Examination of Witnesses (Questions 460
- 488)
WEDNESDAY 1 APRIL 1998
MRS ANNE
DUFFY, MRS
SUE BOTES,
MS LYNN
YOUNG AND
MR MALCOLM
WING
Mr Austin
460. In terms of the effective collaboration
of working, how important do you think that coterminosity is?
Certainly other witnesses in their evidence have suggested that
it is of real value to collaboration.
(Mr Wing) I think it is important and we are at the
moment embarking on a process of consultation with the NHS Executive
on the configuration of primary care groups and we are very pleased
to see that the general direction of the NHS Executive is moving
towards is that the general rule, not in every particular case,
but the general rule is that primary care groups should not move
outside of existing health authority boundaries. In terms of social
services, obviously those questions have got to be raised, but
our view is that we should, as far as possible, ensure that there
are coterminous boundaries, particularly, as I say, and I know
it is not going to be easy, but, particularly as a result of the
primary care groups, we do not want to see a situation where we
have got the boundaries right in terms of the health improvement
programmes vis-a"-vis the Health Service, but we are
crossing a number of local authority boundaries in terms of the
important social services contribution. Therefore, we want to
make sure that there is the widest possible consultation on the
establishment of the new structures that are being proposed and
that the same emphasis is placed on social service boundaries
as has been placed in the draft guidelines on health boundaries.
461. I wonder if the RCN could expand on the
issues of effective joint working in their written evidence and
the difficulties that this raises with primary care services.
(Ms Young) I think in reality it is not unusual for
one health authority to serve or work with three different local
authorities, all with very different cultural and structural differences,
and I think it is a genuine problem of how you address these barriers.
Obviously coterminosity, if I can actually say the word, let alone
spell it, is the ideal, but in reality that is not the pattern
out there. I do not have an answer to this. What I am aware of
are the genuine difficulties that different boundaries actually
cause in reality and I think it would be very challenging for
us all to get the new PCG structure set up in a way which will
actually work in harmony with the boundaries we have, but I cannot
give you an easy answer on that. I wish I could.
Dr Stoate
462. I believe that UNISON broadly does support
the current changes that have been proposed. I am pleased to see
that UNISON wants to work with the Government to make sure that
this does become a workable reality, but I am slightly concerned
about the problem of coterminosity. You say that it would be nice
to have the primary care groups coterminous with local authority
boundaries and social service boundaries. Clearly that is going
to be difficult unless we divide GP practices up because GP practices
historically have crossed borders all over the place for very
good reasons. Unless we are going to draw a line down the middle
of a practice and say that there are going to be two PCGs, which
would be a bit odd, I cannot see how we are going to get that.
(Mr Wing) Well, the current position is that the configuration
of PCGs is going to have to be resolved by July. There is a consultation
paper and there is supposed to be the widest possible involvement
of the interested and affected parties. The general approach is
set out in the consultation paper, that the primary care groups
themselves should be configured in a way which does not cross
health authority boundaries. There will be local exceptions to
that but this is a move towards trying to make sense in new structures
of the problems that will obviously arise if you cover more than
one health authority and more than one health improvement programme.
The consultation paper is silent on the issue of social services
boundaries but these are smaller popular bases, and we think it
ought to be possible because there is a considerable amount of
scope and flexibility set out in the proposed guidelines to ensure
that we do not find ourselves facing the nightmare of a primary
care group having to deal with two or three different social services
departments. The advice that has been issued by the NHS is in
the singular, so there is an assumption that we are talking about
primary care groups and a social services department. We certainly
in our response to the draft circular are pressing that point
very, very strongly. We understand the practical problems, it
is not a problem that is going to be resolved overnight. But I
do think that the changes that are taking place do give rise to
opportunities, and there may be a tendency the other way for existing
groups of GPs, maybe fundholders who may resist change, to try
to configure the primary care groups in a way which is advantageous
to them. Our view is that we have to try and resist that and configure
the primary care groups in a way which is in the interests of
health care.
Mr Walter
463. You have been answering most of the points
I wanted to talk about in terms of primary care groups and relationships
to social services and the fact you still see the two services
of health and social services. I just want to pick up on one thing
you mentioned in paragraph 3.7 of your evidence in terms of talking
about practice-attached social workers but suggesting these should
still be employed directly by the social services department and
not by the primary care group. Do you see that working?
