Official Report (Hansard)
Date: Wednesday, 15 February 2012
Community for Health, Social Services and Public Safety
The Chairperson: Christine, Michael and Brian, welcome to the meeting. I advise members that some of the information that we requested in advance of the meeting is not included in the briefing paper. We had asked for a breakdown of how many meals are provided by the trust; the level of subsidy provided by each trust; the unit costs of meals for each trust; and details of the cost of community meals provided by the statutory sectors compared with the cost of those provided by the private sector. I hope that you have the answers to those questions today. I invite you to make your presentation before opening the floor for questions or comments. Thank you for coming today, and thank you for your briefing paper.
Ms Christine Jendoubi (Department of Health, Social Services and Public Safety): Thank you very much, Chairperson. I apologise in advance because you will already have heard some of this, but it is part of the script, so I will have to repeat it. Thank you for the opportunity to present to the Committee. We intend, if we can, to answer the questions that you asked in your letter last week that we were not able to provide information for at the time.
Meals on wheels is a part of community meals. Community meals comprises not only delivered meals, which are meals on wheels, but also provided meals, which are meals that you would get in a day centre, for example. The numbers are not easy to get for provided meals, so the information that I will give you shortly relate to meals on wheels or delivered meals. That is because often the numbers of the full range of community meals that you would get in luncheon clubs and day centres, for example, are not collected as such. The figures collected for those include volunteer time, and the output would be the number of hours spent in the day centre rather than the number of meals provided. As I said, the numbers that I will give relate to meals on wheels.
Meals on wheels are provided or arranged by trusts for vulnerable people where a needs assessment has shown that the person is unable to secure a nutritious cooked meal and would therefore be at risk of malnutrition should a meal service not be provided. The meals can be provided directly by the trusts or by the independent sector either in the person's own home in the form of a cooked, cooked/chilled or frozen meal, or in a day centre if it is a provided meal.
In September 2011, the health and social care (HSC) sector established a collaborative working group that agreed the wording of consistent eligibility criteria to support and maintain a service user's independence in meal preparation. Most of the wording used in the criteria was borrowed from the Southern Trust's document, as it was the most recent and clearest version. I will mention the Southern Trust again in a moment. All five trusts agreed that this should be recommended as the agreed wording for use by all health and social care trusts and the trusts' chief executives agreed to the use of the criteria as recommended in October 2011. All five trusts now use the new criteria that were sent to you with our briefing paper.
However, the provision of community meals depends very much on location and individual provider. You have already made reference to the wide range of providers in the Western Trust area.
Madam Chairperson, you asked last week for the number of community meals provided by each trust. These are expressed in numbers of clients as opposed to numbers of meals: 1,358 in the Belfast Trust area; 948 in the South Eastern Trust; 573 in the Northern Trust; 340 in the Southern Trust; and 1,026 in the Western Trust. That makes a total of 4,245. Those figures are taken from the 'Adult Community Statistics for Northern Ireland 2010-11'. You also asked about the subsidy provided by each trust and the unit cost of meals for each trust. I apologise that that information was not provided to you in advance, but I think that you will understand the complexity and range of provision when you hear it. The levels of subsidy and unit costs vary from trust to trust and, indeed, costs can depend on local suppliers within trusts. The amounts of subsidy in the Southern Trust vary depending on the four different providers, with unit costs ranging from £4·57 to £5·39 and subsidies ranging from £3·07 to £3·89. In the Western Trust there are 28 different providers, which you have a list of, and the subsidies range from £1·20 to £4·75. The unit costs also reflect that diversity, ranging from £2·60 to £5·00. In the South Eastern Trust there is one level of subsidy of £2·91, with a client contribution of £2·00 and a total unit cost of £4·91.
The Belfast Trust supplies meals through Knockbracken Kitchens, and they are delivered by Domestic Care Services. I apologise for the incorrect information that we sent your researcher last week when we said that Knockbracken Kitchens was a private enterprise; it is not. It is run by the Belfast Trust on a not-for-profit basis. Domestic Care Services buys the meals for the other trusts from Knockbracken Kitchens in the Belfast Trust, and the other trusts buy the meals from Domestic Care Services.
The Chairperson: Does that include the Northern Trust?
