Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 360 - 379)



  360. I will come to Professor Swift in a minute, but I want him to take account of something that is in the submission that the British Geriatrics Society put, which is very interesting. You argue that the guidance on intermediate care has been poorly interpreted, which is fair enough, but that much of the money cannot be traced through to new beds or services, so the implication being, what has happened to all that money. So, as well as saying what intermediate care is, could you expand a little bit on what you think that money is being used for?
  (Professor Swift) Okay. I want to focus on what it is, if I may, and what we meant, as a Society, by that comment. The actual principles of intermediate care are well defined in the DOH guidance, and also in the National Service Framework, and the problem about innovation is that we are working in a situation where we have got a very substantial problem of delayed discharge which is facing us; and, amongst other things, as well as being innovative, intermediate care does have to deliver into that. And I think it is easy to forget that it has to do with delayed discharge, so we need to address how it fits into the whole system. And I think that is right, economically and in terms of the needs of patients, it is right. But the guidance says the following things; it says a targeted group of older people, it involves comprehensive assessment, it has a rehabilitative and preventative outcome, time-limited intervention we have already heard, it involves skilled interdisciplinary practice with a core team of professionals, clearly identified, and it needs to be integrated into the single whole service. And we would argue that if a scheme in some way does not reflect those characteristics then it does not fit the DOH definition, and it is partly because of that that there is fragmentation, and there is no shared accountability as to where intermediate care fits in and how its performance is assessed. It also says in the guidance that it has to be integrated across primary and secondary health care, across health and social care, across statutory and independent sectors, and it has to have clear clinical and managerial accountability. Now we do not see, from the BGS perspective, the signs of that organised approach to a locally-sorted, intermediate care service coming into place, and we believe that has got to happen, you have got to develop an organisation, preferably manned by a group of signed-up, committed professionals, who are the leaders of the service, and who actually take advantage of the diversity and actually sort out where it fits in and what it has to contribute. And then, based around that, in order to satisfy the assessment criteria, you have a single referral point of access. There is a major organisational problem with intermediate care, which is why, at the moment, there is no evidence in any global sense that it is helping the problem of delayed discharge, before, during or after hospital stays. I think that is what we meant. In terms of where the money is going, it is a sensitive issue, is it not, but certainly we know that £150 million of the first allocation was specifically targeted at community care packages, and we suspect, we do not see that that has been feeding into this integrated, intermediate care system. And nobody knows quite, from our perspective, where that funding has gone; it totals about £900 million, I think.

Andy Burnham

  361. Can I just pick you up on what you have just said there. Obviously, there have been extra beds opened, and, you know, my colleague's intermediate care beds, that are not just rebadged facilities, they are a different kind of service; surely, that must be having some impact on the numbers of delayed discharges, even if it is just to stabilise them in a level that we saw, say, a couple of years ago, there must be some impact that they are having on this problem?
  (Professor Swift) You would think so. Part of the problem is that the criteria for access to the intermediate care service are never agreed across the whole system, and we find that widely reported by our members, we have done a big survey of BGS members, in many areas, schemes are set up and there is very much a pick and mix approach to access, so that people with real problems, including those who are hospital-based are excluded, clearly, if we are going to target the hospital sector, you have got to have some shared responsibility and decision-making between intermediate care and the acute hospital sector. I would argue that a partnership which is mutually supportive could achieve that very well, and the problem is, those systems are not in place, so it is very difficult to know. Wit some of the longer established existing models of intermediate care, there is no real evidence that in a total system context they have actually had a major impact on hospital bed occupancy.

  362. Have delayed discharges come down, albeit in a small way, have they gradually come down, or is your experience that there has been no impact?
  (Professor Swift) I think, broadly speaking, many of us are very disappointed by the sense that that actually impinges significantly on the problems that are faced in the hospital sector.

Dr Naysmith

  363. Just finally, Dr Dearden described a situation where, I think it was, there was a community nurse, you implied, who would go in to someone at home and deal with a DVT.
  (Dr Dearden) Yes, the acute response team.

