, there is a much greater level of devolution. With that comes a performance framework, clear requirements and obligations in terms of outcomes, and with that comes local area agreements, but in the end we have to be much clearer as ministers and as Government in every area of policy—this applies to the dignity of older people as well—what are the levers that we have and be very ruthlessly focused on seeking to identify what they are and, where appropriate, pulling them to maximum effect. The final responsibility and power ministers have is to say these things matter. A lot of the work that we have done around the dignity of older people is beginning to have an effect in that it is beginning to be debated and discussed and is in the media almost on a daily basis. Getting these issues debated and discussed, and people understanding how important and serious they are, and that it is not just about somebody else's family, it may end up being about your family or someone you care about's family, is crucially important.

  Mrs McGuire: I think we have also got to recognise that legislation has been there now for a long time and it is about how individuals who deliver public services actually accept their part of the responsibility. I do not want to pre-empt the question on the disability equality duty, but what that does do is recognise that everyone who is involved in the delivery of the public service has a responsibility for ensuring that the rights and needs of disabled people are taken into account. If I could give you a specific example where a reasonable adjustment could be made in terms of a hospital, it might well be that they need to look, if it is an outpatient appointment, at how they manage that outpatient appointment. Do they change it to suit the particular commitments of a learning disabled adult and perhaps their parent or carer? What can be considered to be a reasonable adjustment? The whole concept of reasonable adjustment has now been with us for a long time. Ivan is right: we are not now defining new policy. What we are doing at every opportunity is highlighting to those who deliver our public services in particular, but also to those in the private sector who deliver jobs and various other services, that they have a responsibility to work with those with a learning disability as individuals and not categorise them, stereotype them or make assumptions about what they can and cannot do. That is where, I think, the human rights perspective is so powerful. As I say, I know from earlier evidence that that approach was supported by various organisations and their representatives.

  Q165  Lord Plant of Highfield: But, picking up the point about localism that I have made, some of our witnesses have suggested that local authorities are tightening up a very great deal on the criteria for eligibility and that means that a more and more limited group of people will have access to the best level of service that might be provided. Do you recognise that, and, if you do, how are you going to work with local authorities to ensure that the vision of Valuing People is not eroded by this tightening up under financial pressures of eligibility criteria? A more specific question following that general one is this. If the numbers are tightening up because of the tightening of the criteria the critical group is going to get into the eligibility criteria but the group of people immediately below that group, as it were, who could get very great value from services but whose needs are not as critical, are not going to get them under this tighter regime. Do you recognise that and what steps, if any, do you think you can take to ensure a reasonably equitable distribution between the critical group and the very needy but not critical group?

