Select Committee on Health Minutes of Evidence

Examination of witnesses (Questions 93 - 109)




  93. Minister, can I welcome you and your colleagues and thank you for coming along this morning because I appreciate this is not entirely your area of specialty, so we will take that into account in respect of your answers.
  (Yvette Cooper) Thank you. I have with me Dr Sheila Adam, Deputy Chief Medical Officer, and Judy Sanderson, who is the Team leader responsible for neurological services whom I have also asked to sit at the table in case there are any detailed questions anybody has, if that is alright.

  94. That is very helpful. Can I begin by thanking you for the written evidence you have given to this inquiry, which is helpful, and pick up the point you have just made about who does what in the Department. One of the problems that we have had in respect of this area has been the witnesses who have said to us, "We do not slot into any neat category and frequently we cover a number of categories and fall between several stools." Would you or one of your colleagues describe how this area is handled within the Department itself at this point in time?
  (Yvette Cooper) I will say a couple of things and then hand over to colleagues to describe departmental structures. This is something which affects a lot of conditions. Inevitably any condition is affected by lots of different, sometimes fragmented services, and one of the challenges in any service, whether it is about the NHS provider side providing services or whether it is the Department of Health policy implementation side, exactly the same questions and tensions arise for many different conditions and problems. I think that is one of the things that we have tried to pick up in our approach to national service frameworks, which is to take that comprehensive approach and draw together all of the different elements, whether it is about prevention, whether it is about social services, whether it is about acute care, or whether it is about rehabilitation and to do that on the policy-making side but also on the service delivery side as well. We would recognise that in a lot of these areas (this area as much as any) there are these kind of difficulties and that is exactly the kind of approach which the NSF is supposed to address and I know we will come on to that later. I do not know who wants to discuss the departmental structures.
  (Dr Adam) Obviously this is an area that crosses the three main business groups in the Department of Health. The NHS Executive is taking the lead on health services for people with head injury both in the acute phase and during rehabilitation and continuing care which requires a clinical input. Obviously social services also play a key role in the rehabilitation and longer-term care and they are, as you know, within the Social Care Group of the Department. We are also concerned to integrate thinking on prevention of head injury and the lead for that sits within the Public Health Group. I think the other two bits of the Department to mention are the regional offices of the NHS and of the social care regions because obviously in terms of implementation and performance monitoring and management they play the lead roles. So I think it is an area that genuinely needs to be reflected in each of the three business groups in headquarters and in the two sets of regional offices.

  95. I ask you, in looking at how you handle this area, what kind of figures do you have on the number of head injured people there are in England? We would be interested in your comments on the collection of data by different elements within the Department, obviously there is the health side and there is the social services side who are dealing with different parts of this problem. Also, how do you offer definitions, because there are, as we have been reminded of on several occasions this morning, marked distinctions within the term "head injury" or "brain injury", or whatever that clearly do cause difficulties sometimes. I was very interested in Headway's evidence to the Committee, which I think you may have seen, where they refer to a Parliamentary answer given—I do not think it was by yourself, Minister—on 5th February, where they say a written answer to a Parliamentary question on support erroneously quoted statistics which referred only to traumatic brain injury. The definitions are obviously causing people some problems at a grass roots level and, clearly, there may be some confusion within the Department at a national level. Can you tell us a bit about how you do define it? How is it recorded and how do you pick it up in developing your policy at a national level? To develop that you need to know how many people you are dealing with.
  (Yvette Cooper) The figures that we have and are collected and we have submitted to the Committee in Annex A of the memorandum that we sent. That sets out the finished consultant episodes via the main diagnosis in NHS hospitals, and those are the figures that are collected. We would accept that there are difficulties with the figures and there are difficulties with the way in which they are collected or the diagnosis is made at the time. There is not an easy solution to this. However, the National Service Framework for long-term neurological conditions will cover the issues around head injury. One of the things that may be appropriate for early work, as part of the National Service Framework, may be to assess the data currently collected, and to look at what improvements might be made or what research might be needed. I do not know if anybody else wants to add anything on the way the figures are collected at the moment.
  (Dr Adam) If I can add a concern about the difficulties measuring both the severity of injury and measuring the outcome and trying to make a connection between the severity and the ultimate outcome and the interventions that have been made. We do find that extremely difficult at the moment. As the Minister has said, this should be one of the focal points in the development of the information strategy to underpin the National Service Framework.