  364. Which would normally have taken five or six days in hospital admission?
  (Dr Dearden) Yes.

  365. Would that qualify under your definition for intermediate care, or would it just be good medical practice?
  (Professor Swift) Of course it could, and actually it has been happening within well organised services in our own fields, in different ways, for many years; there are many examples of good crisis intervention, some of them community-based, some of them day hospital-based, and a good comprehensive service spans the divide between the services. So, of course, it could. The problem has to be which individuals have access to that resource. We have already learned that it is not necessarily the cheapest way to put a community care package in, how are those individuals selected, what happens to them afterwards, how is the continuity of care picked up. And we feel so strongly that you have got to develop a single system, where there is some shared accountability between the services, primary and secondary, hospital, medical and social, otherwise it is not going to deliver realistically into the system in a way that we can all measure.

  366. I think I have got answers to all my questions. I think Dr Dearden wants to just add something though?
  (Dr Dearden) What the acute response team can also do, obviously, is help people come out of hospital two or three days earlier than perhaps they would, if what they need is the sort of nursing, TLC, kind of thing, but also we have the therapists that come in and can do that work as well. And the Professor is quite right, there are very clear entry criteria, exit criteria, in other words, there is an aim to being in it, and if you go in it and there is not an outcome expected, you would not sort of naturally get into it. But, in defence of intermediate care, if I may, number one, the number of, shall I say, new schemes actually is still relatively quite low, the number of new staff and new resources going into it, and, of course, quite right, are still relatively low, if you compare it with the acute sector, the actual proportion ratio is still very skewed in one direction. And one might suggest that we have pumped a lot of money into the acute sector and we have not seen perhaps the results that we want, and maybe it is time for a radical rethink of where we start to pump the next big tranche of money, because what we have done at the moment does not seem to have achieved what we have aimed for.

  Chairman: Can I move on to an area we keep kind of hinting at, in some detail.

Julia Drown

  367. In terms of the whole systems point of view, which is what I wanted to finish off on, we do keep touching on it, and you are hinting there about the money not going into quite the right place, although some of the money has gone to social services and some is conditional on the agreement of social services. But what I want to know is, how excusable is it for those authorities, for those places, where there is bad practice, and where you have seen the bad practice places change into good practice, how quickly does a payback come through for them, so is it understandable that in some places managers have been able to achieve, or should everybody be able to achieve it? Is that some people cannot see where the payback is coming through? And this is almost a contradictory question to ask, in terms of a whole system approach, but are there particular issues where we, as a Committee, could recommend particular emphasis needs to be placed on one area or the other? The RCN particularly have talked about rapid response teams, and is that what that has always been successful, so that it is inexcusable if every area hasn't got those? And most of you talked as if the Government has talked about the right things but it is not happening in practice; are there recommendations that we, as a Committee, should be thinking about, where particular action could achieve more, in terms of delayed discharge; you could always say "Money," and that is fine, but anything else?
  (Mr Dolan) For relatively little money, you can actually make a dramatic impact, but first of all I think you have to tackle behaviour, and that is about the culture of organisations, where the primary care, the community care sector and the trusts do not actually talk to each other, and that goes on still far too much. The GPs, when they ring for advice about a patient with abdominal pain, get through to a very junior doctor, who will ask them quite patronising questions, in fact, so they end up going into A&E and waiting many, many hours, instead of, say, seeing a senior clinician. One of the things we are putting into Kent and Canterbury and Queen Elizabeth the Queen Mother in Margate is some therapy teams, and that will be physiotherapists, respiratory therapists and others; that will save 4,500 bed days per year. That means that that will save not just a lot of money but it also means that patients can go home, and that has to be a way of preventing admission, which stops delayed discharges. I worked in King's, in the very dark days, in the early nineties, when the Evening Standard seemed to just live there, on the shift, and would come up to me at the end of every shift and say, "It's bad today again, isn't it?" And it really was tough. And we used to joke, if the patients were there for more than four days we would put them on the nursing off duty; but we turned it around, because we tackled discharges and we targeted the discharges. Because if you enable timely discharges, and I believe this will happen in East Kent, you eradicate trolley waits, you enable patients to get home in comfort and with dignity, you empower the nursing and clinical staff to make decisions that get patients out, but importantly you empower the clinical community staff to get access to senior clinicians in the hospital sector who can give them advice, which means they do not actually have to come in, in the first place; and those are clinical behaviour things, they are not just about throwing lots of money. But there is one thing I would say, finally, which is, in some areas, for example, in intermediate care, the money is there, what there is not is the staff to deliver the service, and that is a particularly endemic problem, which may come from the previous administration, it may come from poor data information, but the outcome is the same. And we saw eight million patients admitted to the NHS in 1990; the last year, we had 11 million people. And you cannot have a Health Service which that does not have an impact on unless you develop it. I was in the States two weeks ago; the bottom line is, I think we have got a fantastically good NHS, and when you look at the American system, where the dollar is about driving a cost as opposed to driving effectiveness, and you have got a system over there which is so piecemeal that they do not actually even talk to each other at all, we have got a lot going for us. And I think what is helpful for this Committee is, it is upping the anti further, and that is no bad thing.

