Examination of Witnesses (Questions 500
- 510)
WEDNESDAY 24 APRIL 2002
SUE ADAMS,
MR BARRY
HASSELL, MR
TONY RICE,
MR BILL
MCCLIMONT
AND MR
BOB LEWIS
500. It is one of those terrible things, you
have got to find the money to deploy it before you begin to get
the benefits from it; because, presumably, the costs are pretty
considerable?
(Mr Rice) To put the costs into perspective, one of
the things I did, when I took up the job, was, I looked at America,
and there is no scope for what we are doing in America, because
the healthcare insurers will not accept an increased cost at the
front end from preventative healthcare, because they do not get
the benefit for three or four years and they are really looking
on a two- to three-year focus. And that is why, I think, when
Mr Lewis talks about having budgets set over three to five years,
we really need to plan for an additional cost and then downstream
benefit. Is the cost high? Well, in the case of the deployment
of the basic technology, we are probably talking about £300
to £750 per annum, per person, there is then the need to
bear the cost of residential care over that. So that is not the
total cost. Obviously, the technology triggers false alarms but
it also triggers genuine calls that require human intervention,
and there is a cost attached to that, but we are not talking about
huge sums of money, against the cost of having 1,000 to 2,000
people with broken hips, in hospital, for, I do not know, 21 to
28 days, or perhaps longer.
501. That is why Mr McClimont was nodding his
head, is it?
(Mr McClimont) Absolutely.
Siobhain McDonagh
502. Ms Adams, this is a question that relates
to your point about poor wiring in people's homes. You highlight
the fact that most older and disabled people leave home and are
returning to ordinary homes in the general housing stock, and
the central contribution of repairs and adaptations. You argue
that a national housing strategy is required; could you tell us
a bit more about what that might entail? And, given that most
of your examples of housing barriers to hospital discharge relate
to conditions that exist prior to a person's admission to hospital,
is it reasonable to expect the NHS to make good such deficiencies?
(Ms Adams) I will split that in two. Looking at my
conclusion, as opposed to a recommendation, that we do need a
more strategic approach to housing and a national strategy, the
thing that really strikes me, when you look at health provision,
we have got a very strong, national agenda on health, with national
targets and national directions, but, on the housing front, we
do not have that at all. Put terribly crudely, the whole philosophy
coming on the housing front is, pass everything out to local authorities;
and the one national target, in terms of quality of housing, that
we have is a decent homes standard target, which only applies
to local authority stock. So the one target we have, in terms
of bringing the housing stock up to a decent homes standard, as
described by DTLR, it only applies to the housing stock that is
owned by local authorities, and the Registered Social Landlords
are subscribing to that, but their stock is pretty good anyway.
And, given that 70 per cent of people live in the owner-occupied
sector, there is no strategy on that front at all. I think there
does have to be an approach where local authorities do come up
with local solutions, but we need some sort of incentive, because
we have heard today about carrots and sticks for social services;
the reality is, on the housing front, for district authorities,
they now have a single pot allocation for all their functions,
and housing has to sort of fight for anything out of that. And
private sector housing, which is an entirely discretionary area,
has to try to argue to get anything out of the local authority
pot. And I just think that is lacking, I think there is no vision
around saying, "Well, we need to do something about housing
because housing impacts on health." That was a very strong
argument at the turn of the century, and it could be argued by
many people that the big improvements in health in this country
were because of housing and sanitation; but that has just been
sort of lost, with this generation, I think, perhaps because we
think we have solved it, people do not think, "Yes, we've
got 1½ million unfit houses." It is pretty obvious,
if you go to Blackburn and Burnley and parts of Leeds and Manchester;
it is not so obvious if you drive round rural areas, because that
is very scattered. If there was one thing I would like to just
see it is a national target around bringing things up to a decent
homes standard across the board, across tenure. Just before I
lose it, as well, I have made another very specific recommendation;
we are literally, at the moment, in the middle of a process of
wiping away the entire system of help for owner-occupiers. We
have had a framework of grants for 40 years and that is about
to be completely wiped away, under a regulatory reform order;
and the philosophy is that you are just going to give local authorities
this general discretionary power to help. And there is going to
be non-statutory guidance for local authorities. In the light
of what we are discussing today, about healthcare and the preventative
approach, about getting people out of hospital, I just think the
bottom line has to be at least statutory guidance that says, "You
will at least put some money into private sector renewal, which
furthers hospital discharge," if it is that specific, but
health prevention. Because, at a local level, I talked about fire-fighting
and crises, you have got new obligations on housing authorities
around homelessness, with the Homelessness Act, and if there is
a tiny amount of money to be spread around it will go on the areas
where you have got to meet the decent homes standard, you have
