Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 20 - 39)



Mr Burns

  20. I want to move on to the question of your monitoring of the length of delayed discharges. Could you just confirm to me that I am understanding some figures you have sent to us in advance? Am I right in saying that if you round it up to the nearest full point, 40 out or every 100 people involved in delayed discharges are actually kept in a hospital bed for over 28 days?
  (Mr Gilroy) I believe that is correct. I did a similar sum and came to a similar conclusion.

  21. I must say I do find that quite staggering because 28 days is by any definition a long period of time, given that whatever anyone says it is infinitely more expensive to keep someone in a hospital bed financially when they should not be there than it is to place them in residential care and I suspect also in domiciliary care. How can it be 40 per cent, actually the largest percentage group? Just to remind you in rounded figures 23 out of every 100 are fewer than 8 days, 18 out of every 100 are 8 to 14 days and 20 out of every 100 are 14 to 28 days. You have 40 people out of 100 languishing in a hospital bed when they should not be there, at great expense and depriving the Health Service of valuable resources to spend on other forms of care. How can it happen?
  (Mr Gilroy) That point is very well made. It is taken in the Department of Health. May I say two things by way of response? The first goes back to the boring definition which I read out. That definition allows for no time whatsoever to conduct a full assessment of what a patient's care needs are when they leave hospital. It must be one of the very, very few performance targets which gives no time whatsoever to due process once the hospital based team has decided the patient is fit for discharge. What has to happen then is that the patient's post-hospital needs need to be looked at and that is what happens. In our judgement that virtually explains the majority of people who are delayed for less than eight days. Delay is an emotive word. It does not have the emotive context in relation to the way the Department's definition is applied at that end of it.

  22. I must say, with respect, you are beginning to sound like the Prime Minister at Prime Minister's Question Time. If that is the case, from the way you are speaking you are giving the body language that you think this definition is either wrong or outdated or not a realistic definition because it does not take into account this period for assessing. Is that a fair assessment?
  (Mr Gilroy) I was merely interpreting the effect of the definition on the analysis one needs to do on the numbers of people delayed and making the point that up to eight days that time is actually being occupied, or should be where local council social services and health authorities are doing their job properly, conducting very speedy assessments.

  23. If that is the case, then the logic of your argument, correct me if I am wrong, is that you think that the definition is not ideal because it does not take into account this time for these assessments and in fact you should knock eight days off.
  (Mr Gilroy) From the perspective of the National Health Service the definition is dead right because it actually counts from the point at which the patient no longer needs to be in hospital. It is absolutely dead right. The only point I am making is that it does not allow, before this slightly emotive connotation which comes with the word "delay" kicks in, for any time to conduct the post-hospital discharge assessment. I am beginning to repeat myself.

  24. I am glad you are because it is beginning to become a little clearer to me. I must say I am getting rather confused by your interpretation of definitions. You did say, did you not, that the definition was absolutely right because it is a definition of the number of days when someone is in hospital when they should be elsewhere.
  (Mr Gilroy) Yes, from the perspective of the NHS; absolutely right.

  25. I shall get back to my original question then because we now understand that. Is it not extraordinary and why is it that 40 out of every 100 patients are staying in a hospital bed under your definition, if I have understood it correctly, for more than 28 days when they should not be in a hospital bed at all because there is no clinical reason why they should be there?
  (Mr Gilroy) That brings the other point in. That point is taken. We are seeking to prioritise the use of the additional resources, the extra £300 million—£100 million this year £200 million next—to target at that end of the delay and we have management information which suggests that it is working, that the biggest number of delays being taken out of the system is at the heavy end. That is absolutely right. This policy is not just driven by a policy of moving people out of hospital, but making sure that people get the right care in the right place at the right time and are not languishing in a hospital bed. We are specifically trying to target the resources at the end you are concerned about.
  (Ms Platt) I just wanted to say something not concentrating on the group you are concentrating on, because I know why you are concentrating on them. If we look at the reasons why people are delayed in hospital at any one time, regardless of whether they are 28 days or eight days, when we looked at our September monitoring figures and before we put the additional money into the system, 22 per cent of people were waiting for their assessment to be completed and that could be for a number of reasons, not necessarily social services reasons, it could be specialist reasons, it could be a whole range of reasons. The question to be asked is whether people have to wait in their hospital beds for that assessment to take place. 21 per cent of people at that time were waiting for social services funding. We know that since we have had the special grant we are making inroads into those reasons. 11 per cent of people are awaiting further care in the NHS, transfer to somewhere else. 20 per cent of people are waiting for a care home placement. 6 per cent of people are waiting for a domiciliary care package and 8 per cent of people are waiting because they were exercising the direction of choice which allows them to choose which home they will move to. The question you have to ask again is whether an acute hospital bed is an appropriate place to wait while you make that decision. We would say that this is where we see the development of intermediate care slow stream type facilities playing a part so that the assessment can take place properly and in a different environment. People might wait in a different environment while they are waiting for different solutions so that we can free up some of the beds which currently people are in wrongly and probably doing their health no good while sitting there.

  26. You have both said in your answers that you have evidence that the extra money, the £300 million over two years, which has been made available is beginning to make an impact and it has been targeted at the top end of the problem. Do you have any figures yet to back that up or is it anecdotal evidence?
  (Ms Platt) It is not anecdotal. What we have is that councils are monitoring their spend very carefully and we have access to their monitoring figures. We shall need to wait for the quarterly monitoring return following on from September to know what that real inroad is.