  368. But two things there. One, when you sort out the delayed discharges, what stops the clinicians just putting more people on their lists and filling up the beds again? And the other thing is, you talked about the therapists being a particular, successful model, but is that a "one size fits all", is that a particular recommendation, you say therapists should be at every trust, or what works for one place does not work for the others? The point is, what is a specific recommendation we should be saying, "This is what the Government should be doing"?
  (Mr Dolan) I think you have to look first of all at what is the local need, and, you are right, there is not "one size fits all"; but, generally speaking, a lot of patients come to emergency departments with respiratory conditions, which could be managed in their own home. So I think you can safely say you can establish these types of services as physiotherapists and occupational therapists, and others, in all emergency departments, and they have got much better psychiatric liaison with A&E departments now than they have ever had, and that is making a good, real difference to patient care. Forgive me, I forgot the first part of your question.

  369. How do you stop beds being filled up again?
  (Mr Dolan) First of all, it is about making it so efficient that actually you reduce the number of people waiting, in the first place; because, as my colleague here says, if you are waiting five or six years, it does not make sense to leave those people waiting. In Margate, for example, there are people waiting for back pain assessment for two years; in Ashford they were waiting for no weeks at all, because one of the clinicians says, "I must see all of the patients with back pain." That does not make sense. And going back to your earlier point, Ms Gidley, why cannot we roll it out everywhere, well that is a really good question, it is one the Secretary of State asks every day; if it is good here, why cannot it be good everywhere.
  (Professor Swift) Can I just say, from my knowledge of the East Kent service, it is one which actually does reflect most of the characteristics that are identified, including, I have to say, geriatrician input; so all those things enable a service, as I said, to take tough clinical decisions, prevent inappropriate abuse of the service, along the lines that you have described, and allow it to deliver into the system. If you do not have those, you have got little bits here and there, which look good, and you can always show results in an isolated context, but they do not feed into the total system. So that what, it seems to me, the task force leads have got to do is to say, according to the guidelines, what is and is not within the framework of intermediate care, and develop that for each locality, and make sure that those ingredients are in place. The guidance really is quite explicit, and if that is followed I think there is tremendous potential in intermediate care.
  (Dr Dearden) There is a baseline management maxim which says, whatever you reward you will get; and if you actually give resources to the NHS and then set targets by which you will immediately and very quickly measure the success, what you might get is an investment pattern that will give you the targets that you wanted. So when resources are made available to the NHS, you need to be very careful the targets that you ask the service to meet, because that is what you will get. And, sometimes, if I may say, some of the targets, that have been asked for the money in return, have not been appropriate for the service, and therefore it has not always been available, although it is there it has not been available for the kinds of things that we are talking about, because some of those are very long-term, some you cannot show immediate results. And this comes to the blocking; if we were to invest, say, a billion tomorrow, we might not be able to show results for a year, two, or three, but if you were to measure them in six months you would see nothing at all. So you have got to be careful not to get it, on one hand, yet to restrict its use by how you judge its benefits, on the other hand.

  370. So you would call for untargeted money?
  (Dr Dearden) Personally, yes, I would like that, that would be very kind. I think you have to make sure that the targets are appropriate.

  371. So what should the targets be?
  (Dr Dearden) I would not say I am an expert in how to do that, and I would not want to comment on that, because, to be honest, I am a grass-roots GP and I would not be able to do that, so I need to be very careful that I do not say that. But I think you need to be careful that what we do is actually measure what is important, because what we tend to do is make important what we can measure, and the NHS, I think, as we talked, we count everything, except perhaps that which we actually should be, because it is very difficult to count it. And, I think, targets, we need to make sure that we do not just target what we can measure, but we actually work out what is important, and, as I say, I would not claim to be an expert on that, but then make sure that that is what we measure, accepting it could take seven or 10 years before we see the results of that.

