Examination of Witnesses (Questions 300
- 319)
WEDNESDAY 20 MARCH 2002
MR ANDREW
WEBSTER, PROFESSOR
CAMERON SWIFT,
DR ANDREW
DEARDEN AND
MR BRIAN
DOLAN
300. So how much of that is actually going on,
in the UK, that you are aware of; or anybody else, if they are
aware?
(Mr Webster) Our experience is, not a great deal,
but other people probably would have more to offer.
Chairman
301. Our example is one of the case manager
who followed the entire process through from pre-planned admission,
they were actually planning discharge at the time of admission,
and following right the way through, and I think we were very
impressed with the concept?
(Mr Dolan) May I suggest, that is pretty well developed
in the learning disabilities fields, where they have case and
care workers who are responsible for the individual clients. It
is not as well developed in the UK, but certainly what we do have,
in most hospitals, are discharge co-ordinators, who predominantly
are nurses; where they are successful is when, effectively, they
are given the teeth to make decisions, and that is to do with
ensuring that the patient has a timely discharge plan, that they
have got care pathways. Because you know the majority of patients
with any number of conditions will have a trajectory through,
which will take us so long, and it does not make sense that there
are internal blocks; so their role is to ensure that the blocks
are smoothed out. The vast majority of patients who are discharged
will be discharged on the drugs they are on the day before they
are discharged, so it does not make sense for the poor individual
to be told that, at 9.30 in the morning, "We'll let you go
now," for the house officer who is on the ward round not
to make it back until half-past two, to then wait for another
four or five hours for their drug prescription to be filled, and
then find actually there is no ambulance, or there is no hospital
transport, to get them home. A discharge co-ordinator, who has
got the decision-making power to ensure those things do not happen,
ensures timely discharges and also facilitates the process for
the hospital. I am more agnostic about penalties, because I think
they should be offering more incentives rather than pointing to
mistakes.
Dr Taylor
302. I think we should make it clear that penalties
do not apply to patients but that where we have seen them in America
they apply to the hospital and doctors involved that have kept
patients in hospital an unnecessarily long time.
(Mr Dolan) No, but they do that in a different way,
by just keeping them in hospital longer.
303. Can I come on to medical staffing, just
a little bit, because I think it was Professor Swift who made
the point about the reduction in junior doctors' hours, which
seemed really to have gone too far that way; is there any way
that discharge co-ordinators, like the care managers we heard
of in the States, really could take on a vast amount of the drudgery
that junior doctors used to have to do, and actually could organise
the patients' pathway through the hospital part of it? Are we
any way towards getting that?
(Professor Swift) Basically, the current situation,
if I can just come on to that from the previous question, the
answer is, there is much less co-ordinated, properly organised
care through the system than there used to be, within the framework
of a single specialty service of the kind that I showed the track
record of, in the information that I gave. And that is very much
where the BGS will be coming from, that we need to retrieve that;
and if you are going to either use financial incentives or disincentives
and/or specific trained individuals to deliver into that system,
the total system somehow has got to be put together again. Now,
the junior doctors' hours situation, I suppose we have tried to
focus, in our advice, on things that we feel we can influence;
it looks as if the legislation is too far down the line to change
that, and, whether we like it or not, that is going to bring about
a disadvantage of considerable scale, in terms of continuity of
care, communication, and so on. So we are going to need to identify
some mechanism, which I think may well involve our professional
colleagues, in trying to pick up that drive and make sure that
that does not damage things even further than they are already.
So I think there is a potential there, but obviously it is exploratory
because we have not been in this situation before, but I believe
very much it could work, provided such discharge co-ordinators
and nursing colleagues are very much signed into the whole system,
as I have endeavoured to describe it.
Chairman
304. Richard, can I bring in Dr Dearden, on
this point?