  Mr Lewis: In the Comprehensive Spending Review settlement the Government has committed now to a process of public engagement and consultation leading to the production of a Green Paper next year on the long term funding of care in our society. I am delighted that the scope of that is beyond older people. I think this is a major advance, something that we fought for, and it recognises that social care, unlike the NHS, has always been means tested and therefore the challenge, in the context of a society which is changing—disabled people now have long lives and expect full lives, quite rightly, as well as the fact that we live in a society where people are living longer and have more complex and challenging conditions), is that as we look at that demographic change which is swirling around us we need to have a new settlement between the state and the citizen in terms of who is responsible for what when it comes to the funding of social care. That is the long term. As for the short term, I have spent my whole life in social care before I was elected to Parliament in 1997. I started off life as a young volunteer at the age of 14 working with people with learning disabilities, which is where I get some of my passion for this from. I set up a small voluntary organisation at the age of 19 looking at leisure and social opportunities for people with learning disabilities. I feel very strongly that we are not getting best value for existing resources. I think the community care legislation of the 1990s was very well intentioned indeed. I think it has led to unintended consequences of an over-complex and over-bureaucratic system with too much emphasis on assessing people and very little on doing anything once you have assessed them. We have got this whole stuff around eligibility criteria which means that we do not realise that our interventions need to be a lot more about early intervention and prevention. If a person with a learning disability is healthy, is working, is having a positive life, they are far less likely to become ill and to become highly dependent on the state and therefore, in terms of best use of existing resources, there is a lot more we can do. We will be announcing very soon a programme of reform, which we will be leading on for the Department of Health but which will be cross-government, on the whole way that we do adult social care in our country. I do not want to go into that too much but I want to be clear about the ingredients of that message. One is a much greater role for personal budgets so that people have a greater level of control themselves over the care that is provided to them and their families. Some people will need a large amount of help to make that a reality. Other people will need a minimum amount of help. Another is a shift to early intervention and prevention and away from a system which starts to respond to people once they have already deteriorated. We need a much closer level of integration between the NHS, local government, the private sector and the voluntary sector in every local community and a focus on the quality of commissioning. I do not just mean of commissioning by local authorities or by primary care trusts or by DWP. I mean the notion of joint commissioning in communities so that we are looking holistically at the needs, in this case, of people with learning disabilities. We talk of a world-class commissioning system. We do not have a world-class commissioning system. We never said it was world-class, by the way, but it is our aspiration. At the moment there are a lot of people who act as commissioners but who frankly are contract managers, who manage an existing market, who manage existing providers but who have not got the skills or the vision or the imagination to first of all get a very clear sense of what their population needs assessment is and, having done that, to really begin to re-engineer and recast services in an appropriate way. I also suspect that we have large amounts of money tied up in out-of-date services that people with learning disabilities do not need and do not want. There is a real challenge there about how we free up some of that resource in an imaginative way but also in a way that takes families with us. I think this is a really difficult one for people at a local level. If you are proposing major reform of traditionally provided services and you have thousands of people marching down your local street it is all right referring to the minister's contribution at an evidence session like this, but when certain politicians (who shall remain nameless) are presenting any change in the NHS and social care as cuts it makes it incredibly difficult to radically move services forward. I also believe we must do this reform very differently from the way we have done previous reforms. You need to win the hearts and minds of people on the front line if you are going to reform a system effectively, and therefore, rather than having a set of reforms that we impose top-down on people working in the social care system (and to some extent in the NHS) you need to try and find a way of reforming the system in partnership with those who are responsible for delivering it in the real world on the front line whilst never, never being afraid to challenge, as Anne said, the poorest of the practices, whether it is about the dignity of older people --- I had a go recently and said some nursing brings that profession into disrepute. Failure of accountability amongst NHS managers is completely unacceptable. It is about achieving this delicate balance between wanting to win the hearts and minds of people on the front line and taking them with us but never being afraid to say that there are certain things which are entirely unacceptable and standing up for the rights of citizens who use services, and their family members in this case.

  Q166  Chairman: It seems to me, Ivan, and we have had an amazing amount of evidence on commissioning issues, whether from people who have given evidence to us formally or when talking informally with people with learning disabilities or we have been out and seen for ourselves in those bodies, that there is a huge amount of really good work going on, often with relatively few resources. You can achieve an awful lot for people who are not particularly seriously disabled. It is like the greatest good for the greatest number argument, I suppose, in terms of a relatively small amount of money being spent relatively thinly and doing an enormous amount of good, and whilst we are inevitably focusing on people with serious disabilities who must have the help, we have to find a way of getting smart in the commissioning process. That is quite an inspirational statement. The real question is how you translate that inspirational statement into what happens on the ground.

  Mr Lewis: Anne has some similar experiences, but, very quickly, the only person employed in the small voluntary organisation I ran back at the age of 18 or 19 (when I had a proper job and a life) was me and a half-time admin worker. This was about getting people access to social and leisure opportunities other people would take for granted—going down the pub, going to the theatre, the cinema, introducing people to the notion of relationships and friendships and acquaintances. The only cost was the volunteer expenses and my salary and that of the half-time administrative worker and the £30 a week it cost to rent a dingy basement room in a not very salubrious hotel somewhere in darkest Salford. The point I am making is not that volunteers should be used to do it on the cheap or that we should exploit people but that there is an awful lot we could be doing in the world of social care which is about alleviating loneliness and isolation, about building relationships between people, that does not need to cost billions of pounds in state expenditure. One of the sadnesses about the community care legislation of the early 1990s is that it has left us with a system where nobody appears to be responsible for things like how do you alleviate the loneliness and isolation of older people or people with learning disabilities? One of the things we will seek to address in the announcements we make in due course will be not saying that the state has a duty to provide people who are lonely with a friend, because that would be a disaster, but that surely the state, represented at a local level, in partnership with local communities, so it has to be a combination of statutory agencies, the voluntary sector and local communities, has a duty to look at its most vulnerable members and build various systems around those members which enhance their quality of life. Some of it is about statutory agencies like adult social care, like the NHS, like Jobcentre Plus, like the Learning and Skills Council, making sure that they fulfil their statutory obligations to everybody in an equal way (they do not do that at the moment in many cases) but some of it is also about communities having a different view of what a decent civilised aspirational community should be in a modern world.

  Mrs McGuire: That is why we are so keen on our individualised budgets approach, because it is not about additional money or additional resources; it is about looking at the resources that are there and how, by reconfiguring them, you can not only give independence, control and authority to an individual disabled person but also improve their quality of life because they are in the driving seat, and certainly some of the early experiences coming back from those individualised budgets are very positive.