Mr Burns

  372. What targets are inappropriate then?
  (Dr Dearden) If you say to someone, for example, "Intermediate care is a wonderful thing, everybody should have an intermediate care scheme in six months," that is what you will have; everybody will have an intermediate care scheme in six months. If you say, "Carers are a very important issue, every general practice must have a carer, identified, lead person," that is what you will have, because the box can be ticked. But, for example, I work with carers nationally, what is the point of having a carers' nominated person in the surgery without the information to pass on, without the access to that person, without people they can contact; what is the point of that person knowing that someone needs respite, if there is no respite to plug into. So, again, if you say you must have one, and this is where we come to chief execs, if you say, "You will have one in six months' time," and that has actually been given, that kind of goal, if that has been given, that is what you will have; but what it might not meet is the criteria, it may not be specific to local needs, because that kind of need assessment, if it has not been done, can sometimes take six or eight months actually to work up, then there is the proper planning, there are protocols to write, so you might take a year or 18 months to get a very good system in place. So, if your target is six months, what you will get is whatever I can do in six months, and that might not be the best thing.

  373. That does not happen with all targets in the Health Service, does it, where they say, "You must do this"?
  (Dr Dearden) I think it happens a significant amount.

  374. It does not always happen with waiting lists, for example, does it?
  (Dr Dearden) I would say, targeting waiting lists is very rarely achieved, I think that is fair to say; but, again, as to the appropriateness of the target, that is a completely separate issue.


  375. You will notice, one or two Members have left, because they anticipate the Chairman raising the issue of the relationship between health and social care, which is something of an obsession of mine, as colleagues are well aware, partly because I worked in a social services department prior to 1974 and saw the difference in the relationships professionally, at that point, with the structure we had prior to the split of elements of health from local government. Now what I want to come back to is this discussion we have had all throughout, the theme, in a sense, of your evidence has been the need to have a whole systems approach; my question to you is, can we ever achieve that without a whole system, without a structure, that makes more sense? If we look at the structure that you are working with, Mr Webster, we have got the health, hospital provision split from the social care provision, and this has been touched on time and time again, we have got the health side of it free, we have got the social care side of it means-tested, going back to legislation, way back in the 1940s, we have got acute hospitals structurally split from primary care. We have not touched on PCTs, we have not touched on care trusts, about which I would be interested to learn your views, but also we have not touched on the issue of the appropriateness of professional roles, because, certainly in my experience, in my own area, more and more we are seeing social care staff undertaking what, certainly, very recently, would have been nursing roles; catheters, stoma care, a whole range of areas, increasingly are being handled by people who are not specifically nursing staff. Now what I am trying to get at is whether you have got ideas about how structurally we can improve the system, in a way that we do not appear able to do, even with all the measures that have been taken to encourage a greater partnership; in particular, this issue of where we have social care defined in the division with nursing care? And I have sat through hours and hours of endless evidence here, and I have yet to find one person who can define the distinction; but yet we have a structure that is based on there being a distinction, which no-one can define. Now I have reached the stage in life where I think, will I ever see a solution. I can see some fairly obvious solutions; what are yours, Mr Webster, we will start with you?
  (Mr Webster) I suppose, and you will have sensed this from our evidence, we start from two scepticisms on this. One is that a structural change will make a difference, and I do not think anyone could argue that there has been a lack of structural change in health and social care in the last 25 years, in fact, there has been almost continual structural change, often distracting; the second is that the bits themselves constitute whole systems. I do not think our experience would suggest that an acute hospital is a whole system that can relate to another whole system, there are as many dysfunctions and gaps and misses within an acute hospital and within a social work team as there are between the two. So I think our starting-point is that there have to be some other ways of making people work across the whole system, and that those are probably some of the ones we have already discussed, some proper mapping, so that people have actually got a sense of who they should be working with, because many people do not know that, the point that has been made by my colleagues about assessing people for services that clearly do not exist, a map of what services were there would help you not do that. And I think a clear sense about what the common priorities are; intermediate care is for these people, all of us will only refer these sorts of people to it. And, I guess, thirdly, the point I made earlier about incentives. There is some work that we are doing that demonstrates that intermediate care can have quite a big impact on the whole system; we are doing some work in the London Borough of Hammersmith and Fulham, in the last two years they have reduced the number of admissions to nursing and residential homes by a half, that is a pretty big impact, and they have increased the age at which people go into those homes by four years, from 82 to 86, on average. So clearly it is possible for their whole system to map what is going on, redesign some bits, redeploy quite a lot of capacity, from care homes into something else, without adverse effects on the acute sector; and there has not been a big structural change there. So I think our view is that the solutions rest around focus and the people, rather more than on the structures and the systems that are operating.