(Dr Dearden) If I can just make a point about the
care or discharge managers. Where it is shown to work very well
is where they do have the teeth, but also where they have community
services that they can then plug into. And I think that is the
important thing I just wanted to raise, that if you have a discharge
co-ordinator you can have a wonderfully perfect plan, but if there
is nowhere to go, nowhere to support them, no nurse available,
no acute response team, no community services, a lot of studies
that talk about `inappropriate admissions' make the point that
they are inappropriate if there are alternatives to use, but since
there is no alternative they are actually appropriate, because
they are the only one. The second thing is, just about the junior
doctors, what junior doctors often call "drudgery" are
those tasks which, of course, they have never been trained for,
they have never been trained in these kinds of things, they are
doctors, they have been trained very clinically, medically, for
diagnosis, for treatment, etc, and it is quite right that, actually,
we look for the people with the skills to do those kinds of things,
the organising, the arranging things, even phlebotomy, you know,
taking blood, there are people who can be trained to do that and
release doctors from that sort of task. So I think it is just
important that we also recognise that, with those discharge co-ordinators,
you have to have in place things in the community that they can
actually use and plug into; where they are available, they have
been shown to make huge effects on bed stays, etc. And, just a
very personal point, I am personally quite surprised at what a
low media importance this idea of bed-blocking seems to have,
because this really is one of the key, fundamental points, and
yet, surprisingly, it does not really get the kind of attention
that perhaps it needs.
305. You said "low media importance";
do you mean there is not sufficient perception in the press of
the implications of this problem?
(Dr Dearden) I think that is probably true, and, of
course, that does influence the public and the public have the
view, and, of course, without being rude, that does sometimes
influence the politicians and policy-makers; except everybody
in this room, of course. The issue, of course, is that if it is
perceived to be low then money, time, resources and thinking time
goes into the very high things, like waiting lists. This seems
to be just one of those things that attach to it, rather than
be addressed as one of the fundamental points; that may actually
be because maybe we are treating the symptom rather than the cause.
Dr Taylor
306. Just another question about the medical
staffing sort of side. I realise GPs are terribly overstretched
and there are not enough of them, just as there are not enough
geriatricians; could you tell us something about GP specialists,
if there were enough of them, what sort of training, how long,
when could they be functioning, if there were enough GPs?
(Professor Swift) The BGS and the RCGP are involved,
perhaps started on a process of joining forces to try to resolve
this, fairly quickly; it should be possible, hopefully, to produce
some papers within the next six months, which will help us to
do that. I think there is great scope in GP specialists in this
area, and I think they are certainly the way that leadership will
come into the primary care side of bridging what is currently
the gap between primary and secondary care, it has been partly
driven by the system. And I think that intermediate care, if it
is properly interpreted as explicitly defined in the DoH guidelines
and in the National Service Framework, and is properly funded,
as far as we can see, the funds for intermediate care seem to
be disappearing into a black hole of rescue packages for local
authorities in difficulty, if that funding can be focused and
identified and built into a common co-ordinated system of intermediate
care, where you have GP specialists, hospital-based specialists,
allied professions, forming a single, management, leadership team,
all with specialist skill and accountability, into the whole system,
then I think there is mileage in intermediate care. We do not
believe it is going to solve the whole problem, but it could form
a very good focus. And, in terms of GP training, we have already
identified a good deal of common ground with the RCGP; there are
some difficulties to be ironed out, but I feel confident that
we will be able to produce a specification and a training package
for specialist GPs.
307. Can you give us any idea of the length
of time, post-graduate training, that will be; are you thinking
of a year, two years, part-time training, or what?
(Professor Swift) I would hope there would be some
flexibility, depending on the exposure that GPs may have had to
the specialist departments in their previous training; but the
theoretical basis of training has been the DGM, which has not
had a fantastic pick-up, the diploma, but I would have thought
that, without that, you are probably talking about a year, with
a clinical attachment.
