Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 480 - 499)



Andy Burnham

  480. A question for Mr Lewis. In your evidence, you describe, in anticipation of the expansion in intermediate care, how Westminster invested in adapting homes so that the full rehabilitation programme could be provided. Can you perhaps expand a bit on that and tell us how much the company did invest in expanding its intermediate care capacity, and whether that was across the country, and also to what extent it has been utilised, or underutilised?
  (Mr Lewis) In cash terms, I could not tell you, I do not have that information; but an example is in Epsom, where we were able to make available rehabilitation facilities, we were able to speed up discharges, we worked closely with the local group practice and with the local hospital. But, again, it stopped because of funding issues; and it is a question of prioritisation. Funding issues/demarcation disputes, was it a social services responsibility or was it a health responsibility, and we still have not entirely got over that problem. There are a number of other examples up and down the country where we were able to make available resources, where we had a discussion with individuals but we were not able to get the corporate agreement to make the thing work. And it is hugely important—

  481. If you had to say whether the problems were with the health side or the social services, where does the blame lie, do you think?
  (Mr Lewis) I hate to get into a debate about blame. I think that the issue is often one of bringing all the players together who are actually able to make the decisions. And I posed to myself the question, I am currently chairing a review in Northern Ireland, is the solution to follow their road, of an integrated health and social services, (a" la" ?) the Care Trusts. And we have been looking at some of the problems that exist in Northern Ireland, because they have many of the same challenges that we face in England, and I have come to the conclusion that it is not that, it is not the actual organisational structure that is the biggest problem, it is making sure that the money is in the right places. Because when you broaden the debate it is housing as well as social services within a local authority, it is health, and also ensuring that we break down some of the professional barriers, and that is not just social workers vis-a"-vis community nurses, it is consultants versus GPs, etc.

  482. Is that possible, to break down those barriers, without that merged organisation though, without fully merging the organisations, do you think, or will you always get those?
  (Mr Lewis) You are always going to have them, to an extent, but it is a question of how you plan and manage services. You need expertise, in order to provide, for example, comprehensive assessments; but, clearly, they should reflect a multi-professional assessment. Now I know that that is the Government's policy, but I am not at all sure, at the moment, that it is actually being practised effectively at a local level.

  483. You also say that you would favour much greater use of intermediate care, both in nursing homes and in clients' own homes. From your evidence though, I get the impression that you have never really been truly involved in the development of those kinds of services; is that fair to say, in terms of capacity planning, have you ever had that kind of input, would you welcome it?
  (Mr Lewis) We would welcome it, we have not had it, in most instances; and we keep on qualifying this by saying there are examples of good practice within local authorities and within health authorities and trusts, and it would be quite wrong to deny that there is some good practice. That what we are saying is that intermediate care is not a bed in a different place, intermediate care is much broader than that, it is not just about discharge planning, intermediate care is about diverting people away from admission to hospital.

  484. So when you are talking about care in someone's home, are you talking about the kind of home care services that local authorities provide, are you wanting to develop those?
  (Mr Lewis) No, not commercially. To answer the Chair's question, I was suggesting that there is an expertise within the independent sector which should be harnessed. I think we should recognise that we are not all experts in everything and that there are clearly those agencies that are skilled in providing services within people's homes, there are those agencies that are skilled in providing the technology and the management of the technology at a local level. It is a question of bringing all those agencies together in a meaningful way, both to plan services and deliver services; and what we are saying is that those processes are not in place, in many parts of the country.

  485. I will finish off with one final question. Mr Austin mentioned the scheme in Birmingham, and you do also mention that elsewhere your facilities have not been used as much as you would like. Do you think that there is a problem, in that you are often in competition with yourself, in that people may go into intermediate care, or they may go into nursing care, and that that is a tension in the system? And if that is always not the case, would it help if people were guided more to the kind of capacity they need, rather than, at the moment, left to make the choice themselves; would that help your . . .
  (Mr Lewis) I think, crucial to individual care is the assessments, and if you have got the assessment right in the first place you can make a judgement as to what is the right pattern of care that that person needs; once you have done that then you can begin to talk about choice, but until that is done it is irrelevant. We have got to strengthen our capacity to provide multi-professional, comprehensive assessments of need, so that care is provided at the right point in somebody's life. Sometimes, as has been said earlier, we do not, we wait until there is a crisis, and then we are into fire-fighting.

