Examination of witnesses (Questions 160
- 179)
THURSDAY 17 FEBRUARY 2000
MS GISELA
STUART, MS
DENISE PLATT,
CBE and MR ANDREW
CASH
Chairman
160. Are you talking about specific grants to
Social Services?
(Ms Platt) No, it was Health Service money, of which
a proportion was passed to Social Services to develop new schemes.
161. Via the Health Service, because people
like yourself were not trusted to spend the money appropriately.
(Ms Platt) That is, indeed, true.
162. That was a previous Secretary of State.
(Ms Platt) Times can change. However, this year Social
Services did have specific grants to promote independence and
to develop partnership working. As part of the conditions of those
grants they were asked to develop recovery schemes, intermediate
care schemes which could be intensive home help schemes to keep
people at home and to support them through illness, while being
supported by their GP, so they did not have to go into hospital.
Or intensive recovery schemes, where people coming out of hospital
could be in residential care supported by different sorts of therapists.
What we saw Social Services do this year was actually carry forward
£9 million of expenditure from the time they had to get money
transferred from the Health Service into this financial year and
add to it another £18 million, which was solely dedicated—that
is £27 million more—to schemes this winter to actually
provide a variety of opportunities to sustain people in the community
or to move them from hospital quickly to recuperate. Because the
planning started very early those schemes are in place and are
sustainable because this grant will continue next year and the
year after, which will give us an opportunity to look at the profile
of services that is necessary in the community so that we can
re-profile some of the budget behind it. That would be our intention.
The Beds Inquiry, to which you referred, is a consultation document
and we are in the middle of a Spending Review. I would not be
a good official as I now am if I speculated on the outcome of
what might ultimately be spent on these facilities.
163. Can I pursue with Denise Platt the point
that I raised right at the outset with the Minister? You have
a long and very positive track record working in local Social
Services, do you not feel frustrated, on behalf of the witnesses
that we had earlier, about the incredible fragmentation of provisions
in areas like Essex and Cheshire where people are attempting to
develop some coherent continuity of care? You go back a long way,
like I do, in respect of recalling when we had a Local Authority
Health Department. We actually had a much more coherent framework
pre 1974, would you not like to see that return in some way? That
might be an unfair question.
(Ms Platt) Nostalgia is not what it used to be. I
was listening to it from the point of view of Cheshire and Essex
and thinking Chesire Social Services have to deal with nine trusts,
several health authorities, et cetera so there are boundaries,
whichever bit of the kaleidoscope you are in, that is true.
164. If you were inventing a system could you
invent a dafter system than we have at the moment? We are talking
about a coherent system of care where a patient can go through
from acute care into the community and back home. Could we have
a dafter organisational system than we have at the moment because
I cannot think of one, quite frankly?
(Ms Platt) I am not sure we will ever reach the perfect
world of having one boundary that would actually suit all of those
different organisations that are operating in your area except
if you are living the Isle of Wight or Isle of Scilly. Even they
did not get it all in one go. A Social Services Director for England
might be the solution here. What we have tried to do with policies
throughout the year is to remove the boundaries that are unnecessary
to that joint working. You did mention pooled budgets. The Health
Act does provide opportunities for the whole of the local authority
to put money into a pooled budget with Health Authorities for
the purpose of health gain, so that is beyond Social Services.
165. It does not address the dilemma between
social care and nursing care. To the point I raised with the Minister
earlier, she said, "It does not matter who provides the care."
As far as I am concerned some of the Yorkshire men I deal with
get upset when they have to pay for a service because they believe
it should be free and if a nurse was providing it it would be
free.
(Ms Platt) I think you have strayed into a different
inquiry from Winter Pressures and the Government will respond
in due course, fully, to the Royal Commission and the recommendations
made. What we have done thus far is to try and remove some of
those difficulties about pooling budgets. We want to see much
more use of those partnership flexibilities when they come into
existence on 1st April.
166. Can I ask the Minister, on the Beds Inquiry
point that you raised earlier on and the numbers issue - the numbers
issue has a direct relevance to the Winter Pressures question
and the problems that have occurred—and we have looked at
PFI schemes and a lot of PFI schemes have quite radically reduced
the number of beds available, what advice has the Government given
to those areas that are planning new schemes now in the light
of the National Beds Inquiry report in terms of the number of
beds that they require at a local level, are we revising our guidance?
(Ms Stuart) What is happening is the decisions on
the reconfiguration in the area and the number of beds required
come well before the decision on how the scheme is planned. Any
decision on the number of beds are made before they go in the
funding stream and the PFI. The two processes are quite distinct
and separate.