(Dr Dearden) On GP specialists, in fact, of course,
we have had those for quite a while, but they are called "clinical
assistants" and they have been working in hospital for quite
a period of time; developing that role is something that the NHS
certainly could do. The concern that we would have, perhaps, is
the reduction in the generalist workforce, and that having the
GP generalist is one of the things that has kept the NHS as cost-efficient
as it actually is, when you compare it with others; so we need
to be careful that in developing a specialist role for GPs we
do not weaken that generalist base. If I may, just on intermediate
care, I chaired a BMA, Age Concern and King's Fund conference,
on Monday, on intermediate care, which was right across the spectrum,
both managers and commissioners, and there were two or three messages
that came from there. One very much is the potential of intermediate
care. The second was the underfunding of intermediate care, and
the figure that was quoted was of £150 million given to health
authorities last year; by their own admission, £50 million
was then diverted into more high priority areas, and so this was
a concern that was raised in that. But certainly the potential
is there. And the third point was that of lack of leadership,
that it is out there as a concept but there does not seem to be
very high level leadership, in "Right, we're going to get
on top of this, we're going to get in control, and this is how
we're going to do it." So those were three main themes that
came out of that, and, as I say, it was a very multi-disciplinary
group.
Sandra Gidley
308. I just want to go back to the capacity
question for a moment. Dr Dearden hinted at it, that there was
no point having the best plan in the world if there were not the
care homes to go to, and I think the Royal College of Nursing
mentioned the staffing shortages. A simple question really, firstly
to Dr Dearden, and Mr Dolan might like to answer as well, and
anybody else; is it simply a lack of financial resources, or are
there any other factors, you have just identified a couple, and
if you are putting in extra resources what is the best place in
the system to have it then?
(Dr Dearden) The difficulty is, it is a chicken and
egg situation, do you start with the money, which I think probably
is the first place, because before you buy something you need
to have the money to buy it with; the problem is, in today's workforce
market, if you went out to try to buy 1,000 GPs, or 5,000 nurses,
actually you would be struggling to identify that group of people
to bring them in. Now there are non-principal GPs and there are
non-working nurses, but attracting them back into the Service
is certainly one difficulty. The second is that we just do not
seem to be training enough in the UK for our own needs, and that
is well documented; we have been importing medical staff and nursing
staff, etc., for a very long period of time. The third issue is
that it does seem to be that, where you have the finances available,
where there is a group of keen people who want to get something
done, you can organise the kind of reorganisations that my friend
here commented on; in my area, we have set up an acute response
team, after about six years of asking, and yet it took six months
actually to get it up and running, once the funds were identified
and a leader was identified. So these things certainly are available,
they are certainly able to be set up, but, of course, the problem
was that they took the staff from two or three other places, which
just left a shortage in the other places. So, again, that is one
of the difficulties that we have, that we are literally robbing
one place, because we do not have the throughput, or even the
people coming in, to replace them; and that, in some instances,
just puts the pressure elsewhere.
(Mr Dolan) I am struck that it is not just about money,
I think there is clearly a shortage of staff, there simply are
not enough nurses and doctors and clinicians available to deliver
the high service standards that the country has a right to expect.
But I think there is another component, which is about the ways
of working, and I think there are dangers in assuming that it
must be management-led, or it must be nurse-led, or it must be
whatever. I think what we should be looking towards is the competencies
of the individuals, so it is what is the most appropriately skilled
individual able to do, and in that way it is about ways of working.
Going back to Mr Burns's earlier comment about is it too simplistic,
in terms of whether it is about PSS, I think, the hospital and
primary, personal services, it is a binary divide, which is actually
quite a false one, and what we should be looking at is integrating
those services and bridging those divides, and that is about people
not actually considering sort of walls and boundaries of where
they work, but actually where does the patient have their care
need. One example of that is a nurse practitioner who works in
Cumbria, goes out on a fast-response vehicle, with the Ambulance
Service, and has reduced the number of 60 year olds coming to
hospital, to A&E departments particularly, by something like
30 per cent. Now the human impact of that reduction in not just
care cost, but time and effort is dramatic; so it is about ways
of working. And the other business, about working lives, because
I think the Health Service, and social services and society at
large, is still not good enough in the way it treats working women
particularly, it still overburdens, and many, particularly in
nursing, of the women who are of child-bearing age, in their late
twenties, early thirties, at their most productive time, at their
most experienced time of their working lives, are often sisters
and then they come back as a staff nurse, and they are told, "Well,
actually you haven't got much to offer the NHS, because . . ."