John Austin

  486. I am conscious that we have actually been looking at intermediate care purely on the basis of a post-discharge facility, but, of course, intermediate care, or the facilities there, can be very useful in preventing a hospital admission. I cannot remember whose evidence it was in, that talked about the issue of direct GP admitting to intermediate care units. Would you like to expand on that?
  (Mr McClimont) Yes, absolutely. I was going to come in there, just to pick up on the intermediate care, in particular. An example in my evidence, at 7.5.a, chronic obstructive pulmonary disease can have individual hospitals treating up to 1,250 patients a year, and 80 per cent of those, in studies, prove suitable for diversion immediately from Accident and Emergency, where they usually turn up, directly into home care, where it can cut costs dramatically. Instead of possibly a month's stay in hospital, you can look after a person at home, with probably better results, at a cost of about two to three hospital bed days; and that is a diversion at the A&E. But, at the moment, for example, it is fairly rare for A&Es to include the services of GPs; something like 40 per cent of the people who turn up at A&E would be more appropriately seen by a GP than by Accident and Emergency staff. Now, if you can pick up large numbers of those by using a GP in Accident and Emergency, in the first place, or by using better `out of hours' techniques, for doctors out of hours, then you can avoid a lot of the congestion that occurs in the A&E in the first place, and reduce the wait there for admissions, because you do not admit them to hospital, you would send them back to their own homes with support. So direct arrangements for GPs, whether it is actually in A&E, whether it is on an `out of hours' service, or indeed during normal hours of GP operation, if we could give them the capacity to commission, within a framework, services of this sort, and people along the table all provide something that would help in this area, there is an enormous capacity to do that. And the technology can make a big, big difference here as well, because the capacity to send somebody with a piece of kit that will monitor them, in some cases, will give a level of reassurance to people for whom, frankly, the risk is not that high but it is a reassurance issue, if you can do that you again relieve some pressure.

  487. This takes me back to the exchange with Mr Lewis earlier, because, in your evidence, you have referred specifically to the constraints on the development of intermediate care services, and you pointed particularly to the limitations of task-based commissioning practices of local authorities. Could you tell us what you think needs to be done to remedy that?
  (Mr McClimont) I think this actually goes across both intermediate and long-term care commissioning. There is a need to start commissioning on the basis of an individual recipient of the service, rather than, at the moment, of coming with a service that one size has to fit all; and particularly in commissioning on the basis of an outcome for that individual, rather than saying, "Okay, until we've got the spare capacity to do another review for you, this is what you will receive, no more and no less, and that is broken down into ten minutes of doing that and five minutes of doing this." Again, care standards will require commissioners, because providers will not be able to do anything different, to change their practice in this area and allow that kind of greater flexibility. We should be moving from a basis of the current system of combined case and care management, in relation to home care particularly, to one where case management continues with the commissioner but the care management is devolved to the person who is delivering the care, which is a provider, whichever sector they happen to be in. There are big problems at the moment in local authorities; you asked whether it was health or local authorities that were causing these difficulties. In local authorities, one of the difficulties is that they are used to commissioning these long-term maintenance services, which are appropriate for some people but do not fit well with intermediate care; so when they are presented with a package of care which starts out very high and tapers away, without their being involved in that tapering remanagement, they run scared, they just do not know what to do with it. We had an example not very long ago where a service was introduced to a joint commissioning scheme and was approved by them, but the local authority refused, because the home care element of it was more expensive than their maximum price, so they withdrew the whole support for the joint commissioning scheme. On the other hand, health have big problems as well, because the consultants, in particular, will not let go, or will not think of alternative means of delivery that do not involve their unit. And we have an example that occurred in Swindon, not very long ago, where again the joint commissioning unit came up with a service, voted the money, had everything set up, but the consultants managed not to refer anybody, or allow anybody to be referred to it whatsoever.