(Mr Wing) The primary care group will by and large
not employ staff, the primary care group is broadly speaking a
commissioner of health services. A primary care trust at stage
4 will employ staff but not a primary care trust at stages 3,
or 1 and 2. We have some real concerns about GPs as employers.
There are 100,000 staff employed by GPs at the present time and
we have a lot of experience in dealing with GPs as employers and
by and large we do not think they make a very good job of it.
Obviously GPs have an extremely central role in the primary care
groups and in the commissioning of services but we hope they do
not become major employers of staff.
Mr Austin
464. Briefly on the question of who should employ
whom and where, could I just raise the issue of occupational therapy?
I recognise the role and function of occupational therapists may
be different in a local authority from that within a health service,
but there you have very fierce competition for a very scarce resource.
(Mr Wing) Yes.
465. If we are talking about other professions
within health and social services being competed for, are there
not real dangers there?
(Mr Wing) There may be. There is, as you say, a tradition
of local authorities and health employing occupational therapists,
and we are the organisation which by and large represents them,
and they are a scarce resource and there is a great deal of competition
between social services and health trusts in the recruitment of
them.
466. Is that wise?
(Mr Wing) It is good for occupational therapists except
that the Pay Review Body might not be too sympathetic to the problem
of shortages and the need to address those. That is the fine detail
that UNISON is more than willing and happy to look at. If there
are more efficient and effective ways of dealing with these problems,
then we are amenable to them.
Audrey Wise
467. I wanted to ask briefly whether you have
any views about the other kind of staff who can be involved in
matters relating to health-come-social problems. I have in mind,
for example, people working in the housing department in relation
to problems which people have and it is often crucial that they
should be properly housed. Do you think there is enough of a relationship
between social services departments and other departments of local
government, which sometimes of course will be in the same local
authority and sometimes in a different one, in relation to health
and this sort of thing?
(Mr Wing) I can only answer that question in terms
of the importance that we attach to Our Healthier Nation,
the Green Paper. It is still out to consultation but that will
inevitably mean that there will need to be much more interdisciplinary,
multi-sector working. Housing departments and other departments
within local authorities are going to have a very, very important
role to play in generally making those health improvements which
are so eloquently spelt out in the Green Paper. The health action
zones will provide a very, very important pilot for establishing
how effectively other parts of local authorities can work together
and the contribution they have to make to improving health. I
think that they are all extremely welcome developments. I suspect
that local authorities differ in the way that they deal with those
issues. Some deal with those issues effectively, challenging the
problems of ill health, and others not so effectively. But certainly
again it seems to be the way forward, the emphasis that is being
placed on public health is one that we find exciting and important.
468. If I can broaden it slightly: we in other
inquiries, particularly another one which is current, Children
Being Looked After, have come across real problems at the interface
between education authorities and health authorities. I wonder
if Mrs Botes has got any views about this interface—education,
health, social services? With children it is often three ways.
Does it impinge on your work? Is it something your members are
conscious of?
(Mrs Botes) Very, very much so, because so much of
the work both by health visitors and school nursing is half social
and half health. Because it is about healthy people and you are
working predominantly with healthy people, what affects healthy
people is the social aspects of their life. It is very much half
and half. So I think health visitors and schools nurses should
really come within the social care White Paper because they do
span that bridge. School nurses are very aware of the difficulties
of combining those three agencies—social services, education
and the health of the child, and to try and keep that in focus.
There are not enough school nurses around to be able to keep a
good eye open for the children who are looked after and they do
fall through the net very often. There are lots of examples you
hear that they are falling through the net in one or other of
those aspects. For example from the health aspect, eyesight or
something like that, will not be picked up. It is very crucial
that there is somebody there to look out for and to combine. When
health visitors are talking to families they are so much talking
about the health aspects, about employment, about housing, about
crime on the streets, about parks and the fact there is nowhere
to play. It is social things that really affect the health.
469. Mr Wing, it has been put to us quite forcefully
in this and other inquiries that education and social services
under the same structural wing, as it were, nevertheless, have
difficulty in working together sometimes and quite often in fact.