or "We don't want you at all, because you can only work 15
hours a week." And what we do is we waste such expertise
and knowledge and experience out there. And something it brings
to mind is George Bernard Shaw's comment about, you think of things
and say why, and I dream of things and say why not; and I think
we should be doing an awful lot more of the "why not"
in health and social care than we actually do, why not enable
patients to stay in their own homes and bring the hospital and
the acute sector to their home. Why have a GP who is already extremely
busy having to do home visits, why not enable a nurse or a physio
to do that visit; why bring them into hospital in the first place,
why not bring the hospital to them. So it is all of those `why
not' issues, I think, would dramatically affect capacity, address
issues around shortages, because, nurses and doctors, they do
not burn out because they care so little, they burn out because
they care so much. When you go home, and I am sure there are MPs
who must feel like this some days as well, thinking, "I didn't
do as good a job as I know I can do," that is very, very
frustrating, certainly for clinicians, and I am sure it does not
apply to MPs, but it is evidently the sorts of things that have
a knock-on and a degenerative effect on the morale and fabric
of the staff who work in the service.
309. What worries me greatly is, we hear of
these isolated examples, like the nurse in Cumbria, and it does
not seem to spread very quickly; if it is a good idea, we do not
seem to have any mechanism for expanding it?
(Mr Dolan) Yes, I know; absolutely right.
(Professor Swift) Basically, we think there are three
key areas; and I was very interested that Andrew Webster, in his
outline, made a very good apologetic for the importance of correct,
accurate, clinical decision-making. If you get it wrong, people
are in the wrong place at the wrong time, you have people in continuing
care who do not need to be there, you have people in acute hospital
beds who are occupying them inappropriately. If you get the clinical
decision-making correct, and I mean across the professions, in
a proper way, with appropriate skills at all levels, then you
actually have a considerable effect on the system, it is not just
about finance; but if you get the clinical decision-making wrong,
it is counterproductive, and it is guaranteed that bed-blocking
and long-term bed occupancy will go up. So there has to be a situation
of governance, of shared accountability, of proper professional
training and of particular skills in this area, in order to have
the certainty that that will happen; and if we do not have that
the thing will not deliver. That is point one. Point two, in addition
to finance, is that you have got to have co-ordination, and everybody
seems to agree with that. If you look at many of the initiatives
in intermediate care, at the moment, they are fragmented, they
do not feed into the whole system, which is, in fact, supposed
to be a criterion of them, they do not have clear, accountable
clinical leadership; and so you have to have a mechanism. And
one of the ways you could do that would be to develop this concept
of the single point of access to an intermediate care service;
in all the meetings that I go to, of task forces and clinical
leadds, that comes up, and you have to try to do something about
that. And the third thing is to do something about perverse financial
incentives; it is not just a matter of the amount of finance.
And, while we would have some reservations about just a blunderbuss
implementation of the Swedish solution, which was that when some
god-like clinician, in his wisdom, says that someone is blocking
a bed they must be removed, thereafter they are charged to the
local authority at the appropriate time, we think there is a better
way of making appropriate clinical decisions than just doing it
that way. And that is the proper enabling of expert team practice,
including discharge co-ordination, including the work that we,
as a specialty, try to do in hospitals, then you might be able
to say, because you can back it up with governance, you can back
it up with performance management, you can back it up with clinical
standards monitoring, when such decisions have been reached then
there is a place to try to spread the responsibility between the
NHS and social services, unless you can get them signed up to
single budgets or pooled budgets in certain areas.
Chairman: We will probably get on to that area
a little later on. I certainly want to explore that in some detail.
