Examination of Witnesses (Questions 282
- 299)
WEDNESDAY 20 MARCH 2002
MR ANDREW
WEBSTER, PROFESSOR
CAMERON SWIFT,
DR ANDREW
DEARDEN AND
MR BRIAN
DOLAN
Chairman
282. Colleagues, can I welcome you to this session
of the Committee, and particularly welcome our witnesses; we are
very grateful for your assistance with our inquiry. Perhaps I
could ask you each briefly to introduce yourselves to the Committee,
starting with you, Mr Webster?
(Mr Webster) I am Andrew Webster, I am
the Director of Public Services Research for the Audit Commission,
so I am here to expand upon the written submission that we have
already made.
(Professor Swift) I am Cameron Swift. I have the Chair
of the Health Care of Older People at King's College Hospital,
and I am President of the BGS; and, like my colleague, I am here
to enlarge on the written submission that you have already had.
(Dr Dearden) I am Andrew Dearden. I am Chairman of
the BMA's Committee on Community Care. I work as a GP in Cardiff,
and I will chair soon the Welsh GPs Committee, and I am here,
again, to expand on our evidence and to answer the questions that
you have.
(Mr Dolan) I am Brian Dolan. I am an emergency care
nurse consultant. I work with challenged organisations and trusts,
and not least with the winter emergency services team, in places
like Bristol, the John Radcliffe Hospital, East Kent and other
challenged places.
283. So, presumably, you have got specifically
a nursing background?
(Mr Dolan) I am an emergency nurse, I am a mental
health nurse, I worked at King's College Hospital in the A&E
primary care service for a number of years.
284. Thank you. Can I thank you all for your
written evidence, which has been very helpful. Perhaps I can begin
by a brief question, before bringing in Mr Burns on some wider
points. One of the issues that we have been exploring, in the
sessions that we have had so far, has been the actual costs of
delayed discharges. I do not know whether any of the witnesses,
I am looking particularly to you, Mr Webster, to see whether you
have any figures. I was a little surprised that when we had the
officials in, at the start of the inquiry, a couple of weeks ago,
they did not have an estimate of what the cost of this problem
to the NHS actually is. As you may be aware, we have done some
calculations, I am not sure whether these calculations are accurate,
but based on figures we extracted from the Government in our Public
Expenditure inquiry. Do you have any thoughts in this area, have
you actually looked at the cost question from your point of view?
(Mr Webster) We have not looked at the cost across
the whole system. If you look at our individual pieces of work,
we have looked at the costs in particular areas, so we can, for
example, give costs about the difference between someone staying
in hospital and getting a decent piece of equipment, or the cost
of a package of home care and the cost of a hospital bed; and,
from that, you could do the kind of calculation that you have
done. But I think that we ourselves are equally disappointed that
such an overall picture is not available, and we have found it
difficult to produce one, partly because of the definitions of
how much of each type of thing there is, and partly because of
the basis on which they are costed within the NHS and within social
care. So I think we feel similarly frustrated that, in individual
cases, individual councils, yes, we could come to a particular
cost, but adding them up across the system, no, we could not.
285. Can I put to you, the figure that we came
up with was, as you probably know, according to the information
we received from the Government last year, the average cost of
an acute bed per year is £120,000; we were told, at the same
time, by the Government that there is an average of 6,000 beds
blocked, but a calculation of that came to, I think, £720,000
a year in England. Would you differ from that, with your knowledge
of the elements that you have referred to, do you feel that is
a reasonable assessment, or do you feel perhaps we have miscalculated,
we have made certain wrong assumptions, would you question that
assessment?
(Mr Webster) I would question the things that are
absent from it, I think.