  376. Would you accept that one of the problems we have is the difference between means-tested and free care provision, within the same broad area? I was struck by the British Geriatrics Society evidence about the issue of erosion of decision-making responsibility, and I quote: "There is the right to choose an institution with a long waiting list and to remain in hospital for the interim. There are currently no legal mechanisms to insist on an interim placement." I will come to you, Professor Swift, in a moment or two, but I am not so sure I would want to be on your ward round as a guy who is insisting, "I want to go into a particular home; why shouldn't I insist?" But one of the reasons that I may want to stay on your ward is, I am not paying for that care, and I would be paying for it, quite possibly, when I was discharged. Is that a problem, Mr Webster, the difference between the resourcing, from a personal perspective, of certain services?
  (Mr Webster) It is certainly a perceived problem on the part of the professionals involved, and I think a fear for a significant number of people who use the system. I do not have the figures with me, but I think, if you looked at the total care market, you would find actually that the vast majority of people received a very high degree of public subsidy, whether or not they are in nursing or residential care. So, whilst there are differences in the means-testing, the levels of subsidy of both are very high.

  377. I was thinking, in particular, of where people actually return home and receive social care provision which is means-tested?
  (Mr Webster) I do not think that there is evidence that people are refusing to return home because of the means-testing, I think the vast majority of people would much rather be in their own homes. But I think there may be a concern that resources are not directed, as we were suggesting earlier in our evidence, resources have not been directed sufficiently into preventive, easy-access, home care, and the revenue stream that supports it might affect that, in some places.

  378. I am increasingly coming to the impression that because I represent a Yorkshire constituency we have different perspectives on some of these areas in the north of England from those of some of my colleagues in the south. Professor Swift?
  (Professor Swift) Your first question was whether we think this is an issue, and I think the answer is, it is not a massive issue, but I think, particularly when it comes to the issue of choice of nursing home placements, for example, which you raised, clearly, choice is crucial for that, for individuals, and something that we all want to respect and go with and allow space for, as much as is reasonably possible. The other side of the coin is that the ethics of delivering a service does require some approach to equity, as part of the ethical framework for that. And, undoubtedly, if not from patients themselves, from families, I think there are instances where the system is played, because hospital care is free, and there are financial reasons affecting the family why they do not want to see the transition take place; they may be ill-informed. Again, I think that if the best possible advice was always available that might happen less often. So I think it does happen. My understanding is that, currently, we have got a three-month cover anyway, which has slightly changed the state of play. We have already talked about the Swedish alternative, which is at the other end of the scale of extremity. It just seems to me that, to reflect equity in the service, there does need to be some corporate shift of balance as to how that decision-making happens, and we need a mechanism to do that. I am not quite sure what that mechanism would be, and it would be best if it were something that both social services and health services agreed was right, rather than something which is driven by, one suspects, in some local situations, perverse incentives on the two sides of the budgetary divide.

  379. Logically, when we are looking at this issue of delayed discharges and talking about whole systems, why, structurally, are you separated from Doctor Dearden in the way we organise the Health Service; if you were not, would that in any way improve dealing with delayed discharges? And then, taking it a stage further, why are you separated from the social care colleagues, who will clearly have a role to play and may well be involved in your ward round and discussions but yet have a separate budget and a separate organisation, a separate structure, different ways of allocating resources, of determining who goes in a particular home, or whatever? Those are the kinds of issues that come up time and time again. And this Committee, in the last Parliament, without being prescriptive, felt that we could no longer defend a separate structure.
  (Professor Swift) Basically, I think systems affect the way people work together, not necessarily structures, and certainly we have seen, over the years, perhaps with the tight constraints on acute practice, greater difficulty in having, certainly in the south of England, anyway, the ideal kind of daily dialogue at senior level with our colleagues in general practice, because they know there is only one solution, that is that they are either not going to go into hospital or they are going to go to A&E, which I would love to see as an ideal place, but may not be the ideal place to sort out these complex problems. So I think the system has affected that partnership. It has also affected, again in the south of England, the partnership with professional social work, social work is seen as based very much out there, and social work involvement on the hospital-based teams has declined dramatically, and therefore the professional advice of that and advantage of that into multi-disciplinary planning has gone, to some extent.

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