  Q167  Mr Sharma: You have already picked up the question I was going to ask, but I had experience, before becoming a Member of Parliament only five months ago, of working in the disability field, particularly with learning disabilities. My main concern is that there is a lack of skills, which you have already identified, but also strict financial controls, so that when a needs-led assessment is done it is done keeping in mind how much money we have, and that is where this new criterion will affect a lot of people who are sitting on the margins. How are we going to improve the staff skills and the skills of those people who are going to decide it in the future?

  Mr Lewis: We spend vast amounts of money on staff training in social care and I am still wondering whether we are clear about the outcomes we get for the money. We should recognise that 70-75 per cent of the provider organisations in social care are in the private sector or the voluntary sector; it is not in-house or direct provision. One of the things I want to do is ensure that in every locality the private sector and the voluntary sector are around the same table as the local authority in designing and developing the training programmes, because we are talking in those cases about the vast majority of the staff on the front line or their workers. We also need, of course, to raise the status of care staff who are poorly paid and often low skilled, and this is a major difficulty generally. No government is going to massively increase the salaries of those people overnight but there is a need to have a serious look at the inevitable consequence of a low-skilled, low-paid workforce when we are asking them to work with the most vulnerable sections of our society. I think Anne's point is really important. If you look at the implications of moving towards a model where the vast majority of people have their own budget, this will change the role of many social workers and social care staff because in a sense they will go back to doing what I hope most of them joined the profession to do in the first place, which is to empower and enable and support people, not simply assess them and tick boxes. Let us be clear: what I am articulating today is a vision about a considerable reorganisation of the way adult social care does its work up and down the country. I think there are many unintended consequences of that well-intentioned community care legislation. It is almost as though people feel they have to do social care, like they do with the assessment criteria, with the same approach all over the country. It has become an industry which does things in the same way. I am not saying there are not real financial pressures because that would not be the case, but can people, hand on heart, say that we are getting best use for the existing resources? I am afraid I do not believe we are anywhere near getting it. We have had the Comprehensive Spending Review settlement. The department budget is spent largely through local government into its whole range of services, including adult social care,—and we should remember that that budget is not ring-fenced, by the way—but what will happen next is that we will be announcing very soon an amount of money the Department of Health has specifically for the reform of adult social care over the next three years, which is over and above the resources that go through local government in terms of the revenue support grant.

  Q168  Earl of Onslow: Minister, I must say I have been very impressed by your complete grasp of this subject.

  Mr Lewis: I am in trouble, obviously.

  Q169  Earl of Onslow: I could almost call you an u­ber-Blairite but perhaps it would be unfair.

  Mr Lewis: It may not be very helpful either.

  Q170  Earl of Onslow: What I am finding it difficult to come to terms with is the fact that although your diagnosis of the problem seems to be extremely good there also appears to be patchy local authority and local reaction. How do you balance the demand which you articulated for more locally-based solving of problems with imposing from the top a standard of behaviour of which we should all be proud?

  Mr Lewis: Is that not the age-old question for politicians of all colours through history and have we not gone from one extreme to another in terms of this pendulum of central, Stalinist, rather u­ber-Blairite control and devolution?

  Q171  Earl of Onslow: I think we are much too centralist in practically everything.

  Mr Lewis: The irony is that people have come to a conclusion that to achieve real change you need to empower far more the professionals on the front line in the localities. There seems to be a consensus around that. Equally, if you think about the amount of time that ministers spend dealing with the latest press release from Age Concern or Mencap or Help the Aged slamming the system for one failing or another, the obvious pressure on the politicians is to take some responsibility rather than say that this is a matter for local determination. I think we may be accused of abdicating responsibility, so we need a far more mature debate about the role of central government vis-a"-vis the role not only of local government but also of local communities and local government's relationship with other statutory agencies. The great difficulty often, I feel, is that there are certain things that happen on NHS wards in nursing homes, in agencies of one kind or another, which to me are nothing to do with resources and nothing to do with the Government's "target culture" and everything to do with poor management and a lack of professionals taking responsibility. I am not prepared to stop challenging the system when I believe it is fundamentally failing in its basic obligations to older people or people with learning disabilities. In terms of older people, if it would not be good enough for my mother and father why should it be good enough for somebody else's mother and father? That is the message that I think we need to send out. You could also use this analogy, changing the words "mother and father" to "family": if it is not good enough for my family why should it be good enough for somebody else's family? Some of it is because these professionals and managers function in very high pressure circumstances in a very difficult context, but some of it is people not taking responsibility and not doing their jobs properly. Any Member of Parliament knows that many of the people who end up in their surgery are there because one public service or another has failed to take responsibility for sorting that person's problem out and instead has passed that person from pillar to post and treated them with complete contempt, as a number. That is why an u­ber-Brownite policy, which we should welcome, is this notion of the personalisation of public services. Of course, the danger of the term "personalisation" is that it becomes another fashionable, meaningless expression, so we have to define it. What it means for me is that we have to move away from regarding people who use public services as part of a system of mass production, which I am afraid is the current culture, to a system which treats every individual in a highly personalised way. I will use an analogy which is controversial, u­ber-Blairite or u­ber-Brownite, and that is that very few people who are seriously ill would choose to go to the private healthcare sector for a solution. They are much better off in the NHS in my view, but why do people often choose—still a small minority in this country—to use the private sector? Largely for the customer care and the highly personalised nature of the service that the individual or the person that they love will get. That for me should not be above the capability of a modern public service, to offer not just the best clinical care but also the best personal and customer care that we can possibly seek to provide.