167. I have a local interest because we are
looking at a new scheme for a capital development in my area,
the current proposal we have consulted upon envisages a significant
reduction in the number of beds. That has not been agreed yet,
the number of beds has not been agreed on but there is a proposed
reduction. In the light of the National Beds Inquiry and the pressures
we have seen this winter and previous winters would the Government
be looking again at such proposals if a scheme that came through
envisaged a reduction of that nature?
(Ms Stuart) I am not sure how far down the process
of planning your particular scheme is.
168. I am making a general point rather than
a specific one.
(Ms Stuart) The whole point of the National Beds Inquiry
was to really strategically look at how we use beds and if any
findings show us that certain kinds of beds and certain configurations
are needed more then, of course, any plans which are coming into
the Department should and must take account of what is being said.
Mr Austin: Like the Chairman, my experience of social services
goes back pre-1974 as well.
Chairman: We are not called Dad's Army for nothing.
Mr Austin
169. Grandad's Army I think. Ms Platt mentioned
the fact that there was the danger of us straying into another
inquiry but I would like to ask, Minister, that since the National
Beds Inquiry showed that two-thirds of hospital beds are occupied
by people over 65 and since half of the growth in all emergency
admissions was people over 75, how can we solve the emergency
pressures at the end of the day without having a clear strategy
of improving the long-term care system?
(Ms Stuart) You are absolutely right, it is also the
change in demography. One of the things that happened this winter
was because of the increase in the admissions of over-65s, the
people who came in were especially frail and they were very, very
sick and they stayed in hospital longer than before and all of
that has to be taken account of. The real thing you have to remember
is that they should only be in hospital for as long as it is medically
important and significant and then move on. That is why I think
bridging that gap is important.
Dr Stoate
170. Can I say that my area in Dartford generally
speaking coped extremely well with winter pressures. I kept in
almost daily contact with them to make sure what was going on.
That was with one exception and that exception was in fact quite
serious. I had a couple of patients who had their operations cancelled—not
postponed but cancelled—because when they actually got there
there were no intensive care beds for them because of the emergency
admissions. What the trust did in response to this was to increase
the ITU beds by 50 per cent, which was remarkable, and I am sure
it could not have been increased any further, and it still was
not enough. Despite the fact that the trust had patients in outlying
hospitals and they really did their best to stretch resources,
they could not meet the quite serious operations that required
ITU after surgery, so patients were quite severely put out and
rightly made a big fuss about it, and I made a fuss on their behalf
as well. The question really is what plans have you got to review
intensive care beds and what plans have you got to increase them
for next year because I believe that we do need an increase in
them?
(Ms Stuart) There are a couple of things in place.
As a result of last year we commissioned a survey which was called
the Review of Adult Critical Care and they are due to publish
their findings in April. We are not just waiting for the official
publication of that review. Two things have happened. Last year
there was an early impression of what was going on in the field,
there was an assessment made that we needed at least an extra
100 beds and the funding for that was made available. What is
also absolutely critical, and the Audit Commission Report on Critical
Care this summer showed that, is not just to have the beds themselves
but also the way they are being used. There were huge differences,
as was alluded to earlier. You need the intensive care beds but
you also need to properly manage the system of high dependency
units to allow that step down. It is changing that management.
The third area is capacity building. No amount of money over six
months will buy you extra nurses if they have not been trained
out there. We are not just having the report, which was commissioned
last year and which will be very useful to take forward, we also
have, and are continuing to have, very close discussions with
the Intensive Care Society to make sure that we start the process
early enough. The retraining for nurses is an extra six months
to make sure that it is not just facilities but also the staffing,
the increase in numbers.
171. That is very reassuring but clearly ITU
is a pressure point every winter and I think this winter it was
particularly bad. I think we have already heard that some of the
people coming into hospital as emergency admissions were critically
ill, more ill than perhaps they may have been previously, more
frail than they may have been previously and spent more time on
ITU. What assurance can you give this Committee that by the end
of this year, in time for next winter, those beds will be in place,
they will be staffed with an adequate level so that we should
be able to avoid the same thing happening again? Can you give
us any reassurance that will happen by then?
(Ms Stuart) I can give you the reassurance that within
what we are predicting and in terms of what we can do with the
capacity, it is one of the absolute priorities in terms of planning
for the next winter to make sure that the critical care facilities
are stepped up. Our biggest constraint on that is going to be
available staff.
