Examination of Witnesses (Questions 60
- 79)
WEDNESDAY 13 FEBRUARY 2002
MS DENISE
PLATT, CBE, MR
DAVID GILROY,
MR RICHARD
HUMPHRIES, MS
MARGARET EDWARDS
AND PROFESSOR
IAN PHILP
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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