Ms Jendoubi: Yes, but not exclusively. Domestic Care Services is not the only supplier in the Northern Trust area.
The Chairperson: I appreciate that, but we are told that the Belfast Trust takes meals from Knockbracken Kitchens and the Northern Trust meals are cooked in Knockbracken. Is that the same?
Ms Jendoubi: Yes. The Belfast Trust told us that it cannot give us the precise level of subsidy because its unit costs comprise its management and overhead costs. It is not selling to Domestic Care Services; Domestic Care Services simply delivers for it.
The Northern Trust produces some meals in hospitals and community facilities. Those are estimated at £1·80 for lunch and a pudding, excluding staff and delivery costs. Clients are charged £1·50. Domestic Care Services charges the trust £4·76 per meal, including the cost of delivery. The unit cost of the meal produced by Knockbracken Kitchens is £2·38. The recipient pays £2·20 and the trust pays £2·56 to cover the cost of the meal and delivery. That is the subsidy. The Northern Trust has advised us that it will maintain subsidies for cases determined before the end of October 2010. However, it has withdrawn subsidies from that date for new cases, so anybody who has been assessed as receiving meals on wheels since October 2010 is paying the full cost of the meal, which is £4·76 from Domestic Care Services.
Many factors have affected how meals are provided. Health and social care staff are keen to emphasise that people have become used to a wider range and variety of meals and maintain those preferences into older age. More men are now inclined to try their hand at cooking, possibly because of the media spotlight on TV chefs, both men and women. There is a variety of factors for people wanting to maintain their independence in that way. Our aim is to provide services that promote independence and choice. Therefore, services based on re-ablement, where the intention is to help people to become able to prepare their food and gain more confidence in their ability to live independently, are increasing.
Developments in how we deliver services, such as re-ablement, are intended to offer an alternative to a previous system that assumed, for instance, that a widower could not be expected to prepare his own meals and should automatically receive meals and other services that, with some help and guidance, he might have been able to do for himself and so retain more mobility, self-confidence and independence. Re-ablement has been introduced in the Southern, South Eastern and Northern Trust areas. You will see a synergy in the trust areas where the uptake of meals has reduced the most markedly. Re-ablement will be introduced in the Belfast and Western Trusts later this year.
The number of people receiving community meals can change over time. For instance, the number of recipients in 1999 was 4,374; the figure is broadly the same now. In the interim, the numbers have moved upwards and downwards, peaking in 2007 at 6,670.
Over time, various factors have impacted on the type of service that people have needed and the manner in which a service has been provided. All the indications are that although fewer people receive a meal delivered to their house, the number of cases where a meal is prepared in the person's home by a domiciliary care worker, a carer or a family member is probably increasing. The trusts' advice also supports the view that re-abling people to organise their own meals in a manner and at a time that suits them with a menu covering a wider range of choices is on the increase.
There have also been different schemes operating from different organisations that have combined to organise meals as part of a wider service, such as links to adult education, groups that provide rural transport, lunch clubs and volunteering schemes. We do not have consistent information on all those services, as the recorded outputs will often reflect or be linked to day care or journeys or volunteer hours, as I mentioned earlier.
The Minister strongly believes in community meals as a low-level intervention that can prevent or delay the need for a more costly later intervention. Our policy has always been geared towards a mixed economy of care for people across all client groups and communities, and that remains the case. A varied service that involves different sectors providing services and a range of groups providing meals in different ways in different places offers a sustainable way forward that can continue to evolve to meet people's needs in the way that they want.
The value of meals on wheels or community meals is clear: they promote independence and can help people to live in their own homes as long as is practicable. However, we should ensure that the various services and methods of delivery respond to cover as many different services and circumstances as possible.
Thank you, Chairperson. I am happy to take questions.
The Chairperson: Thanks very much, Christine. Your briefing paper states:
"The annual uplift in the charge, which is set by the Department, is based on the increase in Retirement pension each year."
It continues by saying, "The current charge is £1.50."
Ms Jendoubi: Yes.
The Chairperson: What does that mean, since you gave us figures for different trusts?
Ms Jendoubi: It means that the Department sets a rate, which is £1·50.