got to meet primary legislation around homelessness, and everything
else is discretionary. And my feedback, from a lot of local housing
authorities, which are my primary connection, is, "Well,
if we've got a limited amount of money, we'll do what we have
to do; and if we don't have to do certain things we wont do it
at all." And I think that is a great pity. There will be
a handful of very good examples, probably, but an awful lot where
there will be a `do nothing' approach, "Because we do not
have to." And I think we need a bit of a stick from central
government sometimes, as well as just handing out this generality
of power. Picking up on your second point, is it the responsibility
of the health sector; my response to that has to be, well, we
have got a problem here, and the answer has to transcend boundaries,
and, no, it is not just the job of the health sector. And my suggestion
is that we would encourage, through that, both guidance to perhaps
the health sector and social services and housing, that they should
be looking at pooling money for doing repairs and adaptations
to people's homes, as well as pooling their budgets for residential
and nursing home care. So, no, it is not just the responsibility
of the NHS; but, pragmatically, there is a cost to the NHS, if
you do not do anything about it. The average cost of the small
repairs that are being done by HIAs is around £200, and yet
it is costing, the figure I was given was, £326, with no
medical care, per 24 hours in hospital. So, in some places, there
have been years of examples where, in the face of not getting
money from social services and housing, health has put money in;
yes, it should be shared. And there are benefits then in the longer
term, or even the fairly short term. There was an initiative that
was very well received in Cornwall, where the health authority
put money into an initiative to improve the insulation and the
heating in the homes of children with asthma, and then there was
a huge reduction in the call on the health sector from those children.
No, it is not just the NHS's responsibility, it is not just the
state's responsibility either, we do have to look at the whole
spectrum of older people and think about housing in general. But
there is always going to be a sector where, equity release and
higher income, middle income, high equity households, they might
be okay on these new products that people are developing to provide
care and do things around their homes, but there is a swathe of
people, half of owner-occupiers are on low incomes now, a lot
of people in parts of the country are on very low equity, and
the private sector is not interested in them. So I do think the
NHS does have to share the responsibility, because there are long-term
savings.
John Austin
503. This is probably to Mr Rice, but Mr McClimont
and Mr Hassell may wish to comment, it is going back to the high
tech stuff. When the Committee visited, on its previous inquiry
into long-term care, we looked at one of the private sheltered
schemes, where the use of technology had enabled people to be
much more independent in the home, for everything from locking
the doors, opening the doors, drawing the curtains, without leaving
their door or chair. And you have talked to us, particularly in
your evidence on 7. about management of pulmonary disease, heart
failure and asthma, and I think some Members here have borrowed
some of the kit, I think, from a competitor company of yours,
to see how patient-friendly it is. And, clearly, this whole monitoring,
which can detect problems pre experience of symptoms, is of great
benefit. But are there limits to the use and exploitation of this
sort of technology, the substitution, as I said earlier, of high
tech for `high touch', and how do elderly, particularly, and disabled
patients feel about it?
(Mr Rice) The answer is, yes, there are limits. Technology
is part of the solution, but only a part of it, and it does not
remove the need for doctors and nurses to have face-to-face, hands-on
contact with patients; it merely can relieve the regularity of
that need, and indeed relieve the need for admission to an intermediate
or an acute establishment. So I think there are limits, yes. Having
said that, if you were to analyse in detail the precise reason
why every person is in hospital or in an intermediate care home,
I think you could find that a significant proportion could have
their healthcare administered at home by a combination of technology
and what would be a more mobile healthcare support force, who
would be visiting them as needed. So I would not argue that technology
is the answer. I think technology can help the solution, but all
I would argue is that it releases the stress on the system and
on the people who are operating the system, it does not replace
the need for them. There is also an issue about acceptance of
technology, and there are two issues there. One is, we have talked
about the clinicians; the other is, if we are dealing with the
elderly then, yes, they are reluctant to use technology, or they
are nervous of technology. I think, if you look at any of the
equipment that is offered in our sector, you will find that it
is very simple to operate, it has deliberately been designed to
be simple to operate and it is easy to learn. We are not talking
about video recorders here, which no-one can ever decipher. In
terms of operation or protocols, it is simple to operate, and,
we have direct monitoring voice links that can assist with any
enquiries about operating it. It is actually a problem that will
go away in 25 years' time, because the technological sophistication
of, with respect, our generation, as we get older, will mean that
we are very comfortable about operating that kind of technology.
Chairman
504. I think there are certain exceptions in
this Committee, to be honest with you.