  488. These are the problems?
  (Mr McClimont) Yes.

  489. So what needs to change to make that appropriate commissioning happen?
  (Mr McClimont) Some of what I said is the presumption of home care, that I said earlier; the other main issue is an outcome-based commissioning. The two elements.

Julia Drown

  490. Just to follow up. You said in your evidence about the payments by outcomes, but you also said about how you thought that the financial regime should change, to get financial disincentives to encourage patients home, and indeed to make sure that you penalise inappropriate discharges, and looking also at trying to encourage the discharge of services by financial means. Can you say a bit more about those?
  (Mr McClimont) I am hopeful that we have seen the green shoots of that in the announcements last week; but, as I said earlier, there needs to be a balance on the social care side with what I hope is going to occur on the healthcare side. We need to incentivise people to look at other options. At the moment, a hospital is paid for while a patient is in hospital; the moment they go out that bed is refilled and they have still got that cost, but they are picking up an additional cost, for which most of the time they do not perceive they have the funding.

  491. But providing there was the penalty for inappropriate discharges, you would support such a scheme?
  (Mr McClimont) Absolutely.

  492. Can you just say a bit more about the payment by outcomes scheme?
  (Mr McClimont) It needs to be done on both a population level and potentially an individual level, because it is no use having population statistics without judging what happens to an individual. So you have to look at commissioning on the basis of "We want this person to reach independence within six weeks," that might be a target; or your target might be maintenance, in some of the longer-term areas, but for intermediate care you would be aiming at a particular level of success. And one of the contracts that I am aware of, for example, sets a target for readmissions and claws back money, rather as the NHS is going to be subject to the same kind of process, claws back money if that is exceeded, and claws back money if you do not get levels of patient satisfaction, and claws back money if you do not hit various targets. So there are incentives to hit. But then, if you can deliver a quality, time-limited, effective service, and you happen to do it very cost-effectively, then I am afraid that, for a little while, until the next time the negotiation comes through, it will affect and improve your profits, or your surpluses, and some people will reinvest that directly into care and others will make their shareholders cheer; but, one way or the other, the individual user and the public purse have both got a good deal.


  493. Mr Rice, you deal with a lot of local authorities, various elements of the Health Service in different parts of the country, I would imagine; in your evidence, you talked about a complex, holistic problem, was a term you used. Bob Lewis was giving an example of, was it health, was it social services. You have put forward in your evidence suggestions of a need for this closer working partnership between the different elements; how do you see the most appropriate model for that to come about? From your experience of dealing with authorities throughout the country, are there areas that you would commend as being possibly the way forward for others to follow?
  (Mr Rice) Yes. PCTs should help immensely, once they get into their stride, in terms of operation, and they get the confidence to understand exactly how they should operate to best effect, because that clearly is a move in the right direction. There are some local authorities who are very forward-thinking already, in terms of an holistic approach to the issue of healthcare provision, West Lothian would be one, County Durham would be another, Sedgefield, who have schemes which offer an integrated package of healthcare which covers preventative healthcare in the home, deployment of technology, deployment of home help, or whatever, right through intermediate into the acute sector.

  494. Now is that on the basis of their common budget, or are they still separate budget heads that we are talking about here?
  (Mr Rice) At the moment, it is on the basis of split budgets, because we are too early into the new regime for them to have a single combined budget, and clearly it has only been operating for a matter of weeks. But they have anticipated, if you like, the future budgeting process, because clearly you do need to have a single pot of money that is capable of allocation, in a sensible way, to the various elements of the healthcare package. I would argue that you need to ring-fence certain pieces, because, given the pressures on the healthcare system these days, it is all too easy to divert money away from some of the longer-term issues, like preventative care, where the cost goes up at the front end but actually then comes down dramatically, one, two, three years in, as you have fewer people going into intermediate homes, fewer people going into acute beds. But it is very easy, rather like cutting training budgets in a recession for an industrial company, to attack those kinds of budgets, in order to address the fire-fighting issues which occur fairly regularly, more at the intermediate and acute end of the healthcare sector. But certainly I could send the Committee examples of an holistic approach in operation, in three or four locations, which would be a model for roll-out on a broader scale.