Andy Burnham
310. Can I just turn the question to Dr Dearden,
for a moment or two, and I wanted to try just to focus on whether
we can establish what the true extent of the bed-blocking problem
is. I would have thought that at any time there would always be
a certain number of beds, even if you had a well-oiled system
that was working very well, just the difficulties of getting people
out, there will always be a certain number of people who are in
the bed and they could actually be leaving, but it is just the
inevitable consequence. I am looking, from figures that the Committee
have been given about performance of trusts in the North West,
and we are looking really about 3 per cent, 4 per cent, many have
1 per cent of acute beds blocked at any one time, and that would
certainly be true of my own trust, the Wigan and Leigh Trust,
and yet the BMA's submission to the Committee says: "At times
our hospitals become gridlocked" is the word that you use.
"Medical wards are full of patients who cannot leave because
no care home place is available." Is the BMA guilty of overstatement,
and you mentioned a low media profile before, are you trying to
spin the story up a bit here?
(Dr Dearden) I do not think you could ever accuse
doctors of overstating anything, and I am sure you just meant
that as a humourous comment, for which I am very grateful indeed.
I think you also have to recognise that trusts may not always
tell you the picture of how things are. And I think the Government
has noticed that with the junior doctors' hours; they took what
trusts said that the junior doctors were actually working, agreed
a deal, and now find that the actual figures are much, much worse
than the trusts gave them.
311. But, gridlock, people have visions of motorways
chock full; is that really the case, when we are talking 3 per
cent, 4 per cent? Even if Trusts are paring it down a bit, gridlock
seems to overstate the case somewhat?
(Dr Dearden) It is actually quite a descriptive word,
that actually says what is going on. If you actually go to many
trusts, you will find that, if you talk to the ward managers,
the nurses, the doctors, on the ward, they will often be able
to identify a much higher percentage than one bed in a hundred.
I will be honest, if the true figure was one bed in a hundred,
I do not think we would be having an inquiry about bed-blockers.
312. Would you suggest we write back to the
Department to say, "We don't believe these figures"?
(Dr Dearden) I think you would have to suggest that
the evidence is, trusts do not always tell you the exact figure.
I would simply say that if the true figure was one in a hundred
I do not think we would be here talking about bed-blocking, because
it would not be an issue. There are certain times of the year
when it is worse, there are certainly times of the year when things
are ongoing, and, our admissions into hospital, we used to talk
about a "winter crisis", where the numbers of admissions
sort of went up; in fact, there is no longer a "winter crisis".
In the middle of summer, in areas of Wales, hospitals closed,
they actually said, "We have no more beds; there are no more
beds open," and we were having to ship people across to Bristol,
which is about 60 miles away, and that is happening during the
summer. So I would suggest that, sometimes, if they are not blocked,
they are certainly full.
Dr Naysmith
313. But is not that happening during the summer
more because people are on holiday, staff, medical staff, are
on holiday, and some wards are closed?
(Dr Dearden) I would not have any figures on that.
My area is not a big tourist area, so people do not come into
the area—
314. No, I mean staffing, rather than bed-blocking?
(Dr Dearden) I would not have any figures on that.
Certainly, staff illness, staff holidays, and things of that nature,
do have an impact on it; but staff gaps, actually, I think, have
a far greater impact, where we do not have the nurses, or the
other staff, so if you wait a week for a barium enema because
there is no radiologist it is a problem. So just coming back to
the sort of bed-blocking thing, I think it is fair to say that
gridlock actually is not a bad description; if you look at the
number of hospitals that close to admissions, it is actually quite
staggering the number of hospitals that close through the year,
even when there is not a flu epidemic, or a cold, or a respiratory
virus, they close regularly.
Andy Burnham: But that might just be a factor
of lack of beds, rather than people inappropriately placed in
those beds; they may just be running at 80, 90 per cent occupancy,
so therefore they have to close to admissions, but they may have
only a couple of people inappropriately placed.