The Chairperson: Do the trusts then set their own rate?
Ms Jendoubi: The trusts do not adhere to it in every case. That is something that we have taken up with the board, because the departmental circular states that trusts are not at liberty to set their own rates.
The Chairperson: You said that the Minister is a fan of meals on wheels.
Ms Jendoubi: Yes; he is.
The Chairperson: That is fair enough. Therefore the Minister's Department sets a rate, and trusts — excuse my bluntness — ignore it. What is happening?
Ms Jendoubi: One of the things that I think it means is that the annual rate that has been set by the Department has not really kept pace with the increase in the cost of meals over the years. The rate has been given an annual uplift and it is possible, indeed it is likely, that it is too low. If you increase a very low rate by 2%, 4% or 5%, reflecting the increase in benefits —
The Chairperson: How come some trusts can stick to it while others cannot?
Ms Jendoubi: Because of the range of providers and the range of different costs.
The Chairperson: I am concerned that the Department can set a policy, which the Minister agrees with, yet trusts can ignore it. That gives rise to a "post-code lottery" in the services available in different trust areas. You answered my question on the kitchen issue, to which we will come back.
As I told members earlier, I talked to the special adviser to the Education Minister, because I was concerned that we could not use schools as the Western Trust does. They said that they do not think that that is a problem. The special adviser is telling education officials that they should talk with health. I suggest that health make that contact with education and come back to us with ways of utilising services. It happens in my constituency; I am sure that it happens in others. In my area, one local school gets its meals from another school in the same area. In trying to manage some of the issues, we need to look outside the box but not beyond our own nose. We need to look at the services available. I would appreciate an update, ASAP, on what contact has been made. I have information from them that I will pass on to you. I will be pushing education to see whether that can happen across the board. I am concerned that trusts can set their own figures for meals on wheels. Other trusts are being proactive in how they deal with it.
Mr Wells: I am surprised that what seems to be a relatively simple service has 57 varieties in Northern Ireland when it comes to delivery and cost. You say that the Southern Trust provides only 340 clients with a cooked meal. Yet the South Eastern Trust, which has a similar population, does treble that, and the Western Trust has almost three and a half times more provision. How can three separate trusts, each applying the agreed criteria consistently, have such a vast variation in provision?
Ms Jendoubi: Can I tell you what the Southern Trust told us about its meals provision? We got the same figures from Domestic Care Services as I think your researcher did. We were concerned to see the drop, particularly in the Craigavon/Banbridge area, where it was most marked. We raised that with the Southern Trust. Its answer was:
"Whilst the numbers of clients receiving home delivered subsidised meals in the Southern Trust area has significantly reduced in recent years, the trust continues to support those who need help to heat, plate or serve a meal or who need to be fed. Currently, some 2,521 clients are in receipt of home care support to meet these types of needs as part of a package of care, which helps the person remain in their own home. Therefore, whilst the numbers of people receiving meals on wheels has decreased, the numbers of people receiving help to maintain their nutritional status remains high and is approximately 47% of the total number of people receiving domiciliary care. The trust has done so whilst improving people's independence and in keeping with the ethos of reablement. The Southern Trust continues to be the second highest actual provider of domiciliary care hours and is providing the second highest amount of hours, on average, to those in receipt of domiciliary care."
Mr Wells: Therefore the trust is saying that it provides the help through care packages?
Ms Jendoubi: Yes.
Mr Wells: Has anybody looked at the economics? Will sending someone to help a pensioner lady who is on her own cost more than delivering the meal to her in the first place? If you are simply giving the care package provider either extra hours or sending her — 99% of the time it is "her" — to someone's home to help them to prepare the meal, would it be cheaper and more cost-effective simply to get the meal delivered by a company such as Domestic Care Services?
Ms Jendoubi: It would be very hard to tell without doing comparative costings. I imagine that if all that that lady — it is usually a lady — were doing while she was there was providing lunch, she would not be there for long and it would not be very expensive, but the comparative costings would need to be done. However, she will probably be doing other things for her client while she is there; things that the trust would have to provide her to do anyway.
