Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 186 - 199)




  186. Can I welcome our witnesses to this session of the Committee. Can I ask you each briefly to introduce yourselves to the Committee, starting with you, Mrs Robinson?

  (Mrs Robinson) I am Janice Robinson. I am the Director of Health and Social Care for the Kings Fund.
  (Ms Whitworth) My name is Diana Whitworth. I am Chief Executive of Carers UK.
  (Ms Harding) I am Tessa Harding. I am Head of Policy at Help the Aged, but I am here as Chair of the SPAIN group which is a coalition of voluntary organisations.
  (Ms Herklots) I am Helena Herklots, Head of Policy at Age Concern England.

  187. Can I ask you to say a bit about SPAIN, how it came into being and the background to it?
  (Ms Harding) It stands for Social Policy Ageing Information Network. It is a coalition of 30-plus voluntary organisations of and for older people, focussing specifically on social care issues.

  188. Thank you. Can I also thank you for all your written submissions which have been extremely helpful and will be the basis for some of the questions that we want to ask. Perhaps I could begin by saying that one of the issues I raised with the government witnesses in the first session with the civil servants from the Department was the actual cost of delayed discharges. We as a Committee drew some figures out of our annual expenditure survey which came up with a broad figure of a cost of around £720 million arising directly annually from delayed discharges. I am looking at you, Mrs Robinson, as to whether you have any figures from the Kings Fund that would either substantiate our estimates or give an alternative figure. The reason I am asking is that the Government actually did not have a figure. I was rather surprised that they did not have any idea of the cost of this particular problem. Do you have any thoughts about that at all?
  (Mrs Robinson) It has been rather interesting in the Kings Fund hearing your calculations, Chairman, because in our national inquiry looking into care and support, when we were looking at the whole gamut of provision for vulnerable people, particularly elderly people, we noted that there was a huge mismatch in the funding between the NHS and social care. We calculated that we needed something like £700 million extra social care in the financial year. That was not just to meet the delayed discharges problem. We were ecstatic when we saw your calculation. We thought we must be rather on the right track. Something in that order, it would seem, is going to be important to try to close that gap between the NHS and social care.

  189. I think we may be misunderstanding each other. Our estimate was based purely and simply on the annual cost of an acute bed in a hospital times the number of people blocking these beds over a year, so it is very much a back-of-a-fag-packet calculation, if I can use that term in the Health Committee! It is a back-of-an-envelope calculation of what we consider to be the figure, but the Government did not have a figure. So broadly you would concur that that is your own estimate on that?
  (Mrs Robinson) Yes, I would. As I say, ours similarly was on the back of a cigarette packet, in the sense that we were looking at what the gap in funding is, recognising what was the historically high record of amounts of funding in the NHS. I think we would stress that we have not calculated what the cost of delayed discharges would be, and nor is our figure designed solely to meet that problem. I think we are talking about a whole range of other provisions in social care that are needed, so it may be in excess of that figure that you have actually mentioned.

  190. Can I stick with you, Mrs Robinson, and ask you another question, because in your evidence you said that delayed discharges had been a problem for at least the last decade, but that the numbers had risen dramatically over the last year. From that point of view, it is interesting that it has risen in such a way when there have been specific funds allocated to try to deal with the problem. What do you see as the reasons why it is a problem which has arisen in very recent times?
  (Mrs Robinson) We focussed on two issues in our submission, as you know, both of which are financial—although of course there are others, but I think they are the main ones—the first being some of the financial problems afflicting the care sector. You are all familiar with the extent to which care home owners and indeed domiciliary care businesses are finding it difficult to cope; some are quitting the business altogether, others are refusing to take on local authority funded clients, because they feel the fees are too low. That means that there is restricted capacity for local authorities themselves to purchase and actually to find the places. Local authorities themselves over just under the last decade, since 1993, have been driving down the cost of the price that they will pay for their own placements, and they are now not in a position, because of their own financial difficulties, to increase those prices. So we are having a real capacity problem that has started to hit this year. An issue that is interesting for us is that again in the Kings Fund inquiry we predicted a crisis looming. We called it a looming care crisis, but actually it started to hit at the end of last year, for those very reasons. I think the second thing, leaving aside the care sector itself, is that the development of alternatives, particularly in intermediate care, has been disappointingly slow. While we have seen over the last few years some excellent developments largely driven by short-term winter pressures on money starting with the previous Administration and going through the new Labour Government, we have not seen the long-term funding coming through so that we can really plan for those intermediate care developments on any great scale at the moment. Indeed, some of it looks as though it is being diverted into other purposes.