  495. That would be very helpful. And, presumably, there has been, within these particular examples, no dispute about where the social care element ends and the nursing care begins, they appear to have overcome the great divide?
  (Mr Rice) It is a difficult question to answer, because everyone wants to do a good job; it is how they see their priorities. Clearly, from the point of view of the clinicians, we touched on this earlier, I feel that we have not done enough to convince them of the benefits of technology, in order to improve the quality of life for the patient, and improve their own quality of life, in terms of the stresses of work. The social workers obviously have their priorities. It is not that they are not trying to do a good job, but with the funding being in separate pots and funding and care responsibility often not being in the same place, particularly with this issue about discharges, then there is a problem. Now I think the forward-thinking local authorities tend to have high quality management and they focus on getting the care pathway, constructed as a whole, and removing those kinds of boundary issues, and the way they do it is to have the social and healthcare people talking to each other and having a common set of protocols that they both buy into and apply.

  496. So you will supply us with further information on this?
  (Mr Rice) Yes.

  497. Ms Adams, presumably you also link with lots of different authorities; can I put the same question to you. What are your views about the way forward, in terms of them working together in a more effective manner, are there examples that you have picked up where you have felt that, yes, they have got the idea, they have got the potential that could assist other areas?
  (Ms Adams) Yes. We have mentioned Bristol already, where it is the one really clear-cut example where housing, health and social services are putting their money where their mouth is. I think we are in a sort of no-man's-land, at the moment, because there is the transition to Primary Care Trusts, and a lot of us have got great hopes and a few fears on this one, and I have made specific little suggestions about the direction and any directive that can be given to PCTs around prevention. I think the comment that was made earlier, about PCTs and all sorting themselves out at the moment, and it is not fertile ground for anything new, and we have to hope that in the longer term they will be. And the big worry is whether they will take a preventative stance, or whether a crisis intervention, completely medical model will prevail. And I have got some good examples perhaps in Cheshire, where they are looking at doing accident prevention work across the county, but then I have got three local schemes, where they were doing accident prevention, where the money has been withdrawn for, what you might call, the home-based accident prevention, tacking down the carpets, removing steps, putting up grab-rails, and the money has been shunted into a purely medical model accident prevention service, where people are looking at drug use and fitness. And, to me, that sort of rang alarm bells, because you have got the potential for pulling it together, but, with the PCTs and a medical model dominance, will we lose out on tackling the housing and the physical environment that people live in. On the issue of money, I do tend to think that we have to have pooled budgets; so often, unfortunately, it does boil down to where the money is coming from and what the priorities are. And my sense is, working in social services across England, I do not know whether in Wales and Scotland, I just get this comment over and again, when I am talking to people about prevention and small-scale stuff in Care and Repair, and adaptations and small things, it is like, "Well, we'd like to be doing that, we'd like to be doing prevention, but it's all fire-fighting." And we have heard quite a lot about the home care provision; the national analysis of trends in provision of home care is a downward trend in the numbers of people getting any help, and a small upward trend in the number of contact hours. And, again, it is fairly short-termism, because you are not actually helping the people where small things might keep them independent for longer and avoid that longer-term crash, I think that is the worry; but I think the Care Trusts will be very interesting, to see whether they tackle all of this. So it is some good news, good examples, you can work together. I would just like to put, I will perhaps get my chance later, but housing just does not come up very often in this, and we have heard a lot about intermediate care and delivering it to people's homes, and I just do have to say, we have to make sure the homes are fit to be in, you cannot deliver these things if those homes are unfit and in a very poor state, on lots of fronts. You are not going to send workers in where the electrics are up the shoot; it is very simple.

