Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 60 - 79)



  60. May I just clarify national occupancy rates? In paragraph 3 you say that a recent survey shows that it is 91 per cent. Presumably that is of care home beds. Is that ideal, what you should be aiming at? We know in the acute sector it has to be lower to accommodate emergencies. Is there a figure you should be aiming at?
  (Ms Platt) In residential and nursing home care?

  61. Yes.
  (Ms Platt) We would not set a figure for that and we have not set a figure for that. Clearly if you have a number of purchasers in an economy and one of the issues when you are looking at a social care economy is that there are many people buying services for themselves, there has to be some level of over-supply but we have not really done that calculation as to what that level of over-supply is.

Mr Burns

  62. Looking at your submission to the Committee, paragraph 2, you have this box about the rates of delayed discharges for patients over 75 from September 1997 to September 2001. Those are just figures for delayed discharges of the over-75s but of course it is not only people over 75 who suffer delayed discharges. I was wondering whether you have the total figure for delayed discharges for all age groups and whether those figures, if you have them, reflect the movement which is in this chart.
  (Ms Platt) Six per cent of both.

Dr Naysmith

  63. In the figures for the over-75s the evidence is claiming that there has been a steady but slow reduction in the rate of delayed discharges and you are saying that the position is slightly above the target of 11 per cent at the moment. Yet if you look at the actual figures for 1998-99, 1999-2000, 2000-01, they run 13.2 per cent, 11.4 per cent and 11.3 per cent, not a startling difference. There are people who will say that there may have been factors operating which are really outside your control. The main one people cite is that it has been a very mild winter this year so far and last year and that that would be sufficient to explain your figures. What do you say to cynics like that?
  (Ms Platt) The measurement of the figures is across September to September, so slightly before winter.

  64. That does include a winter.
  (Ms Platt) Indeed that does include a winter but it has not been that mild in some places. We should not just think of this as a seasonal issue. What we know from health and social care services out there is that we cannot distinguish different seasonal patterns in some of this. This is a capacity issue across the year and we need to approach it through capacity planning across the year. The profile of activity might be different, but just because the system comes under strain in the winter does not mean that there is a satisfactory capacity there the rest of the time, it just means we are lucky. We need to expand the capacity across the system throughout the year.

  65. I fully accept that and I back you up on that. If you were claiming that it was because of things you had done in the last couple of years, then it may not be true.
  (Ms Platt) There has certainly been a great focus on this in the last couple of years and people have worked very hard and with all the difficulties health and social care have been working very hard together. We have reached the stage where we actually have to do some real service development to make the step change and to make this sustainable so that the system is not as fragile as it is at the minute.

  66. That is a good point at which to bring in the National Plan. This talks about the elimination of delayed discharges. We have touched on it already. What is the target rate for reductions in delayed discharges and over what timescale do you expect to see it eliminated?
  (Ms Edwards) You are quite right that the plan actually talks about the elimination of delayed discharges. In reality, for some of the reasons you have heard previously, zero may not be achievable and 2.5 per cent is our thinking at the moment in terms of what could actually be delivered. In the spending review process we are going through at the moment, we are aiming to get there by the 2005 period. We are seeing whether we can accelerate that and one of the reasons for doing that is better care for individual patients, but it is also very important because it will enable us to deliver the other NHS Plan targets. What we are doing is a combined spending review process which says that by doing that, that is by reducing the delayed discharges, this will free up X number of elective beds which will help us to deliver our other access targets. We are doing that work at the moment basing on a 2.5 per cent but we are modelling various scenarios ranging from nought right up to where we are now and working that through.

  67. A fairly stringent target from 11 per cent down to 2.5 per cent.
  (Ms Edwards) Sorry, it is the 6 per cent overall; we are working on the overall.

Dr Taylor

  68. Can you describe the mechanisms you are getting in place to prevent inappropriate discharges too early? There is a very good measure of that and that is re-admission rates of the elderly. Do you have any figures on re-admission rates for the elderly? Do they tie up with the other figures? That is something we do not have in your evidence.
  (Ms Platt) We can give you some of that evidence from the social services performance assessment framework, where there is a performance target for re-admissions which social services met and did manage to reduce re-admissions for older people in the last performance target. We can send that information to you.