Mr Wells: Is it not more likely that she was going along anyway and then they said, "By the way, we are adding this responsibility to your duties, but we are not giving you any extra time in which to do it. You have to cook the meal as well as clean, get the fire on etc". We have the ridiculous situation in Ardglass in my constituency where they are literally running from house to house. They have to wear gutties — I am really showing my age — plimsolls or trainers, because they have to move that quickly to get from house to house in order to do everything in 20 minutes or half an hour.
It would seem logical, but — there is another "but" — the Southern Trust has not actually referred anyone for community meal provision in almost four years. They cannot all be in the position where they can be enabled or where you can provide a care package. There must be people who would, under normal circumstances in any other trust, get a community meal but who are not getting that because the Southern Trust has decided, "End of service".
Ms Jendoubi: That is what Domestic Care Services told us; it said that nobody had been referred by the Southern Trust as a new recipient of meals on wheels in the past two years. It also gave us details of a client survey that it conducted, the first question of which was: "How long have you been receiving meals on wheels?". According to the statistics, 92 clients in the Southern Trust area had been receiving meals on wheels for less than a year. I do not know how those marry up.
Mr Wells: You would think that a company that delivers meals on wheels would know whether it had delivered to a new client in the past two years. The fact that only 340 people in the Southern Trust are still getting community meals indicates that there have not been any new referrals for quite a while. That number is going down for obvious reasons: people moving into nursing care, hospitals etc. That service is withering on the vine in the Southern Trust. I will follow this up with the chief executive to find out how the other provision is working. However, depending on the trust area, someone living on one side of the road in Dromore, for example, will get next to no provision; whereas someone living on the other side of the road will have treble the chance of getting the provision because of their postcode. You would have thought that there would be consistency in the application of the criteria across the five trusts. That is not happening. That may be a good thing or a bad thing. However, you would think that the Department would at least give some direction by saying, "This is what we expect because we are funding it through the board". Instead, however, there is wild variation, with the Southern Trust going down one route and the Belfast Trust going down a totally different one. It provides 1,350-odd meals a year, which is five times more than the Southern Trust.
Ms Jendoubi: Yes; it does. The Belfast Trust has not yet adopted re-ablement as an approach; that is to take place later this year.
Mr Wells: Once all trusts have adopted re-ablement, they will go down the Southern Trust route. Is that what you are saying?
Ms Jendoubi: The reduction in meals-on-wheels uptakes may vary from trust to trust. However, you would expect the re-ablement policy to result in a reduction in new applicants as people are assessed as being able to provide for themselves — it is good to provide for oneself — or to get help to do that in their own homes.
Mr McCallister: When did the other trusts activate re-ablement? The Southern Trust had a collective drop in uptake over three years of 77·5%; the Northern Trust had a collective drop of 45·4%; and the South Eastern Trust had a collective drop of 42%. The Belfast Trust, had an increase, albeit of 0·5%. When did re-ablement kick in? Why are those figures so dramatic? As Jim says, the numbers from the Southern Trust are so much lower. The percentage drop in the Southern Trust over the past three years has been enormous, and there have been similar drops in the Northern and South Eastern trusts. However, Belfast Trust had a 0·5% increase.
Ms P Bradley: May I come in there, Chairperson? You cannot compare that, because other trusts stopped subsidising meals. The Northern Trust introduced re-ablement late in 2010, which was when it stopped subsidising meals for new clients. Therefore, you cannot compare those figures; you cannot say that it is all down to re-ablement, because much of it is down to subsidy. People were choosing other providers, whatever that might be. You cannot compare those figures.
The Chairperson: We also need much more information, which we will come back to at the end. Paula is right, as is John, to raise that issue, because the subsidy stops and the increase in the price of meals happened at the same time. Let Jim finish —
Ms Jendoubi: That is particular to the Northern Trust. The Southern Trust introduced re-ablement in 2010, and it still pays subsidies. The greatest reduction has been in the Southern Trust.
Mr Wells: The Chairperson has handed me a very useful note that she received from the —
The Chairperson: Thank God it was not yesterday; people might have thought that it was a card.
Mr Wells: It says that the Western Trust has a totally different model: it delivers to day centres. Does that mean that it does not do home deliveries?
Ms Jendoubi: It does home deliveries as well.
Mr Wells: Therefore, is the figure that you quoted for the Western Trust — 1,026 — purely home delivery?