  Q172  Baroness Stern: I am enjoying what you are saying very much. I want to talk about the Equalities Public Service Agreement, which I have read. I have it here and it is a most encouraging and attractive document, but my question to you really is about implementation. The implementation of documents like this is associated, I think, in many people's minds with designing a list of things you can measure. Somebody will no doubt be sitting somewhere in one of your offices now designing a list of things you can measure, and the local deliverer is the person who does the measuring or makes sure the measuring comes out right in some way or other and ticks boxes, and then you implement this thing, which is an excellent thing. I want to ask you whether there is another vision you might have about implementing it which would have something to do with the Human Rights Act and the values and ideas in the Human Rights Act, and trying to tell the people who do the delivery about them, and then inspiring them to see this not as another tedious ticking thing from Whitehall (of which they already have so many) but as something that could lead them to give people some pride in their work and a strong sense of values. Have you got any ideas about how you might do that?

  Mrs McGuire: The PSA on Equalities is part of an approach across all of these areas which is very much based on a human rights set of values. In talking about ending discrimination in employment, unfairness in receipt of services and unfairness in the lack of access to participation to public life, I think we are setting out fairly inspirational objectives and ones that may not be easily achieved by the tick-box exercise. Certainly Ivan and I, who do a double act in various forums across the country, and internationally as well, are very much giving out the message that we are not interested in tick-box exercises any more because you are right, Baroness Stern: they can be achieved pretty easily and then they become routine and then just part of the drudgery. This is not about the drudgery of life. This is about being evangelical about the rights of disabled people, particularly those with learning disabilities, to be full members of society. We need advocates, we need champions alongside us on that, and I have to say from my experience, which goes back slightly longer than Ivan's but comes very much from a similar background, that I am now beginning to see those changes, that people who are involved in public life and people who are involved in business, senior members of the business community, are now beginning to talk about learning disability in far more positive terms than, frankly, I could ever have anticipated 35 years ago when I was working with adults with learning disabilities. Yes, we do need to measure the achievements, we do need to look at ways in which we can assess our progress along the road, but we also need to inspire people. We are not doing this because it is a tick-box exercise. We are doing it because it is the right thing to do, and, to hark back to what Ivan said earlier, if it is good enough for my family then it should be good enough for everybody. That is where we are coming at on this, but it has to be an inspirational message and it has to be one where communities hear the advocates, such as Andrew Lee, who was at your committee a few weeks ago and who I thought gave very powerful evidence to you on how he perceived his life both as an individual and as a representative of those with learning disabilities. Certainly from my experience the picture that he painted was very much the picture that I used to have to work with before I was a Member of Parliament.

  Mr Lewis: I agree entirely with all that. The other thing we need to do is recognise that there are some real pioneers out there, some radical forces for change who have been revolutionary in a sense for many years in the learning disability field. In Control is one of the latest manifestations of that, as is some of the work at Mersey Care and similar organisations. There is an organisation I am aware of called Partners in Policy Making, which seeks to give family carers a lot more confidence and assertiveness in challenging the system but in a sensible, constructive, positive way, not in an adversarial way. This is an area where there are lots of hazards. I think the danger is that pioneers are seen as a threat, not an opportunity, and the radicals are kind of marginalised and we need to find a way in the period ahead of encouraging and rewarding and incentivising people who are willing to challenge the norm. I think any organisation that is going to be successful needs to start off by being values-led, and everybody who works within it needs to understand what those values are and why they matter before you get on to talking about people's individual job titles or their individual roles and responsibilities. The best leaders and managers understand that. I have to say to you that I think there are far too many public sector organisations in this country where they do not have leaders and managers who understand that.