  69. Does it tie up with some of these areas which are performing better than others for various reasons?
  (Ms Platt) I should have to go and look at the figures.

  Dr Taylor: I should be very interested to know that.

Siobhain McDonagh

  70. You suggest in your evidence that there is a perverse incentive for medical teams not to identify dementia as this may make placement harder to achieve. Is this a hypothetical problem? If you do have evidence that dementia is being deliberately concealed, is it not a major cause for concern?
  (Professor Philp) I do not really think there is perversity at work here but there is ignorance. What we observe in the hospital setting is that quite a large number of older people develop an acute confusion in hospital and many of these have either a borderline level of cognitive function or they are frankly demented. It is the fact that so many people care for older people in the hospital setting who do not have the specific competences and training to help them to identify and distinguish between confusion and dementia and other causes of apparent confusion that there is a lot of ignorance in terms of identifying people who have dementia. We have made it a top priority for this year's work of the National Care Group Workforce Advisory Team for Older People looking at workforce development to look at developing the competencies of all staff in NHS and social care to recognise and manage people with dementia properly. It is certainly not a good thing to overlook dementia as dementia is a principal cause of delayed discharge because of the complexity that having dementia plus a physical illness produces in terms of developing a good discharge plan. It is ignorance that we do not have the competences shared widely enough amongst the whole NHS and social care workforce at present and it is something we have to address.

  71. Your evidence is saying that there is a reluctance to identify dementia because care homes will not take people on.
  (Professor Philp) The latest figures suggest that about 70 per cent of people in nursing homes, not EMI homes but nursing homes, have a level of cognitive impairment that affects their mental function. There is a sub-set of that group which has challenging behavioural problems, who declare themselves. It is the sub-set with challenging behavioural problems which tends to need the specialist care. There is an issue about how you label care home and care delivery in long-term care. What we are trying to get over in the way we are developing services for older people and developing the training of all staff is that it is everybody's business to be able to manage people with a given level of cognitive impairment, given the high prevalence of the problem of cognitive impairment, particularly in two settings, the acute hospital setting and in nursing and care homes.

  72. I am the trustee of a small private charity which houses elderly people. My experience at St Helier is certainly that geriatricians there seem to think it in their interests to discharge people who are quite confused. When they present in the ward, they are warm, clothed, well looked after, properly fed, but that soon falls apart when they go home and they just do not have the levels of support. Then the landlord who does not have the ability to give that support is completely left, knowing what is going to happen because it happens time and time again. Often it seems that the teams or the geriatricians do not learn from past experience.
  (Professor Philp) The most challenging time for an older person with cognitive impairment is when they move environments. We have to look at care planning. This comes back down to good discharge planning, does it not, recognising the problems and anticipating the problems? People with dementia are a particular group of people who are best staying in their own familiar environment with familiar faces. One of the things we are finding as we are developing intermediate care services, which includes services which help prevent hospital admission for appropriate people and help support early discharge, is that the people who might benefit most from these services, that is people with dementia and a physical problem, an acute problem, are often people who get excluded from these services because they are the most challenging to look after. We are taking a number of steps to make sure that as we develop intermediate care services and other services, we concentrate on managing the most challenging, the most frail and the most vulnerable older people within the services where we are making investment and developing these services. The perversity here is that it is easy to cherry pick, it is easy to pick the people who have the simple problem without the dementia. The challenge for our whole health and social care system, including the extra care housing sector, is to manage the people with the greatest needs in the most homely environment that we can. That is the big challenge that the National Service Framework is trying to address.