  96. If I can look at it in practical terms at a local level, I mentioned in the first session that I was struck by the written evidence from one witness, that you may have seen, who talked about one of the problems of the head injury at a local level is being dealt with by local authorities and the community care provisions slot into certain categories, they went into detail about mental health and learning and physical disabilities. There problems are frequently in more than one of these categories, will the framework offer any clarification as to how, perhaps, at a local level a community care plan may link and bring in additional criteria that will enable such people who do feel they do not fit in anywhere to have their needs addressed more coherently than is happening at the moment?
  (Yvette Cooper) There is an opportunity for the National Service Framework. The position at the moment is that we are at a very early stage in terms of scoping it. Decisions have not been taken about the scope that it should have and about an external reference group to take the work forward. There is a huge amount still to do in terms of deciding what should be in it. Certainly that would be the intention behind the National Service Frameworks. I think what has been the strength of the previous National Service Framework, which is certainly something that we would expect to apply in this area as well, is the fact that they are comprehensive including the potential for and prevention following a patient's journey through all of the different aspects of their experience, including involvement of acute healthcare and social services, as well as community care. Drawing all of those things together gives us the opportunity to address exactly the kinds of things that you are talking about. Obviously it is difficult for me at this stage to say exactly how they might be able to do that, that would certainly be the intention.

  97. It is fair to say that we have looked at mental health and were very impressed by the National Service Framework's impact there, the only slight problem was that it was very aspirational and sometimes it missed some of the practical difficulties that people face at a local level. That is the area I am concerned with on this particular point. There has been some fairly important reports in relation to the rehabilitation of people, for example Welsh Affairs Committee produced a report and the Warwick Study. What has actually happened since these reports, because I cannot see that there has been a great deal of follow-up from the Department? Certainly witnesses indicate that change has happened as a consequence of some of the points.
  (Yvette Cooper) The impact of the Welsh Affairs Committee Report on Services in England has been very limited indeed on some of the issues. I cannot answer for the way in which they have been picked up in Wales. I think that was not a central issue for English services. The Warwick study was published, circulated and the best practice from Warwick study was circulated to the NHS. I understand that some of most important issues around it, for example case managers for rehabilitation, are being picked up. Obviously what we are not aware of is quite how widely it has been implemented, and that is one of the things that the NSF needs to follow up. In the wake of the Warwick work there has been other work, which is starting to come into play. There was the Safe Neurosurgery 2000 Report and the Glasgow Report, which are now being looked at in detail by the joint working group that was set up in the Autumn between the Regional Specialised Services Commissioning groups of the NSS and the Society of British Neurological Surgeons. What that is looking at, is how the key messages from those two reports might be implemented, including the implications for service configuration and networks, and so on. I would envisage a lot of their work feeding into the NSF, but they have already begun working, so there may be things there that could be picked up in advance of the NSF framework. In addition to that there are the NICE guidelines for the assessment and management of acute head injury, recently commissioned and currently be scoped. I think I would accept that there is a huge amount to do, following the publication of the Warwick Report. In the end, because the Warwick Report does not provide all of the answers we need, there is a lot more policy work that still needs to be done before implementation can take place.

Dr Stoate

  98. I would like to pick up on the NICE guidelines, can I ask for some clarification, from the evidence we have received it is not explicit as to whether the NICE guidelines include rehabilitation or not, can you help us with that one?
  (Yvette Cooper) The answer is no if you are talking about long scale rehabilitation. The extent to which you are talking about the way in which rehabilitation needs to be started straightaway then there may be scope to look at it. The focus of the NICE clinical guidelines is the clinical assessment and management of head injury. The decision not to include rehabilitation was taken for two reasons. Firstly the evidence base is much stronger for the immediate clinical management of head injury than for longer term rehabilitation. Secondly, because rehabilitation must be tailored to the needs of each individual, it just may not lend itself to NICE clinical guidelines in the same way. Certainly the intention has been for the NICE guidelines to address immediate care, and for the National Service Framework to pick up the detailed work around rehabilitation.

  99. Moving on to the National Service Framework, which is something that you touched upon, I appreciate it is in its early stage, so you may not be able to give me specifics, the evidence that we have been given says, "We would expect it to cover rehabilitation", but it is very unclear about that. Can you be a bit more explicit about that?
  (Yvette Cooper) We have worded it in those terms because, until we have set up our external reference group and they have begun their discussions, it would be wrong to try and answer every question about what it might include and what it might not include. Our intention would be that it has to include rehabilitation as well. All of the previous National Service Frameworks have looked at everything from prevention, acute care rehabilitation, right through a patient's journey. The intention would be for rehabilitation to be included, with the proviso that we still have to agree the precise scope of the NSF. Nevertheless, the intention of ministers is that head injury rehabilitation should be included.