  Mrs McGuire: And who also do not like the idea of risk.

  Q173  Baroness Stern: Do you have a plan about this PSA, to try and have it implemented in the rather inspirational way that you have both described, and is it somewhere where we can read it and look at it?

  Mrs McGuire: Is that a cunning plan?

  Mr Lewis: What is this PSA? Does it specifically refer to, say, old people?

  Q174  Baroness Stern: The Equalities PSA.

  Mrs McGuire: It focuses on the pay gaps, on discrimination—

  Mr Lewis: Do you mean across the board?

  Mrs McGuire:— across the board.

  Q175  Baroness Stern: Yes, but obviously we are interested in how it is implemented in relation to this inquiry into people with learning disabilities. They are in there and therefore I would like to know where the inspiration turns into doing.

  Mr Lewis: The belief that we can transform the adult social care system in this country without waiting ten, 15, 20 years is one that I hold, and I think Anne holds, and that would obviously make a massive difference to people with learning disabilities. Our challenge in the period ahead, and we are talking about weeks, not years, is first of all to be absolutely clear about what that vision is, and, being absolutely clear about the vision, then to set about the task of ensuring that as many people as possible in positions of influence understand the vision, own the vision and see it as a shared responsibility to make the vision happen. I would say that in relation to adult social care in the assessment couple of years there has been a period of silence in terms of vision and sense of direction and leadership, and that period of silence is coming to a close. The challenge is that we will be able to articulate the vision because in a sense today I hope we have been able to show you some of the ingredients of that vision, but then we need to ensure that organisations that can make the most difference, locality by locality, first of all share it and understand it and then inspire the people who work at every level of their organisation. It is no good the chief execs being good guys if the middle managers do not understand it, do not feel signed up to it, are not included in it and then the front-line staff are alienated. If any part of that chain is broken the danger is that you end up with unintended consequences, but I do think there is an issue beyond this about public sector passion in terms of when you go to work every day are you made to feel as though you have the power to make a real difference and are you encouraged to feel that about your job, or are you going to work every day feeling that you are having to fulfil a very functional set of responsibilities? That is the challenge in terms of the personalisation of public services going forward.

  Q176  Baroness Stern: So I assume you do have a plan.

  Mr Lewis: We do.

  Q177  Baroness Stern: It sounds as if you have got a plan.

  Mr Lewis: We do.

  Mrs McGuire: But it will manifest itself in different ways. One of the PSA targets is choice and control in life. We are looking at developing our independent living approach. We currently have a task force due to report on an approach to independent living, and I know that it is an issue that has been raised on a regular basis in the House of Lords. In terms of issues relating to discrimination in employment, we are currently working with organisations through our disability employment schemes, et cetera, our Pathways to Work, to look at how we tackle those issues. Going back to what I said earlier, we need champions out there and there are champions. They do not always get the publicity they deserve but increasingly it is becoming part of the orthodoxy, I think, in conversation, certainly in the private sector, and Ivan is spot on when he talks about public service deliverers. One of the most positive discussions that I have heard, when we were talking about an individualised budgets approach, came from social workers who had been in the social work slot for a long time, and through the individualised budgets approach they were freed up to do some of the work that they had gone into social work to do, which was not about making decisions for people but about supporting people to make their own decisions. They had become reinvigorated and almost liberated in the way in which they were now pursuing their work, and if we could find a way of bottling it and sending it out across the country we might well do that.

  Mr Lewis: In the north west, when the long-stay hospitals were closed down, the resettlement of people with learning disabilities, there was a network of people with a missionary zeal about the closure of those institutions but also the positive resettlement of those people into the community. We want the same missionary zeal amongst as many people as possible in terms of the right to independent living, and that in a sense is our next challenge.

  Q178  Baroness Stern: I have another much less complicated question, and it is to you, Ivan. In your evidence you told us that CSCI, the Commission for Social Care and Inspection, considers that about 20 per cent of the funding from the Learning Disability Development Fund distributed to PCTs has been diverted to general NHS funds. Do you have a view about that and how can you exert your influence on funding that is meant to go for one purpose to ensure that it does?

  Mr Lewis: Which particular fund is that because I need to be clear?

  Q179  Baroness Stern: The fund is the Learning Disability Development Fund distributed to primary care trusts.

  Mr Lewis: That will all be transferred to local authorities in the future on the basis that we should be focusing on a social model, not a health model, but also the evidence is that that is more likely to be spent on the purposes that it is meant to be spent on. All of that will become the responsibility of local government.

  Baroness Stern: That is a very helpful answer. Thank you.