Mr Brian Taggart (Department of Health, Social Services and Public Safety): Yes; that is solely home delivery.
Mr Wells: Are the 28 providers in the Western Trust, which range from hotels to charities to statutory organisations, providing 3,084 meals entirely for day centres?
Mr Taggart: I would say that it is a mixture of both home deliveries and day centres.
Mr Wells: Therefore, in the Western Trust you get the best of both worlds: you can have either a delivery or you can go to the local community centre and get a sit-down meal with your friends. Is that offered to other trusts, such as the Southern Trust and the Northern Trust? I am not aware of it.
Mr Taggart: Day care is on offer in all trusts.
Mr Wells: But are meals delivered to day-care centres?
Mr Taggart: The Northern Trust provides some in-house day-care meals that it prepares in a couple of its hospitals and several of its residential homes. However, it is a very small number: about 300 a week.
Mr Wells: It is a cottage industry in Fermanagh, and all power to their elbow for providing it. The Minister would have the view that no one in Northern Ireland should be treated more or less favourably simply because of where they live. However, if a pensioner moved to five different areas of Northern Ireland, they could have five different models of provision for community meals. I know that the trusts have to have some discretion, but everyone should know exactly where they stand.
Am I right in thinking that the Western Trust does not subsidise meals? The memo says that the Western Education and Library Board cooks the meals.
Ms Jendoubi: Some meals are cooked by the Western Education and Library Board in the school kitchens, as the Chairperson said earlier.
Mr Wells: Do they recover the full cost from the client or the trust?
Mr Michael Swann (Department of Health, Social Services and Public Safety): We do not have that information.
Mr Wells: It said that £1·50 was the cost that was redeemed and that that was uniformly applied; but apparently not.
Ms Jendoubi: No; it is not uniformly applied.
Mr Wells: Not only do you get a different service, but you pay more or less for it depending on where you live. There are so many varieties, and that is why it is such a confusing issue to tie down. The Department could go a long way to help by imposing some uniformity on how you get meals, what you pay for them and where you get them so that people know where they stand. However, if you impose the Southern Trust's criteria and everyone goes the way that it has gone, the service will die out in about 10 years' time. If so few people are coming in and so few people are being provided for in the first place, in 10 years' time there will be nobody left to avail of it.
Ms Jendoubi: It becomes uneconomic to provide it.
Mr McCallister: At the rate the Southern Trust is going, it will be quicker than 10 years.
The Chairperson: Especially when all the trusts had agreed the criteria, and then there are changes.
Ms Jendoubi: I am not sure that the Department would want to impose uniformity on how meals are provided. However, I think that it is our responsibility to impose uniformity on the quality of meals, which is part of the nutrition strategy as referred to by Dr Thompson in the research papers, and on what people are expected to pay. I do not think that it is acceptable that someone in Ballymena should have to pay £4·50 while someone in Coleraine pays only £1·50. That is something that we need to straighten out with the trusts through the board.
Mr Wells: What you are saying is that the Southern Trust criteria will be adopted. If you do that, the numbers will go down by 77% in Belfast and by another 20 percentage points in the rest of the country. You will be left with about 1,500 people in Northern Ireland getting community meals, and that number will decrease fast. It becomes totally uneconomic for a private contractor, or anyone else, to provide that. Therefore the service is doomed if it continues the way it is going.
Ms Jendoubi: We cannot predict what the numbers will do in Belfast, but we would expect to see some reduction if more people were able to fend for themselves independently. We could not say that it would reduce by 77%; that happens to be what happened in the Southern Trust.
The Chairperson: The Minister said that he would carry out a review of adult social care; will this be included in that review?
Ms Jendoubi: Yes.
The Chairperson: We should not automatically assume that a private contractor should be providing this. Some trusts have not outsourced it. The review may cover some of the questions that have been asked today.
Several members wish to ask questions, and I am conscious that the Minister is coming in. I have asked that he be held off for 10 minutes. This is an important issue, and I do not want to rush it; but I ask that members keep their questions as succinct as possible. That is no reflection on the next speaker, Kieran.