286. Tell us what you would question then?
(Mr Webster) Clearly, there would have to be some
other things in place for those beds not to be used by the people
that are in them, and you would need to have an adequate costing
for those. And I think the whole thrust of our submission to you
is that actually identifying the cost of one bit of the system
does not really give you the answer, what you have got to do is
model the cost of the whole system. And what we have been encouraging
individual health communities and local authorities to do is to
sit down and do precisely that, look at everything they have got,
look at all the costs, map it out, see where the pressures are,
see where the payback would be; and our experience is that they
find that incredibly difficult to do, because of the difficulties
of sharing the information, having consistent understanding of
the costs, and because of differences of view about what is in
the map and what is not in the map. So I think that you could
come to a headline figure that definitely there is money that
could be released to do other things, but it would not come to
a simple figure like that, because you would have to calculate
the cost in the whole system; that would be different in different
places.
287. Do any of the other witnesses have any
points to raise, on this, specifically?
(Dr Dearden) I do not have any specifics about the
actual cost of the beds themselves, but what might also be worth
factoring in are things like the actual cost of the patient time
and the relative time that they have to take off, to take people
back to the GP, etc. Also, another significant one is going to
be the drug costs; for example, if someone can have a bypass done
today then actually they need a tenth of the drugs that they might
need over the next 18 months. So one of the additional costs to
a bed that is blocked, to use that phrase, is the knock-on effects
to the people who cannot get operations done; and then you have
got GP time and district nurse time, for example, where the nurses
perhaps are seeing people once or twice a week, where, if they
could get those things done, they may need to see them then actually
only once or twice more. So actually there is quite a community
effect and a community cost to each acute sector bed, and, as
has been said, that is a little bit more difficult to factor in.
288. I think also the economic cost of people
who are ill and cannot get access to a bed that is blocked by
somebody who does not need it?
(Dr Dearden) Absolutely.
289. We have looked at that. Does Professor
Swift have anything to add to it?
(Professor Swift) There is no simple answer to it;
a simple end-point is a national rise in duration of stay of hospital
bed occupancy by about 2 per cent, and that is a very simple,
measurable end-point, which has massive implications, of the proportions
that you have been describing. And hospital bed occupancy, if
it is inappropriate, unquestionably is the most expensive component
of the system. So, I think, as an end-point in itself, it is crucially
important; and the trend, of course, is extremely worrying, as
well as very frustrating, for those of us who work in the system.
290. Mr Dolan, do you have anything to add?
(Mr Dolan) One of the problems with delayed discharge
is that actually we do not do enough to avoid their admission
in the first place; because it is not going to be delayed if they
do not have to come in. And some work we are doing in East Kent
hopefully is going to release something around 60,000 bed days,
which is the equivalent of 164 additional beds in that health
economy, simply by initiating a raft of measures, such as rapid
access to endoscopy clinics, so they do not have to wait weeks
on end, getting very quick responses to whether they have got
a DVT, enabling the rapid response team, so that the nurses can
go into the A&E department, if somebody has got an acute chest
infection, take them home, look after them for a relatively short
period of time. Now there is not going to be delayed discharge,
they are not going to get sucked into the system, if we do not
have them in, in the first place. And I know all the points my
colleagues raised are absolutely right, but I think I would pick
up particularly Andrew's point, there is the human cost, which
to some extent is not particularly measurable, but its profound
social and personal impact perhaps is greater, and it has a knock-on
effect to the NHS at large, because it undermines people's confidence
in the National Health Service.
291. In the system you are describing, the alternative
system, have you done any calculations as to what it would cost
to develop that alternative system, but what it would save in
relation to the occupation of acute beds?
(Mr Dolan) Yes, we have. We are going to pump something
like £6.2 million into the local health economy, but that
will save around its own cost as well, in the longer term; because
what you are doing is making the service a lot more efficient,
so people are not sitting in beds for long periods of time when
actually they did not need to come in, in the first place. So
the back end, in terms of how much it saves, has not been measured
up yet, but we have actually got very clear costs; even just 50
emergency slots for a week across that health economy will save
something like 7,800 bed days, so a little, even a 1 or 2 per
cent difference, can have a disproportionate knock-on effect,
which has to be good for patients, more than anybody else.