172. I appreciate that but obviously you are
planning to increase staff.
(Ms Stuart) Within those constraints it is a priority.
Audrey Wise
173. The report which has just been issued on
hospital infections makes it quite clear that some of the emergencies
are actually created, as it were, or happen in hospitals. The
report points out that it can mean several extra days in hospital.
I appreciate that it is a new report and I do not know if you
have seen it. There are some quite staggering things even from
a cursory look, for instance the lack of hand washing policies
in hospitals which I find incredible. The lack of such a simple
protocol means the loss of hundreds of millions of pounds and
a greater need for all kinds of provision, nursing, beds and everything.
Do you intend that there will be considerable attention paid to
this question of hospital infections?
(Ms Stuart) Yes. Most of us listened to The Today
Programme this morning, which is our major source of information,
and I heard Alan Langlands, the Chief Executive of the NHS. He
very much welcomed the report but also, as I understand it, it
was previously in November that the Department announced the new
standards for NHS hospitals and the management of hospital acquired
infections. Again, a circular was sent in February to all the
hospitals outlining some 15 new standards of what we expect every
hospital trust to deal with to minimise the incidence. It is something
that sadly happens in a large number of hospitals across the world.
We need to minimise this. It comes back to this earlier thing
that particularly elderly and frail patients should not be in
a hospital unless they really need to be there. The Department
is not complacent at all about this, there are very stringent
standards that have come out.
Audrey Wise: For a long time, of course, there
were cuts in cleaners and cleaning happening, which I myself think
has been detrimental. I know that it is the practice of the National
Childbirth Trust, for instance, to advise mothers to take into
the maternity ward when they go in for delivery their own cleaning
materials. That happened with my daughter-in-law and I said "did
you actually need them", thinking perhaps it was a bit of
over-kill, but, no, she told me that, yes, she did need them.
I hope that the Department will give special attention to this
because high tech is all very well but if you have not got the
hand washing and the toilet and bath cleaning then you are going
to get trouble. I try to run a reasonable level of hygiene with
my family but it sounds as though it is actually better than hospital
standards and that dismays me. I do not feel happy, I just feel
"heavens above". Could I suggest that you pay particular
attention to those things.
Chairman
174. There is, of course, evidence that we are
all keeping too clean and, therefore, are more susceptible to
infection. That is the Yorkshire man speaking.
(Ms Stuart) I think it is worth noting that there
were real hang overs from when people went out to competitive
tendering and mistook price for quality and whilst the term best
value is a local government term, that change in which you compare
not just what something costs but what it delivers you, has been
a real recognition. I think the cleaning contracts were a classic
example where authorities were forced to go for the lowest price
which did not deliver the quality.
Audrey Wise
175. On the issue of beds, we have talked about
intensive care beds and critical are and intermediate provision,
but it is often the intermediate side of it that is thought of
as being the kind of stepping down. The person has had surgery
or something and then where, oh where, is the old fashioned convalescent
home? There is the opposite thing that can happen. There is a
facility in Lambeth, whose official name I forget, which works
in conjunction with St Thomas' and this Committee has visited
them twice and it is not so much a stepping down as a "let
us have a look at you", an intermediate between home and
hospital rather than between hospital and home, if you see the
difference. I hope that you have a look at that, or your Department,
with a view to maximising that kind of best practice as well.
(Ms Stuart) You are absolutely right, we do see a
year on year increase in emergency admissions. When there are
emergency admissions people are more sick, if that is an appropriate
term, than they have been in the past. There is a real need for
looking at these early stages. If I can come back to this whole
planning process, that is that we deliver the right care at the
right place at the right time. Too often their only option has
been seen to be the hospital and I think we need to move away
from that.
Mr Amess
176. You might like to know that when the Bed
Report press release came out yesterday, when I went to the library
I was told that it was still at the printers. That does seem,
as ever, deeply insulting to parliamentarians.
Chairman: David, can I say that I got a copy
of the report last week. The report was in the Vote Office last
week. Something has gone wrong somewhere along the line. I obtained
a copy through the Vote Office last week.
Mr Amess
177. I accept that correction. Maybe the enquiry
I made was misunderstood. Can I now go on to intensive care beds.
Will you tell the Committee again how many extra intensive care
beds have been created?