Mr McCarthy: Let me record my admiration for the work of this service. Our main concern is the reduction in people either applying for or getting the service; that is what worries me enormously as I am sure it does everyone in the room. You spoke of the eligibility criteria; was the document consulted on? Does it apply only to people in critical need? If so, people in substantial, moderate or low need will soon fall into the criteria of critical need; therefore you are going round in a circle and not fulfilling what you are supposed to be doing. I am asking whether this is a restrictive eligibility policy that would inherently undermine the Department's nutritional strategy.
Ms Jendoubi: The eligibility criteria for meals on wheels are different from those for domiciliary care. In applying the criteria for meals on wheels, they look to see what support an individual can get from members of the family, what they can and cannot do for themselves, whether they would be a risk to themselves if they had to handle hot plates, whether they can move food in and out of the oven, and whether they can feed themselves. When those questions have been answered, you can determine whether a person is capable of feeding themselves or not. If they are deemed not capable of feeding themselves, the meals service is provided. However, that is different from the eligibility criteria for domiciliary care that is split into four bands.
Mr McCarthy: Have the eligibility criteria been raised so high that a huge number of people have been excluded? That is what I take from it.
You mention the reduction in your paper, but you do not seem able to explain it. You use the word "may" a great deal. You say that it "may" be due to the availability of supermarket ready meals or that it "may" be due to re-ablement measures. That is very vague. Is that telling us that you do not know, or that you are not sure?
Ms Jendoubi: We have not surveyed the population that no longer get meals on wheels to find out why they do not. This is the information that we are getting from the boards, and the boards get it from their social workers and domiciliary care providers in the main. The closest we can come to an answer is that factors are prevalent in society nowadays that were not prevalent 10 years ago, such as the accessibility of ready-made meals in local supermarkets. That just was not there 10 years ago. There are people who prefer to have the choice.
Mr McCarthy: That is fair enough. However, the wee man who lives miles down a lane who cannot get out of the house will not go to the supermarket to get food; he depends on this service to get a half-decent meal. That is being cut away. He is being deprived. His health will go downhill; he will end up in hospital, and that will defeat the purpose of the service.
Ms Jendoubi: If that man depends upon the meals-on-wheels service, he will continue to get it. However, it is unrealistic to expect trusts to continue to provide services to people who are capable of, or who could become capable of, providing them for themselves.
Mr McCarthy: That goes back to the question that I asked Dr Janice: is this a way for the trust to save money?
Ms Jendoubi: Trusts are obliged to ensure that every penny is spent in the most necessary, economic and cost-effective way possible.
Mr McCarthy: Yes, of course. However, they are not to gamble with the life of an elderly person who cannot get to a supermarket.
Ms Jendoubi: All the trusts have assured us that the meals-on-wheels service, like every other service that they provide to old people or, indeed, to anyone in a vulnerable group, would be withdrawn only after a full assessment of the person's needs, discussion with them and time allowed and arrangements made for them to receive their meals from some other source.
The Chairperson: I ask Janice to stay and listen to this because she provided us with a paper. Many issues are coming up today, and we may still need answers to our questions. We will come back to this next week, but before that I will have another look at Hansard. I do not think that today can be the end of this; we need to keep coming back to it.
Ms P Bradley: I want to return to the eligibility criteria. We have been told that the purpose of the eligibility criteria is to promote access to the provision of meals. The document says that all five trusts are using the new criteria. We have a copy of it.
The criteria are for the preparation and eating of meals; they are not for the provision of meals. Only one paragraph has anything to do with the provision of meals; the rest of the document is all about the preparation of meals. As you say, that is to do with the occupational therapist doing her assessment, passing her findings on to the social worker, and the social worker puts a package of care in. Only one bit is relevant. The eligibility criteria are not being used for the provision of meals; they are being used only for the preparation of meals. Is that how it is at the moment?
Ms Jendoubi: Yes.
Ms P Bradley: Therefore there is no eligibility criteria for the provision of meals at all. There is only one paragraph in the document that is relevant to the provision of meals, and that asks whether you:
"Have a more able bodied relative/companion who is willing"
to provide meals. That is the only bit in all the eligibility criteria that the Southern Trust has used, and those are the criteria that
trusts are now using. They are no different from the criteria that I would have used for years as to whether someone required a home help — other than that one paragraph that asks whether you have someone to help you.