Mr Burns
292. Mr Webster, in your 1997 report, The
Coming of Age, it was described there was a vicious circle
in which too few resources to support people at home meant that
older people often were admitted to hospital, increasing the pressures
on hospital lists. It also went on to say that the length of stay
in a hospital was declining and that that was giving fewer opportunities
for rehabilitation and increasing the pressure for admissions
to residential and nursing homes. This, in turn, obviously, had
a fairly dramatic impact on local authority resources, and then
had a knock-on effect on the whole funding mechanism. Would you
say that, five years down the line, that is still the situation,
or have there been either improvements or a deterioration, or
a shift in the problem, as a result of this?
(Mr Webster) I think that things have changed quite
a lot since 1997, and we have been following that work up, through
the work that our auditors have been doing and through other studies.
And I think there are clearly some areas where there have been
significant improvements, particularly the development of the
intermediate care, that rehabilitation point about do people get
more support to get home. There is more evidence that things are
jointly funded and managed between health and social care; in
a recent analysis we did of intermediate care, nearly half of
them were wholly jointly funded, rather than relying on one service
or the other. And there are places where quite radical changes
have been made to the distribution of resources, so that there
is less pressure in the places that we identified. So I think
we can point to a number of improvements. But clearly there are
areas where things are still causing difficulties in the way that
we described, in that vicious circle, and, I guess, three. One
is the prevention point, which some of my colleagues have already
made, which is all these costs are incurred only because people
get in the system in the first place, and some relatively simple
interventions, quite often, could stop that. Secondly, co-ordination,
it is still an immensely complex process for people to get through
the whole system, all of those stages. And, thirdly, there is
evidence that social services budgets are still under very substantial
pressure, and the average that a council is spending is 11 and
12 per cent above SSA; lots of them have got overspends on children's
services, lots of them are having difficulty meeting their estimates
on older people's services. So I think you can identify that the
capacity to change as fast as that report suggested was necessary
is still quite difficult for people to deliver.
293. Would it be too simplistic to suggest that
if, in the Budget on 17 April, in the Health Service financing,
the Chancellor were to concentrate this year on personal social
services, rather than on the acute side, because, certainly after
year two of this Government, one has seen substantial increases
in the money to the Health Service, particularly, which has been
concentrated, more or less, in the acute side, if the Chancellor
changed tack and started to pump in significant increases in the
projected amounts that he was planning to do on the PSS side of
the Budget, would that solve the problem, or is that too simplistic
and there are still other ingredients that mean there is a problem?
Because you do have the situation, as you rightly have suggested,
that local authorities are spending significantly over their SSA
on social services, you have the care homes complaining that the
local authorities are using their dominant position to force down
their prices, so there is a situation frequently where the self-funders,
in effect, are subsidising the people being funded, or part-funded,
by local authorities, and you see care homes closing, because,
of course, the value of their property probably greatly exceeds
the effort it takes in keeping them open?
(Mr Webster) I think it would be too simplistic to
think that would solve the problem.
294. So what would be better then than simply
increasing significantly the money to PSS?
(Mr Webster) I guess it is worth pointing out, there
has already been quite a substantial increase to PSS.
295. I am taking that as read; but—but—on
the other side of the coin, those in the sector, and certainly
those in local government, in social services, who have the responsibility
for providing social services, would argue that that is not the
case in reality, whatever the figures are, it is nowhere near
enough to meet the ever-increasing demand?