  191. Can I ask you—and other witnesses may want to come in on this point—about the way in which, compared with not dissimilar European countries, we seem to have invested very heavily in institutional forms of care for older people, and the market has gone in a very big way for institutional forms of care which are inevitably perhaps more expensive models of care than some of the simpler solutions that other countries have come up with. Do you concur with that? Our Committee went two years ago to visit Denmark and saw a country there with, in my view, a much more civilised system of community care and did not have care that was too institutional, they seemed to manage without it. Do we need to think much more radically about the whole basis of provision in terms of long-term care for older people particularly, to resolve some of the problems we are addressing in this inquiry?
  (Mrs Robinson) Yes, I would concur with that. On the long-term care front, I do think that we need some forms of care for some particular groups of people, particularly those with advanced dementia and so forth (but for sure there are many other models that we can invest in and which we are starting to see), but it is still pretty much embryonic in this country. I think that when you look at what has happened to intermediate care, your point is well taken. There are all sorts of intermediate care services which do not need to be based in a new building with all the costs and rigidities that that implies, but there is undoubtedly the case—and colleagues sitting behind me are working on this—for redevelopment in this country. There are huge pressures, particularly among hospital staff, to invest in beds, always to go for using the hospital, using the care homes, rather than putting the money into rapid response teams who do an excellent job. So it is not about one or the other, but actually having a much better mix than we have at the moment.

  192. Miss Harding, do you want to come in on this?
  (Ms Harding) I just wanted to say that if you look at the picture, we have rising numbers of very old people, people in their eighties and nineties and beyond, in this country, and that figure is rising quite steeply now. We actually have fewer people receiving care in their own home. We have a greater number of home care hours, but those are going to fewer people. We have got fewer residential and nursing home places over the last few years for a whole variety of reasons and we have got fewer hospital beds. Those are down by around 4,000 between 1998-99 and 2000-01. If you have got rising numbers of much older people and you are reducing the number of services to provide support you are going to get pressure on all the points of crisis. That is the accident and emergency admissions to hospital and it is the problems around delayed discharge because there is nowhere for people to go beyond the hospital system. You are going to get more and more pressure on the emergency side of the services and the most acute side of the services.

Mr Burns

  193. Mrs Robinson, I was interested to hear your comments about the problems of capacity with the closing of some homes and the loss of some beds. Do you or the King's Fund keep records of the number of beds lost?
  (Mrs Robinson) No, we have not. Just in the course of our inquiry last year we had a quick look at what was happening. It was a snapshot though. We do not regularly and routinely monitor developments in the care home sector.

  194. Do any of the organisations before us keep records of the number of beds lost plus on the other side the number of beds gained by new homes being established, and whether there is a net gain or a net loss in the number of beds for residential care for the elderly in this country at the moment?
  (Ms Herklots) One of the sources we use for that is Laing & Buisson's work and certainly what comes forward to us is that the issue is more complex. It is about local and regional mismatches between demand and supply. In some areas there is clearly a shortage of care homes and in others there may be an over-supply and the problem is there is not a match between those two things. The other issue, coming back to the Chairman's question—

  195. Can we stay on this a second. You mentioned you use the Laing & Buisson figures so you will know from those figures that if you took at random, say, the last five years they show there is a significant overall fall in the number of beds. Presumably you have noticed that. Do you accept that as an accurate keeping of figures?
  (Ms Herklots) Laing & Buisson is the best that we have got on the figures. It seems the best.