I know from many years' experience that many people have no one to help them. You said that ready meals and such are so much easier to get than they were 10 years ago. That is true; I know that, and they are great. Many of us have to use them because we work day and night. However, the other factor that applies 10 years on is that we have more dysfunctional families; we have more families that no longer live in a nucleus and whose dynamics have led to family breakdowns.
There are many more people now with no one belonging to them to provide a meal than there were 10 years ago. North Belfast lies in the Belfast Trust and Northern Trust areas. Therefore if you go into hospital for rehabilitation and they work out your care plan for going home and you live on the Whitewell Road, happy days; you are in the Belfast Trust area and you will get a subsidised meal. However, if you live in the Northern Trust area, you will not. It is a postcode lottery. Whether you get meal provision or not depends on where you live in north Belfast.
I am still concerned about the eligibility criteria. How do they help someone assessing a patient on meal provision? They do nothing for it. I worked on re-ablement when it came in, and generally it is great. Sometimes it works very well; sometimes it does not. There are patients who cannot re-able or who are difficult to re-able. For example, it would be difficult to re-able a dementia patient back to independence. There are clients who will never be re-abled and who will require some sort of service, so we cannot say that re-ablement is the be all and end all to bringing everybody back to some sort of independence; it is not. A domiciliary care worker has a 15-minute slot to prepare a meal; I would love to see what sort of meal they prepare in 15 minutes. They must be fantastic, because the only thing they could possibly prepare is a sandwich, which does not meet any nutritional strategy.
According to the key characteristics that Janice left with us, everyone using health and social care services is screened to identify those who are malnourished or at risk of malnourishment. I would like to know the figures in our trusts for the number of patients arriving at hospital malnourished, or where malnourishment is a factor in their being admitted to hospital. It is a big issue. We are looking at preventative measures and at keeping people out of hospital and in their homes. We are now looking to keep people out of residential care as well, and there are many factors that will just not marry up. My main concern is about how the eligibility criteria have anything do with cooked chilled meals or meal provision; they do not. They have nothing at all to do with that, so why are they even in this pack when we are talking about community meals?
Ms Jendoubi: There is no doubt that too many people arrive in hospital with malnutrition problems, and the trusts recognise that. There will always be a need for community meals. You are absolutely right that keeping people nourished keeps them out of hospital. The eligibility criteria are based on ability. Can you prepare a meal for yourself? If you cannot, one will be provided for you or someone will come in to prepare it for you. There is no doubt that providing that level of support — providing a meal for somebody once a day — is one of the most effective ways in which the trust can do early and low-level intervention work to keep people out of hospital or residential care. The trusts are trying to deal with how to do that. For many people is it better to keep them on their feet, trying to be independent and cope by themselves, but there will also be people for whom you simply cannot do that. There is no argument about that whatsoever.
There is one other point. You asked Dr Thompson whether anyone got free meals or if they were all subsidised. The answer is that if you are over 75 or in receipt of pension credit you get a free meal.
Ms P Bradley: Who offers that? I never before heard that anything was means-tested or age-tested.
The Chairperson: Is that policy across all trusts?
Mr Taggart: That is policy across all trusts.
The Chairperson: Well, it is policy not to charge above £1·50, but we will not get into that.
Ms P Bradley: Therefore policy in all trusts is that if you are over 75 or assessed as requiring —
Mr Taggart: You should get it free.
Ms P Bradley: You should get it free.
The Chairperson: Paula, we will ask Dr Thompson to find out more detail on that. I would also be interested in a breakdown on the number of people arriving at hospital with malnutrition who get a care package.
Ms P Bradley: May I ask for a breakdown of the number of people over 75 who receive their free meals?
Mr McCallister: The numbers are in the briefing paper.
Mr Wells: Those refer to the number of meals; they do not say whether they are free.
The Chairperson: Even a breakdown of the number arriving at hospital or other settings with malnutrition and who are getting a care package. The point is people getting only 15 minutes.
Ms P Bradley: They may not be admitted with malnutrition but with something else, and malnutrition contributed to it.