(Ms Stuart) Can I just explain first how they are
counted. It is a snapshot at any one time. What makes a bed an
intensive care bed or a high dependency bed depends on the level
of staffing and nursing that goes round. Figures were placed in
the library on 17 January. That was the snapshot at 17 January
which stated that the number of intensive care beds and high dependency
beds was 2,362. At the moment we are in the process of verifying
all of these figures by going back to the chief executives and
ringing them. If there is any change in that figure then that
must be seen in that context. It literally changes from hour to
hour as to what is one. In a sense this led to the debate of saying
where were the 100 over the winter, because we said that we provided
funding for an extra 100. The very nature of when is it one and
how is it defined is that it is either being occupied by a patient
or ready to take a patient. It really is rapidly changing. These
are the figures which were placed in the library on 17 January.
178. Thank you for that. So this was why the
Health Secretary wrote in a letter that there were 100 extra intensive
care beds and the Prime Minister, on the David Frost programme,
said that "two-thirds of the 100 beds announced were lower
level high dependency beds which are not equipped to provide the
artificial ventilation needed by many victims with flu complications"
and the Department later confirmed that it was 30? In January
the Health Secretary reported that there were 197 people with
flu per 100,000 of the population. In that same statement he described
the outbreak of flu as an epidemic, and so it came to pass that
we had an epidemic. Of course, the Health Secretary justified
those figures because of what the Chief Medical Officer said.
He pointed out that the heavy usage of NHS Direct and the number
of people going to pharmacists meant that many patients would
not show up on the conventional GP based tracking system. That
is all well and good but, as I understood it, for an outbreak
of influenza to be described as an epidemic there must be 400
people with flu per 100,000 of the population. The quote that
I want to put to you is "It is nonsense to say that the crisis
is due to winter pressures. The number of beds is so totally inadequate
that the slightest problem throws us into crisis. This Government
has had long enough to do something about it". That is what
the President of the Hospital Consultants and Specialists Organisation
said. Is he talking nonsense?
(Ms Stuart) I would never be so presumptuous as accuse
any eminent professional of talking nonsense. It is two fold,
if I may answer this backwards. Has this Government had long enough
to do anything about it? The biggest constraint on capacity is
the work force. It takes three years to train a nurse, seven years
a doctor, fifteen years a specialist. I suggest that we have started
to address the real changes in bringing people in. The flu debate
I think we need to address, and what happened when the Chief Medical
Officer made that statement. I would not want to second guess
his reasons but his duty is to respond to sudden surges. The official
figure showed an increase from 141 to 171 in real pockets. I was
very interested to hear earlier that one of the witnesses was
saying in Cheshire they did not have a particular problem. They
were localised pockets. It should not be seen in isolation because
it was not just flu, it was flu-like symptoms. It appeared to
hit the over 65s, a much larger number, than any other age group.
For example, in the week ending 9th January the level of over
65s having bronchitis was the highest level in fifteen years,
at a level of 943 per 100,000 of the population. It was flu and
flu-like. In addition to that there was bronchitis. In addition
to that, it was hitting disproportionately, it would appear, the
most vulnerable age group. That was one area. Also it is quite
true that people did use NHS Direct much more. We had 250,000
calls over the millennium period with symptoms along those lines.
To me one of the most telling statistics was the sales by Boots
of over-the-counter flu remedies. They said that over the Christmas
week in Boots the sales increased by 58 per cent compared to the
previous year and in January it was up by 24 per cent. There was
some real evidence that whilst we had the scope and practices
to track this there were a whole lot of combined factors to say
this added to pressure.
179. I thank you for all of that but I suppose
what I am really after is when the Health Secretary made this
statement on 10th January about it being an epidemic, who was
that helping? Was that helping the National Health Service? Was
that helping the people who were ill? The charge could be directed
at some quarters that for eighteen years at winter we did not
have epidemics because, perhaps, there were no targets, et cetera
but suddenly since 1st May 1997, bang, we have real problems because
targets have not been met, it is all going wrong, and hey presto
there is an epidemic. This is a good excuse and it is not supported.
I know you have gone on about the NHS Direct and Boots figures
but, as we know, in a court of law people defend murderers and
sometimes people agree with them, so all arguments can be advanced.
It does not seem to be supported that this was an epidemic.
(Ms Stuart) I think the context of that statement
is when the Secretary of State makes a statement in the House
of Commons it is to explain the situation as it is on the ground.
Sometimes the explanation may not even be helpful, the purpose
is to clarify. Can I also comment on the charge that this was
a kind of invention? The number of deaths over the quarter period
has increased when compared with the last five years, the current
figures would suggest something between 3,000 to 4,000 over the
previous year's figures. There is real evidence out there that
things were tough.
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