(Mr Webster) I think I would go back to saying, where
is that demand coming from, because still there have been more
people placed in care homes every year, over the last few years,
so there has been a continuing growth of people going into those
homes; there has been more focus of home care on the more vulnerable
people, so there has been more attention paid to the people who
might be presenting those kinds of pressures. And I think that
it would be much more constructive to produce a stream of funding
that required particularly community health care and social services
to be looking together at how they deploy resources, rather than
thinking that if you pumped a lot of money into one bit of the
system, because it is really the kind of opposite side of the
coin to if you had more beds there would be a solution, well,
if you had more beds in an acute hospital, some people could stay
in them longer, if you had more beds in care homes, some more
people could get in. We have looked at some councils where they
have managed to reduce the number of people going into care homes,
prevent people needing that care, have not placed any greater
pressure on the acute system, and have got better outcomes for
the people; a lot of work has been done, for example, in Hammersmith
and Fulham, to completely re-engineer that whole system. And,
I think, if you were going to put money in, it should be directed
at enabling people to do that, rather than put more money into
care homes.
296. Just one final question, because it is
rather interesting, from something you have just said, have you
done any work to assess the comparative costs between providing
someone with a domiciliary care package and someone being put
into a residential home, to see if it is noticeably cheaper to
keep someone in their own home with a care package?
(Mr Webster) We have done comparisons, but I think
it is difficult to come to a conclusion that it is going to be
cheaper for any individual, because it depends very much when
you do it. A preventive package of care for somebody at home could
be very cheap and save you a lot of money later, but you may be
in the position where somebody could get a better outcome staying
at home, with a lot of frailties, that is more expensive than
going into a care home. So if you wanted to get best value for
money all our studies would point to prevention, aimed at the
times when people were most vulnerable.
Sandra Gidley
297. Another question to Mr Webster, if we can
move away a little bit from prevention. You suggest in your submission
that some of the delays are as a result of the fairly cumbersome
procedures within the hospital, and you actually suggest some
ways of streamlining the procedures; a couple of them I thought
were tinkering at the edges slightly, I was going to say `departure
lounges' but you recommend `discharge lounges', that beds are
freed earlier, but, more interestingly, I thought, you suggested
planning discharges earlier and involving key people on the critical
path, and introducing discharge co-ordinators. And this was something
that was so much in evidence when we went to visit the States,
in particular, to such an aggressive degree that there were actually
fines in place if people spent too long in hospital; obviously,
if they developed another illness that was taken into account;
but the financial pressures concentrated the mind wonderfully.
First question, what evidence is there that, these processes and
procedures, a sort of solution is being adopted in the UK; and
how do you feel about some penalty system?
(Mr Webster) There is evidence that discharge co-ordinating
and earlier planning definitely yield results; the figures that
we have highlighted in our submission, at St Mary's, they show
that the number of delays has fallen very, very substantially,
the number of days lost has been half to a third what it was before,
so certainly it is possible to smooth that process in a way that
yields real results. And there is no reason to believe that that
would not be true in lots of hospitals, because the processes,
conceptually, are relatively similar. And there is certainly evidence
that the incentives in hospitals are not organised, in the way
that it works at present, there is too much of an incentive to
pass the responsibility to somebody else in the hospital rather
than to ensure that the patient moves to another, more suitable
place. It would be a big culture change for the Health Service
to have financial penalties associated with those things. Though
I think you are touching on something that we do highlight in
our submission as probably a major deficit in the health care
system, which is, there is not anyone who manages the whole process
of somebody's care, and so there is not anyone who has an incentive
to see that the whole thing works. And I think what you are describing
is probably one of the tools that those sorts of people use, in
American health maintenance organisations; so introducing the
tool, in itself, probably would be quite easily absorbed by the
complexities of the Health Service, but introducing—
298. Sorry; can you put that into plain English,
do you think it would not work, or it would?
(Mr Webster) They would find ways of it not working,
is what I am saying; whereas, if you give somebody the responsibility
for making sure that it does work, they would have to have a much
wider remit and range of tools than just attacking a particular
point in the process.
299. But they do not attack a particular point
in the process, that is the point, they analyse the process very
specifically from A to B.
(Mr Webster) We are making exactly the same point.
They manage care through the whole system, rather than manage
a little bit of each person's care.
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