  100. I am very, very pleased to hear that, obviously that is a great concern of this Committee because rehabilitation is really what we are looking at the most. You mentioned the Royal College of Surgeons before, but of course surgeons do not deal with rehabilitation. This is an issue we are keen to pin down. You are prepared to say that you are expecting this to happen and you want to see it.
  (Yvette Cooper) Yes, I expect and want to see the rehabilitation of head injury in the NSF.

  101. Moving on about the NSF, it is already stated that it will not be ready until 2005. What will the Government do about rehabilitation between now and then, that is obviously a considerable way off, and is there anything you are doing between now and then to help rehabilitation services?
  (Yvette Cooper) It may be that some of the work that is commissioned as part of the NSF may lead to more rapid progress. There may be areas around research that may be important that will need to take place and may actually provide for things that could happen more quickly. There is also some guidance on rehabilitation and employment that was issued in 1999, joint guidance between the Department of Health, the Department for Education and Employment and the voluntary sector, which was about interagency partnerships around this rehabilitation and education and helping people back into work, all those kinds of areas as well. That guidance has also gone out. What we are now working on is a pilot on job retention and rehabilitation with the DfEE and the DSS. That work is also under way at the moment. I think that will provide us with some scope for progress in the short-term as well.
  (Dr Adam) In a slightly different context, the context of intermediate care, as you will know rehabilitation is a major component of that, with a view to helping people move through hospital and possibly preventing the need for long-term institutional care. Although it is not linked specifically to head injury, we have been very clear that intermediate care, although primarily focused on older people, will be there for each service who can benefit from it. In terms of taking forward the general rehabilitation agenda over the next two or three years there will be investment through intermedicate care, and I expect to see some progress. Obviously, the second point, this is very staff dependent, it is another of those areas where we are looking at the work force and capacity building. Just to make the link back to the NSH Plan, where there are proposals to increase the number of therapists between now and 2004, and we know that they play a key role in any rehabilitation programme. That is the background context while we do the more detailed work on neurological conditions and head injury in the NSF.

  102. What we have heard from our previous witnesses was that the services currently in rehabilitation are very patchy across the county. There are some examples of excellent practice and some examples of where little seems to have been, that is obviously of great concern to us. One of the witnesses said earlier, if the government raised the priority of that, and the government was pushing from the centre it might concentrate chief executives minds more in terms of providing those services. We also heard from Dr Turner-Stoke who felt that the evidence of rehabilitation was now extremely good, despite the Warwick Study that you mentioned. Given that the evidence is now getting much stronger and given that our experts tell us that more emphasis from Government would raise the profile, is there anything you think that the Government should be doing or could be doing to try and raise that profile?
  (Yvette Cooper) By setting out our choice of subjects for the NSF that is a sign that the Government are starting to raise the profile around these issues. You will be aware that the NSFs are major pieces of work in terms of policy development and implementation and there are also other major pieces of policy being implemented across the NHS. We have quite been quite careful to take each NSF one stage at a time and not to try and do NSF on absolutely every single subject under the sun, all at once, because we cannot cope in terms of developing the policy in the right way, but also the NHS will struggle to implement all of these changes, and quite substantial changes in other service development, all at the same time. By focusing on cancer, heart disease and mental health over the first few years those are very much prioritised in the minds of chief executives and the minds of the NHS across the board. The next stage of the NSF programme will focus on renal services, health services for children and on long-term neurological conditions. That is exactly what we are doing and we would expect increasing interest in the NHS across the board as the process of the NSF takes place and as the work is done. We will need to draw on what is happening right across the NHS and draw people into the process of development over the next few years. It will not simply be that we tell people at the end of the process in four years' time or five years' time what will happen, we will need to draw people into the process of development in the same way we did with the NHS Plan as we go along. That does provide us with the opportunity to raise the profile of rehabilitation across the board.

  103. That is very encouraging and it is very good news to hear that the government has plans to make a big difference. Can you outline what the current guidelines are for health authorities, because there is a very patchy take-up at the moment? What is currently being told to them?
  (Dr Adam) I think probably the best answer is the detailed guidance which has just gone out on intermediate care, which includes a section on rehabilitation. That is certainly the most recent statement we have made, and the most comprehensive. It is also, as you know, linked to investment. In the minds of your chief executives that is going to be quite influential. We are just in the process of looking at the proposals for service development for the coming financial year 2001/2002 and we are certainly seeing rehabilitation within intermediate care playing through.

