Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 200 - 219)



Sandra Gidley

  200. Just a quick follow-up on this point. One of the performance indicators now is readmission rates. Since that has become an indicator has there been any improvement in the rate of readmissions, because presumably that was put there to deal with this very problem? Are you saying that it has had no impact?
  (Mrs Robinson) I have not seen anything in the performance measures that shows that there is improvement in that.

  201. Has there been any work done on comparing before and after?
  (Mrs Robinson) There probably has but I am not aware of it.


  202. Ms Harding, do you want to come back to Dr Taylor's points?
  (Ms Harding) I will try and pick up your point of the key causes of delayed discharge. Quite frequently people end up in hospital when they should not have got there in the first place because of inadequate social and health care support. The whole area of helping people gain and maintain a good level of health is a very important one. It is there in Standard 8 of the National Service Framework. We have got an awful lot to do to turn it into a reality. At the moment hospitals are picking up a lot of people that maybe should never have got to that point in the first place. Secondly, there is evidence within the hospital system that there clearly is good practice where discharge planning starts from the moment that somebody gets into a hospital bed and that people have a sense, including the person themselves and their family, of what is aimed at in terms of through and beyond the hospital experience, but that certainly does not always happen. Much too often it is a last minute "we need the bed; you are going to have to leave", and much more functional and ill-thought through and ill-planned with very little time for the older person themselves or their family to make sensible choices and come to terms with what needs to be done.

Dr Taylor

  203. So poor planning still exists?
  (Ms Harding) I am sure it still exists, and we need some more of the good practice. The big area we certainly hear a great deal about on our helpline and other people's is the whole business of implementing discharge. People are stuck in hospital because the services are not there for them to return home. The social services department says, "I am sorry, we have not got the money to enable you to have that extra visit a day or that night cover or to be able to fund that place in a residential home." There are times when it is literally not dead men's shoes but dead women's beds it seems that people are waiting for. There are ample examples of that, that social services departments simply do not have the funding to enable people to leave hospital.
  (Ms Herklots) I certainly agree with what colleagues have said already, but I would add two or three things to the issue of before hospital. The lack of preventative services, and particularly problems around older people living in poor housing who therefore might be at risk of falling or running into health problems because their house is damp or poorly heated, is generating admissions to hospital that should not happen. The whole system of housing adaptations, which the government is reviewing, certainly needs to be improved. Once people are in hospital there can be problems of communication, not just between the hospital and outside but within the hospital itself. The consultant may make a recommendation for discharge based on that person's physical condition but it may be some time before the physio or the OT can get there to do an assessment to see if they can be discharged home. There are some issues around communication within the hospital environment itself. In terms of then implementing the decision, one of the key factors in delayed discharges is transport. There have been three studies that have shown this. Age Concern London did a study looking at the experiences of older people in London and both the Audit Commission and the National Audit Office have looked at the issue. The National Audit Office found that NHS trusts cited transport as a prime cause of delay in hospital discharge in about a quarter of the cases. Something as apparently simple and fundamental as getting the transport there on the day of discharge is actually causing some problems.

Julia Drown

  204. Picking up the points that Age Concern were making there. In your evidence you talked about welcoming the preventative services but you were a bit concerned they were focused on trying to avoid hospital admissions. You talked then about some issues on housing and other issues that need to be addressed. If you were in charge of policy how would you have gone about delivering intermediate care?
  (Ms Herklots) Certainly we welcome intermediate care and the principle of it. What it misses, though, is really going back a stage not just looking at the sort of package of care you need, whether that is around coming out of hospital or perhaps being at risk of going in, but about maintaining older people's independence in their own homes and preventing unnecessary admissions. That can be services as fundamental as information and advice to older people.

  205. Would you say that the Government should be doing those things "instead of" or "as well as"? Is the top priority something different for you?
  (Ms Herklots) Intermediate care and preventing delayed hospital discharge will not succeed in its objective unless you also invest in preventative services which are around practical help at home, housing adaptations and repair, and combatting older people's isolation as well. Quite a lot of helping people stay independent is about making sure that they have got the confidence to do things. If you are isolated and living on your own and not getting some support that can put you at risk of deterioration. Intermediate care is a positive step forward but it does need to be matched with a broader range of community services as well.

  206. Was not the idea when intermediate care was looked at that it would be something more than beds and it would be some of these other services as well?
  (Ms Herklots) I am not sure what the idea was, but it certainly has not come through. What has come through is a time limited model, which itself causes some problems because after the period of intermediate care ends there is then a new transition.