  27. You will be aware in another field that local authorities, when they have problem cases they have a statutory duty to house, if they do not have housing stock, they possibly put them into bed and breakfast accommodation. Right?
  (Ms Platt) Yes.

  28. Do you think it would be appropriate to put patients who are bed blocking, for want of a better phrase, into bed and breakfast to free up NHS beds?
  (Ms Platt) I suspect if people were fit enough to cope in bed and breakfast then we could find a solution based in their own home to support them, that they would need more care than you would get in a normal bed and breakfast place. The whole reason they are waiting is because they do need more support in their own home. If they do not need any more support or they can cope in a reasonably independent environment, which bed and breakfast accommodation is, then they should be at home.

  29. Basically it is not an ideal alternative, not a panacea.
  (Ms Platt) No, not without other facilities put in place.

  30. Given your role as Social Services Chief Inspector, would you care to comment on what I believe is happening in Shropshire, where this is happening?
  (Ms Platt) I do not think it is happening in Shropshire. Shropshire social services have had an interesting offer made to them that farmers who are looking to diversify their business at this difficult time might offer accommodation to people who are in hospital in beds inappropriately. Shropshire social services are of course looking at the option which is being put forward but are looking at it from the point of view of appropriate care rather than just getting people into any environment.

  31. Can you categorically tell us as of now that Shropshire is not doing this?
  (Ms Platt) I can tell you that Shropshire have had this offer made to them and I am not aware that they had made any such placement. If I were aware, I should want to know a lot more about it.

  32. When did you become aware that Shropshire—
  (Ms Platt) Two days ago.

  33. So fairly updated.
  (Ms Platt) I hope so, but it sounds as though you may know more. If you do, please tell me.

  Mr Burns: Members of Parliament tend to be reliant on other people for information and one has to believe what one is told. I am very grateful.


  34. May I just ask about the issue of discharge planning? The delayed discharge question is interesting. We have an agreement as to when a person is fit for discharge. What I want to know is when the discharge agreements begin. If I am going into hospital to have a double amputation of my legs, surely somebody will realise that when I come out I shall not be able to dash upstairs to the loo and to the bedroom. When does the planning actually start? The definition you have given us appears to imply that is only when there is this agreement. Does it start before then and if so when?
  (Mr Humphries) In every part of the country there should be an agreement between the Health Service and social services about what procedures should be followed about discharge. Good practice means that in many cases the actual process of assessment should begin when the person is actually admitted because it will be clear that, if for example an elderly person is facing major surgery, they will not be able to be discharged without some sort of care or support. These days we encourage colleagues to view discharge not as an event, but as a process which does require careful planning and the earlier that starts in the person's stay in hospital, the better it will be.

  35. Presumably it could also be before they go into hospital in certain circumstances.
  (Mr Humphries) Indeed; absolutely. That is even better.

Dr Naysmith

  36. Going back to definitions, what is your definition of this multi-disciplinary team which has to be called in to decide whether people are fit?
  (Mr Humphries) It will depend on the particular needs of that individual, but a typical multi-disciplinary assessment would involve a social worker, it would involve nursing staff on the ward who know the patient, it might well involve a physiotherapist or occupational therapist and it could involve other clinical specialisms as well.

  37. How difficult is it to set up an individual assessment of that type? Can it take time to do?
  (Mr Humphries) It can take time but where there is a proper multi-disciplinary team approach in place, it all should begin to happen very quickly. It will be helped by the introduction of the new single assessment process because one of the difficulties that does get in the way sometimes is where different professionals need to do their own separate assessments. All that will be brought together under the new single assessment process and that should make things a lot easier and make things work.

  38. I was not quite clear when you said that a single consultant could be part of this process and then the multi-disciplinary team. Can a single consultant decide on her or his own that this can happen? When do you call in the multi-disciplinary team?
  (Professor Philp) The key to whole systems working seems to be in the detail of how care is delivered that brings a multi-disciplinary response to the needs of the older person. The National Service Framework for Older People sets out a number of service models which we know are good practice and are conducted in parts of the country to level up so that all services have that standard of care. Within the general hospital standard it specifies the components of the specialist multi-disciplinary team for older people by professional group and that is a medical consultant in geriatric medicine, a nurse, an occupational therapist, physiotherapist, a dietician and a social worker. The leadership needs to come from people with specialist knowledge, but good whole systems working does not mean that every member of the team in every case has to do his bit of the assessment because teams need to work in the way that they understand each other's roles and responsibilities and for a particular patient it may be one or other member.

  39. Are you saying that they do not need to meet every time?
  (Professor Philp) That is a requirement in the National Service Framework for Older People. The specialist team needs to meet and needs to establish the standards of multi-disciplinary assessment throughout the hospital including the requirement to begin discharge planning within the hospital early on in the person's care. A point which is important for the Committee to pick up on that my colleague Mr Humphries was mentioning is that the single assessment process, which we are introducing to promote whole systems working, means that information has to be passed on within the system so that prior knowledge of an older person's needs defined by the primary health and social care team should be available to the staff who are assessing the older person on their admission to hospital. That prior knowledge would include information about their housing status, their levels of mental functioning and any physical impairments they may have which would threaten their independent living.

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