John Austin

  104. Whilst I welcome the comments that Dr Adam made about intermediate care and welcome the emphasis that the Government puts on the expansion of that facility, by and large that has been seen as and area, predominantly, in terms of the care of elderly people, is it necessarily the right sort of focus or location for the young person who has acquired their brain injury at a young age in a road traffic accident?
  (Dr Adam) We have certainly been clear that we do see older people as the prime service users but we have also been very clear that, where the services are appropriate, they should be available to a wider group of people. I would not want to see a 25 year old being looked after among a group of very elderly, very frail people; that would not be appropriate. But the types of services that we will see developing may have something to offer younger people too. Obviously, it is important when we talk about head injury to be clear that we are not just talking about the generic rehabilitation services but we are also focusing on the more specialist neuro rehabilitation services, part of neuro science services. Thinking on these will really be developed through the NSF, and in the work that is now going on in the joint working group, looking at the early implementation of the two reports that the Minister mentioned earlier. What we are trying to do is knit together local service development over the next few years with the thinking that we will be taking forward in the NSF to look at how we can build better services for the particular group of people that we are talking about this morning.


  105. One of the points that was raised in the earlier session was not so much John's point about inappropriate placement in the care sector but inappropriate placement after tertiary provision, within say general wards or wards, as in one instance, full of older people where a younger person with this kind of problem is really inappropriately placed. Is that a concern you have about the practicalities at the present time?
  (Dr Adam) It is a concern that I hear often when I talk to people about services for people with brain injury. For me it would be one of the issues that I really want the NSF to focus on. Without jumping ahead I am sure we will want a group of people looking specifically at services for people with brain injury. Within that I think we want to look very carefully at what the present problems are, what the service gaps are, and what we need to do to begin to address those. I think we are all conscious that this is a service that will benefit from a thorough look across prevention through acute management to rehabilitation and care, and I do think the NSF is going to give us the opportunity to do that.

  106. The Minister mentioned the concept of the case manager and the idea of a co-ordinater from whatever professional background has come over loud and clear this morning as a clear area of need. Where that person has existed in a positive way it has been extremely helpful to families and to patients. Looking at the current structure where do you view the most appropriate professional role to undertake that process? We have heard of various people doing the job but obviously in many areas nobody is doing the job and it is meaning that patients and their families have not got that key guidance and support at a very difficult time.
  (Miss Sanderson) There is guidance out there insofar as the Warwick Report summary is out there which concentrates entirely on good practice and the findings of the Warwick Report. The Warwick Report was a best seller within the NHS and Warwick University had a lot of demand for the full reports so that people could read it to learn the lessons and apply them to services.
  (Dr Adam) Certainly the learning from a number of areas where case management has been proposed has shown that it is an approach that works well for different groups of people with complex and continuing needs. To some extent it is more about personal attributes and skills than any particular professional background. Obviously therapy staff, nursing staff, social services staff, would all be suitable in theory, but we would be looking for the right kind of person who wanted to do this work as well as making sure that they had some core clinical and practice skills that they would need to do assessments, plan care and monitor progress. We would very much support that approach, and I think the pro-active management of rehabilitation and also handling transitions, for me, comes very clearly out of the Warwick Report. People are vulnerable when they move from one team to another or from one setting to another. We need to look at better ways of handling case management from one team to another team, or from one setting to another setting.
  (Miss Sanderson) Warwick did not identify a specific staff group as being the perfect case manager. They saw different people in the role who came from different professional backgrounds. It was an interest in patients and patients' families and patient rehabilitation that made a successful case manager rather than their background.

  107. What interested me in particular was the role of the hospital social worker, which is a key element here because clearly they are employed by the local authority but working within a hospital situation. If a person is leaving the hospital sector to live in the community they would be ideally placed to ensure that resources were brought in to support that person in their own home and also to address this problem of community care plans specifically looking at the particular needs of this group of people.
  (Miss Sanderson) We are looking really at a combination of two factors here. People need rehabilitation to the best state of functioning they possibly can, but once someone has been rehabilitated and goes back home they then need the support within the home. This support should look to give a good quality of life, to try to minimise some of the deficits people suffer after brain injury, and to relieve some of the tensions that are within the home. A brain-injured person may have suffered personalty change and once out of hospital families may get what appears to be a stranger coming home. This does not seem to be the person you were married to before or your son or your daughter—and that does create a lot of problems which do need support.

  108. The message we are getting is, yes, the acute phase is handled well, the tertiary side is handled well, but the response and what happens after that is where people are saying—
  (Miss Sanderson) And the link between the two.

  Chairman:—We need to do better.

Mr Burns

  109. Notwithstanding the fact that the Warwick Report was a best seller in the NHS, how confident are you that it is not a flawed document?
  (Miss Sanderson) It was peer reviewed to make sure it was methodologically sound. It did look at a number of new areas as far as research into rehabilitation was concerned. We have no evidence to show that it is a flawed document. What it did not do was find the evidence to support the primary purpose it was set up to look at, which was the association between the amount of input of rehabilitation a patient receives and the final outcomes.

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