  196. I would certainly agree with you. Could you then explain—and you may not be able to because it is not your responsibility but you may be able to throw some light on it—the confusion I have when every time you tell a Government Minister about the Laing & Buisson figures and the overall fall in the number of beds over, say, the last five-year period, they say that is not a case, there has been an increase in the number of overall beds. That is a significant difference given the number of beds lost that the Laing & Buisson figures show. Have you done any research to clarify who is accurate, Laing & Buisson or the Government?
  (Ms Herklots) No, we have not.
  (Mrs Robinson) It would be interesting to know which sorts of beds everybody is counting. I know in the past when any government of any hue has talked about beds they have put together a whole of range of things, including what may be step-down intermediate care facilities in hospitals which are not part of the acute hospital set-up. It may be that they are both speaking the truth but we need to know who is counting what.

  Mr Burns: I understand that and that is probably the mistake I made at the beginning because I assumed the Government would be working on the basis of beds for care for the elderly. When you then table questions to them specifying that it is just residential nursing beds for the elderly in homes, you still get, for some odd reason—maybe it is not an odd reason, it depends on who is writing back and who is from the Government—a clarion call that beds are rising in total numbers.


  197. Can I add a cautionary note as somebody who would see the decline in care beds as a possible marker of success of alternative provision. We need to look at this in the whole. Presumably we do not have any mechanism whereby we can establish if there has been a fall-off in the number of care beds and nursing home beds if there has been a similar take-up of investment in alternatives within the community. I am sure that most of us would prefer to see investment in the community preventing people needing nursing care beds in the first place.
  (Ms Herklots) The problem is that the focus has been on just one element of the care market, if you like. Another important aspect of this is provision of things like extra care sheltered housing, which offer care and good accommodation and can be one alternative to residential care. What we are missing at the moment is a mix of different options for older people in the locality that they want. Too often the choice is between a care home or not enough care at home and there needs to be the development of a lot of different options in between those two things.

Dr Taylor

  198. Can I ask you an introductory very vast question. I am looking for one-word answers and trying to put them into topics. The question is what do you see as being the key causes of delayed discharges? The way I would like to tackle that is in four stages: first of all, before anybody gets into hospital; secondly, when they are in hospital getting over the inefficiencies to speed the hospital progress; thirdly, the delay in coming to the discharge, whether it is by the consultant or the multi-agency team; and fourthly, the delay of implementing the decision. Is it fair to just list them under those four headings? Who would like to go first—before getting to hospital, avoiding admission?
  (Ms Whitworth) It is interesting that you should ask me to answer the question first, Chairman. I think one of the issues we would say is that carers' experience is that they tell us about the problems of people being discharged too soon, so it is quite the other side of the coin because if there is a problem that they might be seen as part of the source of the delay, it is for a number of reasons. It is interesting that you talk about the period before hospital and the processes in hospital. One of the problems is that very often carers have had previous very poor experience of hospital discharge processes. They may already be on a roundabout of people being discharged and readmitted, so they are very concerned about that. They also have the view that they are not properly prepared at home to be able to look after somebody who is discharged. I think that goes back to the previous discussion which is about the lack of resources that are available in the way of domiciliary care for support in the home. Thirdly, I think the issue, of course, is about lack of residential home placements for people. Perhaps there is also the major issue which is that a carer will have a view on whether somebody is well enough to be discharged, and we do hear frequent stories of people who have been discharged when they are clearly unwell and then are subsequently readmitted or even die.

  199. Thank you. Mrs Robinson?
  (Mrs Robinson) In a way I do not want to answer the question in the way you put it. Will you allow me to do it slightly differently, because I think it is important to look at what is happening with individual doctors, nurses, social workers and whoever are working with individuals, but we need to look at what I am calling "structural" pressures on those people which influence their behaviour. I therefore come down to two things again, one which is money, which is why everybody squabbles, people do not squabble very much when it is not an issue and, two, the political pressures on the NHS at the moment to get people through those beds very, very quickly, to get the waiting lists down is probably, and very possibly, encouraging some Health Service staff to move rather more quickly than they might otherwise do. I think the political pressures are quite intense at the moment.

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