Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 40 - 59)



  40. How often does it happen that a multi-disciplinary team meets and then decides that the individual is not ready to leave hospital? Does that happen very often?
  (Professor Philp) I meet with my multi-disciplinary team every week and many of the people we are discussing have extremely complex problems on average taking six or seven drugs each of which reflects a serious problem with complex problems in their home environment, who is going to look after the dog, the state of repair of the home and so on. The role of the team is to think creatively about the problems that person has but recognising we want to ensure that older people do not have to stay in hospital for longer than they should but their needs are not going to be met by a simple move to long-term nursing-home care. Most older people want to resettle back home. We are developing this range of intermediate care services which bridges the gap. People going into intermediate care services from hospital have to have regular multi-disciplinary assessments of their needs, so for these people who have complex problems throughout their passage through the system, both within hospital and following discharge, until a suitable long-term solution is found to meet their needs and their condition has stabilised, until that has taken place, there needs to be regular multi-disciplinary specialist review of the needs.

  41. You are not answering my question. I understand what you are saying. You are telling me that it is complicated and that people have prior knowledge, they get together, not just to discuss discharge but to discuss other things as well.
  (Professor Philp) It is standard good practice. The short answer is yes, it does happen.

  42. How frequently?
  (Professor Philp) The frequency in hospital for an old person with complex problems is usually on a weekly basis.

  43. So if someone has their situation assessed one week, then it is seven days before it can be assessed again.
  (Professor Philp) No, because the care management of the individual is ongoing. The team needs to co-ordinate their relative contributions to the person's care and ideally will be based on the older person and the family's views and priorities about what they need and want as well as the professional perspective. That is a stock-take meeting. In between times there will be people who are taking the lead in the person's care and carrying through the management plan and revising that in the light of changing circumstances.

  44. You say it is good practice and I am sure you are very much associated with good practice but I bet there are lots of places where practice is not quite as good as where you operate.
  (Professor Philp) We know that, because we have an ageing population and older people are now the majority users of hospital services, two thirds of hospital beds are occupied by older people with complex problems, it is not enough simply to have a specialist multi-disciplinary service for older people in hospital doing good practice. Every hospital in the country will have a specialist multi-disciplinary team, every general hospital doing good work. The key challenge is to spread the good work so that all practitioners in the hospital setting have the skills and competencies to manage people well which includes the team meetings. The answer to your question is that not every general ward has a weekly multi-disciplinary meeting of the relevant specialists and they should. We are moving towards that as part of the implementation plan for the National Service Framework for Older People general hospital standard, which is standard 4.

  Dr Taylor: My immediate concern has been answered by the discussion because Mr Gilroy's original answer to Mr Burns rather implied that discharge planning did not start until the multi-agency team got involved when it should start the moment the patient goes through the door, which I think we have been reassured about. May I just come back to Mr Burns' point about Shropshire? It is not only Shropshire. In Worcestershire I have had many letters from extraordinarily angry farmers who think they are going to be expected to look after intermediate care patients in their bed and breakfast places.

Julia Drown

  45. You are saying that if people in the interim, before the meeting comes up, could be discharged, problems could be resolved. But are you telling us that there will be some issues where you do need the multi-disciplinary approach and if that meeting was on Fridays and an issue came up on Monday they would be waiting for most of the week before it could be resolved?
  (Professor Philp) It is certainly bad practice if the team meetings get in the way of the efficiency of using the hospital bed and an older person moving on. It is good practice to have regular reviews and to anticipate problems. What would happen between a team meeting, if it was thought that an older person could go home within a couple of days of admission to hospital and if they had complex problems but going home meant going to an intermediate care service at home, that would be perfectly acceptable, provided there was further ongoing multi-disciplinary review. We are looking now not as a simple, "This is your hospital package and this is your community package". We are trying to integrate things by having the single assessment process as a way of integrating assessments, recognising that people's needs are transparent and their care is transferred from one place to another. The principle is that you do get ongoing multi-disciplinary review until the person reaches the next stage in their care needs.

  46. You said what you want to do is spread that best practice nationally. How long does it take to spread this practice?
  (Professor Philp) We have set quite challenging milestones in the National Service Framework for Older People. We are looking up to 2005-06 to implement best practice across all the domains in the National Service Framework and we have particular milestones relating to the general hospital standard about establishing the key interfaces, ensuring that effective discharge planning procedures are in place from the beginning of a hospital admission for old people. Someone can give me the figures as to when these particular milestones are, but they are set out year on year up until 2005-06.

  47. Can anybody else who is working on this say when we might expect best practice to be across the country?
  (Ms Platt) The Health and Social Care Change Agent Team which Richard is leading at the minute is here to start the promotion of best practice around planning, working together, joint working together and getting the system better together. It is a team which has a core team working at the centre with Richard and a lot of people who are practitioners in the service, who know what they are talking about, who are best practitioners who can be called in to help others. We have funded Richard's team until the end of the year in the first instance and then we shall review how far we have got. Some of this is big cultural change around attitudes and all the things you have been talking about, about the hospital system getting in the way. It can be not just when the multi-disciplinary team meets, but when the pharmacy is open, when the ambulance gets arranged. All sorts of systems operate in institutions which people get used to and part of the role of the Change Agent Team is to get in there where there are difficulties and to try to help people unblock their own systems so they are not holding up the patient from getting out.

  48. But we may all have to be delayed a long time before we get the answers.
  (Ms Platt) I hope not, because some of us are getting closer to retirement than others and would quite like it to be sorted out.