  207. I think we are going to pick that up later. Can I pick up one point that Carers made where you said that one of the problem carers come to you with is there are not the nursing beds when they need them and that is why somebody ends up going into hospital. In dealing with those calls could many of these be dealt with if there were domiciliary nursing services to support those people at home? In those cases is it really break down where those people cannot be cared for at home?
  (Ms Whitworth) In many cases you are talking about a carer needing a residential home placement because they feel unable to carry on caring at home. It might be that proper domiciliary care arrangements would enable them to carry on caring. Very often you are talking about somebody very elderly caring for somebody very elderly and at some point that capacity for caring is no longer there. We do believe people should have a choice about whether they carry on caring or not and residential care is sometimes the only option.

  208. Is it the only option or you were saying earlier it might be possible and people might want to do the care themselves?
  (Ms Whitworth) Yes, but I cannot tell you how that would break down.

Dr Naysmith

  209. We have already talked quite a bit about the alternatives to hospital admissions but there were a couple of points in the King's Fund evidence I would like to pick up related to that. You suggested in the evidence that there is a lot to be done in the area of preventing people reaching what you call "crisis point". What do you mean by "crisis point"? Is it signalled up so you know it is going to happen and why are the signals not picked up?
  (Mrs Robinson) In our submission I referred to a study we had undertaken looking at winter pressures and what has been going on in London in particular, and what we found there—and clearly this refers to your question about emergency admissions—is lots of old people being admitted in an entirely predictable way. We looked at what had been happening over a period of years and found that crises—pneumonia setting in, bad episodes of bronchitis, really acute illness—was happening time and time again in a particular month in the winter. You could predict when it was going to happen and most of those people turned out to have chronic respiratory disease. It is not surprising when you hear it now but I do not think people did know it until they looked at the statistics. It is entirely possible if we worked in a very different way, which we have not done in this country, and target those people who are known to the services, they are known to their GPs, they are known quite often to social services and community health as people who have chronic respiratory disease, who are likely to be at huge risk of developing severe illness in the winter months and there is a whole range of things you can do over and above making sure they have their flu injections. The kind of things Age Concern are saying—putting in intensive care packages of care and support, including improving housing, so that they do not get cold and damp.

  210. What would you do to get this onto the political agenda to try and make sure this kind of thing happens more often?
  (Mrs Robinson) There are two things. One is looking, where the Chairman began, at what is the cost of these delayed discharges at the moment. That it is better to invest money elsewhere is clearly an argument to be made. The second thing is to find some way of supporting primary care, essentially in deprived areas, for the kinds of peaks and troughs we are talking about in this King's Fund study, and supporting primary care to do the outreach work and work with those individuals. At the moment many of those general practices are not well set up to do that. I think there needs to be some real investment in general practice and primary care more generally, and in the inner cities particularly.

  Dr Naysmith: I do not suppose any of the others would disagree that we need more of that kind of preventative action.


  211. Has any of this been piloted anywhere? Have any of the health action zones thought about this kind of approach?
  (Mrs Robinson) I do not know about the health action zones but the London Regional NHS Office with its social care counterpart has mounted quite a large-scale development programme for older people's services in the capital and they are trying to, in different ways, what they call "case find"—find these people who are known to be at risk and known to be vulnerable and work intensively with them. It is early days to find any answers to what they are doing but they are trying that in a very imaginative way.

Dr Naysmith

  212. Does the London National Health Service Social Care Office that you are sponsoring impinge on this area or is it something quite different?
  (Mrs Robinson) I am sorry?

  213. The NHS Social Care Office which is mentioned in your evidence; is that related to this area or is it something totally different?
  (Mrs Robinson) Yes it is. The NHS London Regional Office and The London Social Care Region have mounted this services' development initiative and we are supporting them with various briefings and facilitating meetings and bringing managers who are working together into the King's Fund for some leadership development courses to help them work together better.

  214. Is it going well?
  (Mrs Robinson) It is early days but, yes, so far.

Sandra Gidley

  215. Picking up on a point Tessa raised earlier on discharge planning, when we visited Vancouver and the States, there were quite good examples of how discharge planning works and particularly aggressive management, I have to say, in the States which was driven by the insurance companies wanting to make a profit, to the extent where the discharge was being planned almost before somebody went into hospital. How widespread is that in the UK? How aggressive is it and how prevalent is it? It is something that is on the up?
  (Ms Harding) I do not particularly know the answer to that but I am not sure that anybody does. I think it is one of the reasons for the existence of the Commission for Health Improvement—to identify and help spread good practice within the NHS. We do not have good systems for doing that at the moment. I could not tell you what the proportion is.