Dr Taylor

  498. What I really want to ask is not what I am going to ask, because I want us to get on to Tunstall and to hear about the innovations; but, before that, just very quickly, we have already heard about GPs and admitting to intermediate care, I gather, from the Independent Healthcare Association, that before 1993 GPs could admit direct to nursing homes. Is that so, that that stopped in 1993, and why did it stop and why cannot it start again?
  (Mr Hassell) It happened up until 1993 because of the funding arrangements at that stage. Without going into a lot of detail, from 1993, when the NHS and Community Care Act came into force, the responsibility for purchasing new places moved to local authorities, and therefore the right to place and fund was with local authorities. Hopefully, with PCTs, we will see them beginning to purchase a wide range of services, many of the services we have been talking about today, not only residential care but intermediate care, and indeed I think it is critical that PCTs understand the importance of purchasing intermediate care. I think one of the other services which we have not touched on today, which is relevant both to partnerships in providing services in the community and delayed discharge, of course, is the mental health facilities, because it is another area where there are huge opportunities for delivering better services. If I may say, Dr Taylor, just commenting on intermediate care, one of the reasons why some of the schemes that I outlined earlier have succeeded is because they managed to transcend the normal barriers, and, in fact, that health authorities and trusts, local authorities and independent sector actually manage to sit down together and work together. And I think our vision probably for the future is that we will see more of that sort of working, plus the assessed needs of people, giving us some form of seamless services, which would be beneficial to everyone.

  499. Thank you. I am desperate to go on to Mr Rice and really hear about all these innovations in monitoring in the home that we should be supporting, because I do not know that many of know what is available?
  (Mr Rice) The basic technology that the social alarm business is built up on was either a personally-triggered alarm or a fall alarm triggered by, what we call in the aerospace industry, an uncontrolled descent, i.e. software that interprets the fall and therefore can appreciate that the person falling is probably unconscious, or certainly going to be hurt, and can trigger an automatic alarm. Now that technology was the base for the business of Tunstall and the base for the other social alarm providers in the UK, it has moved on a lot from there, it has moved into two areas. It has moved into the area of providing total care support in the home; so, currently, the technology can provide support, for example, against flood, against build-up of heat, fire, intruder alarm, panic button, it can arm an intruder alarm behind someone going up to their bedroom, or whatever. And when you talk about the psychology of the elderly, of course, it is not just about them actually not being well, it is also about their perception of threat. So the technology is capable of offering a very complete protection package to the elderly, which keeps them at home, keeps their confidence up such that they can stay at home, which clearly, from our point of view, because hospitals, as you know, are very unhealthy places too, it keeps them at home, it gives them a high quality life and keeps the will to live high, which I believe, although we cannot prove this statistically, extends their life. The other area in which the technology is developing, and it is developing fast, is in what we call Telemedicine, or Telehealth care, which is vital signs monitoring and disease management; now this is where we can relieve the load on the acute and intermediate healthcare sector even more profoundly, and that is by measuring the vital signs of a person who is vulnerable. And it is not necessarily someone who is elderly, there are 1.2 million people with diabetes in this country, and we think there will be four million by 2010, it is a serious condition, with acute episodic attacks and an overall, gradual deterioration, which very much lends itself to Telemedicine care in the home, to minimise the extent to which care is required in intensive care units. But, equally, hypertension, with nine million sufferers, asthma, with several million sufferers, there is a tremendous number of conditions that do not necessarily affect the elderly, with which technology can help to relieve the pressure on the healthcare system. So that is why, when I look at the statistics, I do not think the statistics on bed-blocking are wrong, but they are measuring a fairly precise definition of bed-blocking; there are things that technology could do to free other beds in the system. Now what do we need to do to deploy it successfully; I think we have a major job in educating and selling the benefits of that to the clinicians, because, quite rightly, the clinicians take great pride in direct and intense control of their patient relationships and have a reluctance to embrace new technology. That is no fault of theirs, I think we really have not communicated it well enough, and that is the job that we need to spend a lot of time on over the next three to four years. It also needs, I think, support at Government and local authority level, because, properly encouraged, I suspect, it can have a very profound effect on the pressures on the Health Service, in terms of reducing admissions and minimising the need for additional investment. I am not saying there is not substantial need, for new hospitals but we can help to reduce the need. Building hospitals is not necessarily the only answer, in our view, it is deploying techniques, technologies and practices that reduce the need to use hospitals.

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