Does this influence your view that it is not so much structures
as other kinds of action towards joint relationships that are
important?
(Mr Wing) Yes. There needs to be a strong lead on
the importance of multi-disciplinary working and there have been
lots of examples of where that has been successful. Social services,
housing, education and health have been very successful, for example,
in joint work on HIV prevention. There are lots of examples of
multi-agency, multi-disciplinary working and I think we need to
reflect the structures that we have got and try to make them work.
I sometimes have difficulties in working with the department upstairs.
I do not think wholesale reorganisation is a necessary prerequisite
of making progress, so our emphasis is on the multi-disciplinary
approach and extending that. It has got to be addressed comprehensively
and it has got to include not just health and social services,
but education, housing, social security and a range of agencies
both within the two we have been talking about this afternoon
and others outside of health and local government.
470. Perhaps I could move on to a different
question. The Macmillan Cancer Relief run a carers' scheme which
we understand is a form of home support with specially trained
health care assistants offering personal and basic nursing care
as well as undertaking various household tasks. They claim that
their scheme fills a gap not met by statutory bodies. What do
you think of this? Have you come across their scheme? How does
it strike you? Would you be in favour of this kind of pattern
being operated by health and local authorities?
(Mr Wing) Personally I think that we have looked at
the carers' scheme not in too great a detail, but what strikes
me most clearly is that it is fully funded by the Department of
Health. It did cross health and social care, but there were none
of the problems that we have talked about this afternoon in terms
of users having to make a financial contribution and it was certainly
a very successful pilot in allowing patients choices that have
not been open to them previously, so the voluntary sector has
a very, very important role to play. Macmillan in particular has
a wonderful track record and the carers' scheme seems to have
been a considerable success and we would certainly support more
of those schemes, but what I am not aware of in terms of Macmillan
is what involvement the NHS and local social services departments
had in those pilots. They were not required to put funding forward,
but you can bet that they were closely involved in the management
and involvement of the process and it seems to have worked extremely
well. I think it is perhaps also worth saying, because we have
talked about health professionals a lot this afternoon, that most
of the care in the Macmillan scheme was delivered by health care
assistants, non-professional, non-registered staff, and I think
that that is very, very important to recognise
Chairman
471. Do any of the others wish to answer that?
(Ms Young) Yes. I think we would like to see the development
of and encourage services that provide the services that people
need and want and if those services are provided by competent
people when and how people require them, then I think we would
want to see that happen more and more. I think, bringing out the
subject of crossroads, the crossroads provide the most phenomenally
valuable service to many people who would otherwise go without
and I think that we ought to acknowledge that.
Julia Drown
472. Can I just pick up a couple of points with
Ms Young? The first one is about single-registration care homes.
You said that it was a complete anomaly that patients are able
to receive intensive nursing in their own home, but have to move
from residential care home to a nursing home if they need a similar
level of nursing. I wonder if you could expand on that, and I
wonder particularly whether it is a problem with private nursing
homes because I do know of some local authority homes where nurses
do go in and people are able to stay at the residential home.
(Ms Young) The 1984 Registration Act is actually somewhat
bizarre and outrageously out of date. It does not fit in with
the way we provide care today, so it does need to be looked at.
What we are pushing for is a single-registered home, and it does
not matter whether it is independent or local authority-owned,
but the significant factor is that it is a single-ticket home
whereby if the person goes in with a certain level of independence
and their condition deteriorates, they would not have to move
home. It is rather strange that as an older person, if I lived
in my own home and my condition deteriorates, I can receive hopefully
a very high level of nursing care within my own home, but I would
not be able to receive that if I was in a residential home. In
order to get that care, I would have to leave what I may consider
to be my home and I might have been there for a number of years.
473. Can you confirm that if it was a local
authority home, it would be possible?
(Ms Young) No, it is not whether it is a local authority
home or whether it is independent, but it is whether it is a residential
or a nursing home. There are two categories of registration.
474. Well, how come I know of a local authority
home where nurses do go in and help?
(Ms Young) Is it a residential home?