  216. Are you aware of any good practice that might be interesting for us?
  (Ms Whitworth) Can I make a comment. As you know, we are looking at it from a slightly different point of view and after we published our report on carers' own experiences of hospital discharge which were very dismal and showed that things had generally got worse since 1998 rather than better, our office in the north of England carried out a survey of 23 trusts up there looking at their hospital discharge policies particularly to see how they address carer's needs. We found that whilst there was mention of carers' needs in the majority, what happened in practice was not very good. There was some good practice in that. Because when we published the report we agreed not to identify the trusts, that information is not available to me now, but certainly I can make available to the Committee some further information about what we found when we looked at those trusts. Generally speaking, the experience is that whilst a policy might look good on a shelf it is in the implementation of them that many of the problems occur. You see decreasing consultation of families and carers around the discharge and of course that is absolutely crucial if you are going to discharge somebody who needs support in the community, it is very important that should be in place. We also found that people were also reporting that they felt less involved and less informed and they were less likely to get a copy of the discharge plan.

  Chairman: It would be very helpful to receive that as soon as possible.

Dr Taylor

  217. Several of you have mentioned in your submissions the need for statutory guidance linked with good practice guidance. Should that be one of our strongest recommendations?
  (Ms Herklots) I think it should. The problem is that the Government has introduced new guidelines for continuing care which has replaced the previous hospital guidance and that has left rather a confused situation. Since the original guidance was drawn up much has changed both in health and social care. There is a real need to clarify what the responsibilities should be so that older people and patients are clear, but also to work on the hospital discharge workbook which was very good in terms of setting out what should happen. That is the sort of place where you could record some good practice and some expectations there about what should happen. Just on that point, we think it would be important that it would cover NHS patients in private hospitals as well. An issue that is raised with us from time to time is that sometimes private hospitals may be less familiar with the need to plan discharges than NHS hospitals and if, as appears to be happening, there is an increase in people going into private hospitals for NHS care then that is an area that should be covered by the guidance as well.

  Dr Taylor: That is certainly a recommendation that we can forward.

Sandra Gidley

  218. Does anybody else have any comments on discharge planning before I move on to my next question. This is to Helena. What evidence has emerged from your community care studies about the criteria for discharge? Is there any evidence that there is pressure because of pressure on acute beds and what do you think the Department of Health could do to promote more effective discharge planning?
  (Ms Herklots) The evidence we get is from older people and their relatives who contact us and, indeed, from social services and health professionals who are trying to battle with the system and make things happen. The main thing to say is that there is quite a variety of practice. There are some pockets of good practice where people work very hard together to try and plan good discharge, and some examples of that that local Age Concerns are involved with, for example, is where someone visits the ward regularly and works with the health staff there and then "goes home" with that patient and provides support actually upon discharge. This project is particularly focused on people who live alone. Those sorts of things are happening, which are very good. The problem is that what happens in the hospital would be to a large part determined by what is available in the local area in terms of care, and that is what affects decisions. So if, for example, there is the availability of care home places at the fees that the local authority will pay then obviously that is an option and people may get discharged to a home of their choice at that level. Too often, though, there are waiting times for funding or there are problems where there are not any care home places available at the local authority rate. What we find there is that relatives are put under pressure to top up so that their relative can be discharged. It puts relatives in a difficult position because they are obviously worried about their loved one in hospital who wants to be discharged, but if there are not care home places at the local authority rate then it puts them in a very difficult position.


  219. Have you or any of the other witnesses any evidence of the way in which people who have resources and capital are perhaps being discharged from hospital earlier on the basis that local authorities do not fund them and therefore it is cheaper from their point of view? I can recall one case where there was fairly clear evidence that this happened and the family were aggrieved when they were allegedly told by a ward sister that had their mother not had the resources then she would have remained in hospital.
  (Ms Herklots) We have not carried out a thorough investigation of this but there is anecdotal evidence where if somebody is able to top up or pay their own fees they are able to get out of hospital earlier. We have certainly had anecdotal evidence of that.
  (Ms Harding) From similar sources there is anecdotal evidence through helplines and so on.

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