  49. You did outline and in the evidence are some of the main reasons for delays. Could you say a bit more from your perspective about where the main frustrations are, where you think the quick gains could be and where some of the more longer-term gains are?
  (Ms Platt) The issues which different parts of the country face are different. In the South East the problems which are faced by councils in the South East are the care home capacity and the level of fees. Much of what those councils will be doing is reviewing their fee structures and their fee policies. In other parts of the country the issue is a lack of capacity of staff because many of the care workers we are talking about in home care services or care assistants who work in these facilities are often on very low wages, so are attracted into other parts of the economy. That plays itself through again into a local authority commissioning strategy and how much the fees are. In other parts of the country it is because the range of services we are talking about in intermediate care is inadequately developed so people may be going too quickly into residential care when with the proper rehabilitation facility they may have gone home with the very minimal type of care package. We have identified a variety of reasons in different parts of the country, which is why some of this is a very local issue and why we want to go into very local systems to work out what it is we need to unblock.

  50. You said in your evidence that one link identified by the national beds inquiry was high levels of acute bed provision with more problems and also that where there are inappropriate patterns of service for social services these are often the results of the historic availability of surplus care home capacity at low cost. Both of those seem to suggest that more beds actually could result in more problems.
  (Ms Platt) It is certainly the case that where there are beds people are very anxious to fill them. That might not be the best in the long term and it is easy to do without a proper assessment. We do know, in talking to older people, that they do want to go home and to be supported at home while it is safe for them to be so. Because we have not had the investment in intermediate care and rehabilitation, in the past it has been quicker and easier, if the facility has existed, to place people in an environment where, when they have been there for a bit and their house has been sold, it is very difficult to move out even if their level of functioning has improved. We come back to where I started really that you can tackle in some very crude ways the issues of delayed transfers of care but actually this is about a proper service development for older people, so they are in the right place, getting the right care at the right time and that should be our longer term aim. We have some short-term strategies which can be driven and hit all those targets, but if we want to get some sustainability in the system we have to develop a new pattern of service for older people which gives them more choice and independence and a variety of care where they want to be.

  51. Does that mean, if there is a potential problem with having more beds because they just get filled, that rather than what most of us did, which was to welcome the 7,000 additional NHS beds, we should instead be rather concerned about that?
  (Ms Platt) I am sure that NHS beds are always valuable because they can always be used for a variety of circumstances. What we would want to emphasise is that it is not just beds. You can have beds in people's own homes. It is actually the best package of services which enables people to be where they want to be.

  52. Trent is the region which is doing best on the figures at 3.3 per cent. Do you have in your mind that Trent still has some way to go or is there some nominal percentage that you would take, given the points Mr Gilroy made, as acceptable, as what one would expect to have best practice?
  (Mr Gilroy) The judgement we are making at the moment is that there is a figure below which you cannot get it while the definition is as it is. It is about 2.5 per cent rather than the 6 per cent it is running at at the moment. Trent, like everywhere else, has health and social care communities in it which are in trouble and the worst of the ones on that list, the South East, has health and social care communities which are doing pretty well. It is very patchy as an issue. We think Trent got to Change Agents first probably. They have been running a collaborative across the health and social care system designed to get the top managers into showing common leadership rather than parachuting in where there are problems. We do think they probably got somewhere rather faster than the rest and part of the background to the Change Agents initiative is running that sort of approach out more generally.

  53. Mr Burns was talking about 40 out of every 100 patients being there for over 28 days. Is the issue not 40 out of every 100 but 40 bed days out of every 100 bed days and in fact it is just a few people who are spending a very, very long time in NHS acute beds? Is that right?
  (Mr Gilroy) Yes, that is right.

Mr Burns

  54. Can we just check that is right? I thought it was not.
  (Mr Gilroy) It is older people and it is based on the proportion of the number of people who have their discharge delayed by this length. My immediate answer was wrong.

  55. Yes, it is the number of people, not the number of beds or the proportion of beds.
  (Ms Platt) Yes, for the over-75s we are talking about numbers of people. 12 per cent of over-75s.

Julia Drown

  56. No, no, no, we are talking about over 28 days. It is not 40 out of 100 people. It is 40 per cent of the bed days are taken by a few people.
  (Mr Humphries) No, it is 40 per cent of people who are over 75 whose discharges were delayed.

  57. Right. So percentage of delays is not percentage of overall delays it is the percentage of the people. I wanted to clarify that.
  (Mr Humphries) No, it is the percentage of the people.

Jim Dowd

  58. You have given us six specific grounds and one "Other reasons" as the principal causes of these delays. Is there any correlation between different reasons here and the different segments shown in the delays? For example, would that be uniform across all those four bands or are there more particular reasons resulting in longer delays or particular reasons which can be more quickly resolved resulting in shorter delays?
  (Ms Platt) The things which are within our control quickly are speeding up the assessment and introducing the good practice reasons that Professor Philp was talking about. Those things are quicker to get into place. Anything which relies on new capital development is clearly longer to get into place, which is why looking at how resources can be differently used is an important issue here and one of the things we are encouraging people to do on the ground. A lot of local authorities, for example, have residential care or sheltered housing accommodation, which are not used for those purposes, but could be used for a different model of service if we could staff them up and use those services differently. We are encouraging people to look very innovatively at what they can develop. Clearly anything which requires capital or people to be recruited to expand capacity is going to take longer than speeding up an assessment.

  59. I am just extrapolating at the moment. Although home adaptations and equipment only account for 6.7 per cent overall it could well be a much higher figure of that 39.5 per cent at that end.
  (Ms Platt) Yes.

  Dr Taylor

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