475. Yes.
(Ms Young) Then it is the district nurses that go
in and actually carry out probably quite minimal care. What you
cannot do in a residential home is provide 24-hour nursing care,
so it is quite a fundamental difference which I think needs to
be addressed.
476. Can I just pick up a separate issue which
is that we talked earlier about how primary care and community
care groups might work in the future with a district nurse leading
care assistants and providing care in the home and we also talked
about how things like hospitals can suck away all the resources
from other services. How do you stop that continuing? The district
nurse would be under pressure to keep healthy discharged people
from hospitals, to help provide services in the community so that
people do not need to go into hospital, which we would all support,
but it means that the other area, those rare things which are
provided sometimes in the country, like basic, nearer to home-help
services, would never get a look in and that is one of the roles
that social services would like to hang on to and one of the reasons,
I think, why social services are sometimes resistant about getting
completely into bed with health. How is that new model of primary
care and community care with the district nurse leading going
to avoid that happening?
(Ms Young) I think we are going to be expecting quite
a lot of the new primary care groups to actually achieve some
kind of balance out there so that people do not feel very compromised
and then we are putting all of our resources into one area of
care whilst at the same time neglecting another area of care which
I think we have got a history of doing rather well. Historically,
mental health and the care of older people missed out because
the sexier side of care is in the high-tech hospital and I think
we have now got the opportunity to achieve a much healthier balance
and I think it is how we are able to invest and support the new
primary care groups which I think have the potential of actually
commissioning and planning services in a much more balanced way
because of the proposed make-up of the primary care groups which
will be involving medicine, nursing, social care and the public
participation. I think we should have faith in that proposed mix
that the people with the skills and the talents coming from those
different backgrounds will be able, given the right support and
resources, to plan and develop services locally to actually provide
the maximum help for the most number of people, but it is not
going to be easy and I do not think we should think there is a
miracle out there because of the new primary care groups. We have
got to find ways of making it better.
Ann Keen
477. The White Paper actually says that it should
all be an evolutionary approach.
(Ms Young) Indeed, a ten year plan.
Ann Keen: That is without question. I think
everybody is agreed on that. That is what we really need to see
on the ground, how we can build people working together.
Audrey Wise
478. Can I refer to the charging issue but specifically
in connection with nursing homes, residential homes, wherever?
Where you are nursed makes a huge difference to whether you have
free nursing or not. I know the RCN view because they submitted
evidence to us on this in a previous inquiry, which is that nursing
should be free wherever you get it, so you can get free nursing
in hospital, you can get free nursing at home—and I am not
going here into the social care area but thinking of what everybody
would regard uncontroversially as nursing—but you do not
get free nursing in a nursing home. I know the RCN's views but
I do not know the views of the other organisations. Do you have
any views about that? Do you think nursing should be free wherever?
Or do you think the present system is a reasonable one?
(Mrs Duffy) The CDNA would definitely go along with
the line that nursing should be free. We feel quite strongly that
nursing homes, which have just expanded throughout the country
over the last ten, 15 years, where quite often people are nursed
for a period of time within, say, private nursing homes and suddenly
they can no longer afford to stay and they may have to leave.
It is a whole upheaval for elderly people, and very sick people
have been moved at different stages of life. Home should be home
and if they need nursing care, it should be available.
(Mrs Botes) Yes, we would agree with that.
(Mr Wing) Yes, we would certainly agree as well.
479. The previous Select Committee was very
attracted to it as well. I appreciated very much the Community
and District Nursing Association provision of a case scenario
with examples of different action which enabled somebody to stay
at home or go to hospital. I just wonder whether you have perhaps
slightly overstated some of the differences. I would not like
to be unable to give full value to it so I would like you to comment.
You have on your hospital scenario, a person with chest infection
and pneumonia, the action of going to hospital involving ambulance,
accident and emergency, lying on a trolley for perhaps many hours,
and then you have a heading, "24 hours later—antibiotics,
oxygen, pressure sores ...", it seems to me to be ever such
a fast development of pressure sores. If that person is going
to be so inclined to pressure sores, would you be absolutely sure
she would not have pressure sores if she was in bed at home?