Mr Brady: You said that the Northern Health and Social Care Board withdrew subsidy in October 2010. How does Kieran's "wee man down the lane", who is, presumably, under 75, manage? If he is on a pension or means-tested benefits, there is a difficulty with affordability. Has that been addressed? Paula spoke of the correlation between malnutrition and the withdrawal of the subsidy and how that has affected older people. Is it possible to research the correlation between those?
Ultimately, it is accepted that the pension scheme here and in Britain is the meanest in the developed world. It will get meaner because they have changed it from the Retail Price Index to the Consumer Price Index, so the increase in April will be less than it would normally be. I am on the Social Development Committee, and that issue will come up at our meeting tomorrow. Welfare reform coming down the road will make things worse. Is it possible to get facts and figures to factor all that in, or is it too early?
Ms Jendoubi: We can certainly pursue that with the board.
Mr Brady: That is fine.
Mr Dunne: Christine, you talked about the cost of the service. It is clear that there is inconsistency in the cost to the public. Will you carry out a review into the issues that have been raised here?
Ms Jendoubi: Yes.
Mr Dunne: Will you come back to us later?
Ms Jendoubi: Yes, indeed.
Mr Dunne: Right, that's grand. We raised the point about free meals, and you clarified that. We are driving towards the implementation of the Compton report. Is this consistent with what Compton really needs? There is a big drive on care in the community, and the Minister has committed to that. Those of us who have been out and about with meals-on-wheels providers were impressed with the service. It is not just about delivering a meal; there is a social aspect, which is great and we recognise that. It is important that that service be reviewed and improved. I believe that it will become a strong part of care in the community, and the Committee would be supportive of your carrying out a review and coming back to us. Do you feel that it is consistent with Compton's requirements on care in the community?
Ms Jendoubi: I think what 'Transforming Your Care' expected to see was a reduction in residential home care, more services being provided in the community and more support for people to live independently. Whether that necessarily involves an increase in the number of people getting free meals on wheels is another matter.
Mr Dunne: I agree.
Ms Jendoubi: There is much to be said for a re-ablement policy and for the support that people will get through voluntary organisations, for example, in befriending and social support that does not necessarily involve the delivery of a meal.
However, there will always be a cohort of people for whom community meals form an essential part of the support that they get to live independently, and the mixed economy of provision is equally important in that regard. If you need a meal provided to you, you should be able to get one delivered to your home four days a week, and on Fridays you can go to the day centre to get a meal there. You should not be required to be chained to the house in order to get your meals-on-wheels delivery. It is important that people have as much control and independence over how they receive the support from the trust as possible.
Mr McCarthy: The Department should not be putting obstacles in people's way to get that service, which is what I suspect is happening at the moment. You talked about how trusts operate differently. There should be no obstacles: if people need it, let them have it.
Ms Lewis: Christine, you said that a survey of past recipients of community meals had not taken place. As part of any review, will you assure us that there will be an investigation into what is happening with people who used to partake of community meals but who no longer do so?
Ms Jendoubi: We can pursue with the board how best to find out why numbers have reduced so much rather than just taking trusts' word for it. It may not be able to identify people who are no longer in receipt of a service, but we can certainly explore with the board how that might be done.
Ms Lewis: Part of the problem is that nobody seems to understand what exactly is happening with the numbers. Everything possible needs to be done to find out what exactly is going on and why so few people are in receipt of community meals. What has happened? There are good news stories about re-ablement, but we need to know exactly what has happened.
The Chairperson: There are more questions to ask and more information that we need for our own benefit. Both Kathryn and Janice will be in touch over the next couple of days to get more information based on today's evidence. It is important, Christine, that we get an urgent update on your discussions with the board about policies being ignored. It is important that you formally raise with the Minister that there is a policy or a circular, or whatever it may be called, from the Department that trusts seem to be ignoring. I would hate to see policies or circulars coming from the Department and trusts deciding on whether to ignore them or not. It is concerning that that happened in this case.
We will come back to this over the next week or two once we get more information. I would appreciate you working closely with Janice and Kathryn to give more of the information that members have requested on this very important issue. It is, after all, about Investing for Health and ensuring that people stop going into the acute sector. On behalf of the Committee, thank you very much for your presentation, your paper and the information that you provided.