  73. How do you strike the balance between an individual's desire to return home and their inability to do so? The excuse people fall back on is that they want to go home when objectively, just as a lay person without experience, your common sense would suggest that this is not a situation that is going to be able to sustain itself.
  (Professor Philp) Indeed that is the reality of the challenge people are facing in thousands of individual cases every day. The approach is to manage care well, which is not to think of things as this either/or, either you get acute care, or you get long-term care, either you stay at home or you need long-term care, but to think for each individual what the opportunities are for preventing disease and promoting health. For example flu vaccination is probably one of the reasons why we are getting through winter more easily now. Secondly, what diagnoses can be made and treatments given. Thirdly, how we can maximise the rehabilitation and the independent functioning of the older person. Fourthly, how to adapt a home to make it more suitable for somebody who has dementia or physical illness. Next is how you support the family in their role and then what services are needed at home. It is only at the end of that chain that you should really be asking the question: should this person be cared for somewhere else? What we are always fighting against in a system which is under pressure, under pressure to discharge, under pressure to get quick solutions, is to be systematic and go through and address all the needs the older person has so that getting it right at the end of the day is actually the most efficient way for the whole system to function, but particularly to meet the needs of older people to maximise their independence and their quality of life.

  74. On the ground it is very, very different.
  (Professor Philp) On the ground it is hard, there is no doubt.

  75. The Committee is aware from earlier inquiries into mental illness and the care and rehabilitation of head injured patients, as well as from evidence now received from the Old Age Psychiatry Faculty of the Royal College of Psychiatrists, that delays in transfer out from inappropriate acute hospitals are common and severe. Most of the action seems to relate to older people. What action is in hand to help with the delayed transfers where a clinical speciality, say mental illness, is involved?
  (Professor Philp) The Older People's Directorate is working very closely with the mental health policy group and there is a National Service Framework for mental health care for working adults and there are several measures in that National Service Framework which address the needs of the client group you refer to in your question. The key issue for me and our team is how we work closely together with the mental health team and make sure that implementation of the mental health National Service Framework and implementation of the older people's National Service Framework ensures that nobody who has mental illness falls through the gap between these two stools. I met with Lewis Appleby, who is my equivalent National Clinical Director for Mental Health just today before coming here to discuss that issue in relation to the development of dementia services for younger as well as older adults. I do not have chapter and verse on everything that is in the mental health National Service Framework, but I know that there are several important parts of that programme. Perhaps I could pick out one particularly in that area which is of equal concern to us and to them which is about partnership with unpaid carers, often family members. The key to sustaining the person with a mental health problem, of whatever nature, or an older person with a mental health problem such as dementia, is to ensure that support is given to the family carer to allow them to continue in their care-giving role.

Andy Burnham

  76. Dr Naysmith was asking earlier about things out of your control affecting delayed discharges. One example is social services who are not under your control.
  (Ms Platt) I know what you mean: I do not manage them.

  77. You do not set policy for social service departments, do you? I get the feeling that policy varies quite widely from one social services department to another across the country. Is that true and does it have an impact on delayed discharges?
  (Ms Platt) The National Service Framework we have been spending quite a bit of time talking about applies to both health and social care, so social care will also have to apply the standards which are there for the NHS in all departments. We are currently undertaking a major inspection of services for older people in all local authorities. We are doing it in a number of tranches. What we are seeing is much better working together across health and social care, much more thought about care planning, some severe constraints because of resources. That is not to say that 150 local authorities cannot do it in different ways because they have different arrangements. What we would emphasise is that as long as the way they do it respects all the values which we want to see in services for older people, it is actually the outcome of independence and being sustained in your own home or the right environment which is what we are looking for. It is the outcome really.

  78. One of the things I was getting at was for instance charging policy. Some social services departments will charge for home support and some will not. You could imagine a situation where an older person would balk at that and say that they did not want to pay that. Does that worry the Department?
  (Ms Platt) The Department has consulted upon guidance on fairer charging policies across local government to encourage a more consistent approach to people's income and assets and to the way in which those policies are set.

  79. There is a very mixed picture is there not?
  (Ms Platt) There is a very mixed picture and there is still a small number of authorities who do not charge because it is within a local authority's discretion as to whether it charges or not.

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