(Mrs Duffy) This patient has been lying on a trolley
for several hours. If you put an elderly, thin person on a trolley
for several hours, where they can become incontinent while lying
on a trolley, that will certainly damage the skin and the skin
will break. So you can have the situation very, very quickly,
within a matter of hours, where pressure sores do occur.
480. So the difference is essentially the question
of lying on the trolley. She would not be doing that if she was
in her own home?
(Mrs Duffy) That is right.
481. I am grateful to you for that. Can I just
ask you to enlighten me slightly on the other scenario, staying
at home. "Community nurse assessment, oxygen therapy at home,
chest physiotherapy, intravenous antibiotics, nursing continued
assessment for first 24 hours .." and then home care help
as well, and you point out the difference is the much better outcome
which is likely from that, and I agree with you. Can you give
us a bit more indication of the extent of the nursing input which
is needed there?
(Mrs Duffy) Very recently throughout the country there
were hospital-to-home schemes where patients really had all the
services being brought into the house. They had their district
sister coming in who was carrying out a complete assessment, there
was the GP coming in initially, the sister was able to keep constantly
in touch with the GP throughout the crucial time, maybe the first
24, 48, 72 hours. Whatever was needed was able to be brought into
the home. If somebody needed around-the-clock attention, it was
there. Unfortunately, a lot of the schemes that we were providing,
the money just dried up and in a lot of these cases they were
no longer able to have schemes in certain areas. District nurses
throughout the country do strive very, very hard to try and pick
up problems and really before they occur and quite often they
can help in the prevention of having someone admitted to hospital.
By having a nursing team on demand, able to go in, the sister
is best placed as to who should take over the care. She can link
in with the professional nurses, she can link in with Marie Curie,
and there are so many other agencies that she can link with out
there in the community that can provide proper 24-hour nursing
care and it is readily available.
482. So your experience clearly, you are telling
us, is that that does produce a better outcome?
(Mrs Duffy) Definitely and you have less anxious patients,
less anxious relatives, the patients are where they want to be
and they have not been disturbed at all, they are still in their
own bed.
483. And you clearly think that this leads to
less future expenditure?
(Mrs Duffy) Definitely.
484. Can you give us any idea of the differences
in the immediate expenditure? I accept the point about the long
term, but I am curious to know whether you have done any costings
for the actual immediate episode and how it compares.
(Mrs Duffy) I do not actually have figures here, but
when you take into consideration how much a hospital bed per day
costs, it is an awful lot more money than keeping someone at home
and having a sister, a district nurse going in and maybe another
grade of nurse going in. A visit from a GP which may take half
an hour or an hour again is a lot cheaper than having somebody
in hospital. With the cost per bed per day and being seen in hospital
by several departments, maybe including radiology, and having
several maybe unnecessary tests, lots of different blood tests
which maybe are unnecessary, when you add up the overall costs
of admitting someone into hospital, it certainly works out a lot
less expensive to keep them at home.
485. Perhaps you would like to send us some
information about schemes which have existed which have been stopped
or are ending because of a lack of funding.
(Mrs Duffy) Yes.
486. It does not seem to me to be a good idea
to pilot schemes which prove successful and then stop them.
(Mrs Duffy) That is right, and that has happened very
recently.
Audrey Wise: Perhaps you could let us have some
of that information.
Chairman
487. If my colleagues have no further questions,
do any of the witnesses wish to add anything that has not already
been covered which you think might be useful?
(Ms Young) Can I just bring up the subject of incontinence
because I have been asked by quite a few people to try and make
the point, if I can, that incontinence is health care and it is
free.
(Mrs Duffy) Could I just give a mention also that
we do not have enough specialist nurses where nurses have undergone
further education and training in specialties within this country,
and there is a big gap of further specialist training for specialist
nurses.
Audrey Wise
488. What kind of specialties?
(Mrs Duffy) I could think along several lines, like
stoma care, breast care. There are just so many specialist nurses
that could be very valuable.
Audrey Wise: Of course stoma care nurses are
very important for going into people's homes.
Chairman: Can I thank you all for coming along
today and giving oral evidence and also for your written evidence.
We have taken note that you will be following up with further
evidence in response to one or two of the points that we have
raised. We are most grateful to you for your help.
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