Julia Drown
315. Can I just add to that, our data suggests
that is seven in a hundred beds are a problem because of delayed
discharges, and it is not the rest of the problem due to doctors
ensuring there is maximum throughput, which is using up all the
other beds, but appropriately, within hospitals; if that is the
case, would you say that perhaps the data of seven in a hundred
might be reasonable?
(Dr Dearden) Again, it depends on what you define
as a bed-blocker, because a bed-blocker is also someone who—
316. I am not calling them a bed-blocker, I
am talking about delayed discharges.
(Dr Dearden) I am sorry. If you are talking about
someone for a delayed discharge, that is obviously different from
other people waiting for things like investigations, and that
sort of thing. Also, it gets into somebody in the middle of a
chest infection being put on a surgical ward, which kind of stops
the surgical things going on. I think, seven to eight for delayed
discharge, purely delayed discharge, would probably be more accurate;
again, a figure of 700 per cent on what some trusts are actually
putting forward. I am sure that would be a more accurate figure.
(Mr Dolan) When people have talked about services
running at 80, 90 per cent, hospitals run most effectively when
they are working at about 87 per cent of their capacity. I have
just left the Kent and Canterbury Hospital this morning, and there
were 25 patients waiting on trolleys and beds in the A&E department,
because there were simply no beds there; seven of those people
have been waiting more than 12 hours, one will be waiting there
for 48 hours by 10 o'clock tonight. The system, when that happens,
what you have is a hospital that is running at 100 per cent capacity,
and if you include those 25 people you are looking at 100-102
per cent capacity. So there is a simple number of beds issue;
but, I think, beds alone, beds, in a way, are a bit of furniture,
it is about the nurses and doctors and the allied health professions
who are there to deliver the care to the people in the beds. But
I think, also, in some respects, beds are, to some extent, I would
not say a red herring, I am looking for a better metaphor, but
you will be surprised to learn, I trained as a mental health nurse
in the west of Ireland, and in the little county that I trained
in we had more beds per head of population than anywhere in the
western world; it did not mean we were madder than anybody else
in the western world, what it meant was we had more beds. Now
it is down to about 15 per cent of that bed number, it does not
mean that we are healthier, in mental health terms, than anywhere
else in the world, it just means we have got fewer beds, we are
using the system a lot better. And it has to be a whole system
issue, it is not just about doctors and nurses going off on holiday
in the summer, it is about the way we use the resources. So, for
instance, a solution, do your surgery in the summer months, do
or, say, of your elective work in the summer period, the spring
and summer, because that is when the medical patients tend to
be fewer in number. You can predict emergencies, there is nothing
surprising about an emergency; we know, on a Monday, that things
will be busier in the Health Service than they will be on a Wednesday
and Thursday, those are things that we can predict. And because
the planning is not as good as it could be, and clearly in Wigan
and Leigh, some of those problems are created.
Andy Burnham
317. That is my point, it is good. At any one
time, we have a maximum 4 per cent, so we have very good joint
working, we always have had, with social services; and I do think
the problem is overstated sometimes, it is certainly not as big
an issue as people often make out.
(Mr Dolan) I believe you are right. And I think it
is also about patients waiting on trolleys in emergency departments
are the manifestation of a systems problem, where the whole system
has not succeeded in keeping them there. I entirely endorse Ms
Drown's comments about not calling people bed-blockers, that is
blaming the patient, it is about individuals whose discharge is
delayed.
Chairman
318. We will call them gridlockers in future?
(Mr Dolan) So they get their own car as well; it is
great.
Andy Burnham
319. If then the problem is understated, and
you think it is a major problem facing the Health Service, when
would you say, from when would you trace the origins of this problem
that we now have; if you were looking for dates, what caused it,
that took it from a relatively peripheral problem to a big problem?
(Dr Dearden) If I may, I will just remind you that
the National Bed Inquiry found that a significant inappropriate
or avoidable use of beds was actually 20 per cent of bed days;
and so the National Bed Inquiry suggested that one in five bed
days were inappropriate, if there were alternatives to it. So
we are talking about, in some areas, quite high figures.
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