(Mr Rice) And myself, as well. But that does not solve
the immediate problem, which is that we have got particularly
the elderly, who are very nervous about operating technology,
and we need to work hard, I think, to continue to make it simple
and to demonstrate its operation and give them the links that
they need. For example, it is not impossible to have a system
where there is almost daily contact with people who are being
monitored, not because there is a need for that regularity of
contact but really just to check that they are okay, it is very
important from the psychological point of view, and if they have
got any issues, building that kind of personal relationship, which
a number of local authorities have, with the people that they
are monitoring and caring for is very important in their psychology
and their general quality of life and will to live. So I think
technology is part of the answer, but it is not the whole answer.
Dr Naysmith
505. Mr McClimont, this afternoon, you have
been taking a pretty robust attitude and position about the capacity
to manage people at home, partly through Telemedicine and Telemonitoring,
and you have been nodding your head at a lot of the things that
have been said by Mr Rice. And also, in your evidence, you say
"home health care should be the first choice and the centre
of planning for the future;" so that kind of means a new
presumption of care in the normal place of residence, is what
you are really arguing for. Do you think this is viable, in the
short term, and how can we get to that stage; this does not really
happen at the moment, does it, it is not an immediate response?
(Mr McClimont) No, it does not. If I can pick up the
other half of it first. I just really want to point you to the
case studies that I gave in my evidence, in 6. For example, the
44-year-old mother with young children, who had her chemotherapy
at home, and during the period she was getting that, she would
otherwise have been in hospital, she managed to get a job, look
after her children, and all we did was switch the infusions to
the evening, so that she could do the job full time. A 79-year-old
lady who was able to live at home in the country, instead of being
admitted to the London hospital that was managing her care. A
middle-aged male executive, who carried on working throughout
intravenous antibiotics. Or anybody who has to wait four hours
in an outpatient clinic, just to get their blood pressure taken,
or something of that sort; absolutely absurd, and you can get
rid of those. Is it viable at the moment; yes. My presumption
of home-based care, yes, it is viable; it is viable because in
itself it actually has no cost, and it has no compulsion, that
that is what you are going to do. All it requires is for every
professional, when they are thinking about the proper care setting,
to think first about home care instead of first about hospital.
So that it is still going to be the case that many people will
go into hospital, it is still going to be the case that many will
go into residential and nursing homes, when that is appropriate;
and I have to say also that cost is still going to be a major
reason why you make that choice. But the first assumption will
be that you will go to home care first, and, yes, there is the
capacity, if we allow the funds to travel on the basis of "Can
we achieve an outcome for this individual?" rather than saying,
"I need to fund 53 beds in that particular building, in that
area." That is a structural problem; it is viable to do as
a presumption, what it will do is prompt the professionals to
make the changes that we need to make over time.
506. So who has to change their behaviour; where
does it come from?
(Mr McClimont) I think there are going to have to
be changes throughout the system, and all I am aiming for is somebody
to actually think about it before they act.
507. Mr Rice, I was just going to ask you about
your views on that, because you argue in your evidence for a UK-wide
policy for Telehealth solutions; so how do you feel that that
can come about?
(Mr Rice) Addressing that issue, the infrastructure
exists and is working now. Tunstall are monitoring people, in
the way that we have described, now. Only this morning, I was
at Bill's company and I observed patients being monitored, vital
signs, remote Tele-vital signs monitoring, in real cases, it is
happening now. We are talking about using existing infrastructure,
we are building new technologies on the top of it, but it does
not require, for example, new telecoms protocols, or anything
like that. So really the barriers are, I think, prioritisation,
and psychological, in the sense of accepting the ability of technology
to help in addressing the issue, and then taking the appropriate
measures to integrate it into the rest of the healthcare offering.
This is possible today, this is not talking about the future,
we are really talking about something that is being deployed as
we speak.
508. Finally, do you think it would be fairly
straightforward to get different commercial providers to work
to common protocols?
(Mr Rice) I think it would, yes. Clearly, it is in
everyone's interests to expand the market, because then we satisfy
a broader base of customers, and, frankly, in the end, we might
be working for 425 different local authorities and housing associations,
but we are working for essentially two customers, which are the
UK Government and all it represents, and the patients, and, therefore,
it is clearly in their interests to have common protocols. We
only have to look at the plethora of practice management software
and the problems that that causes, in terms of an integrated system
in the UK, to understand that it is in everyone's interests to
have a common protocol, and we would certainly support it and
I think the other providers in the industry would as well.
(Mr Hassell) I think what we are talking about here,
as far as I am concerned, is the diversity and development of
new services, and I think we would be foolish, in this country,
to ignore the potential of high-tech developments, but, at the
same time, I think, certainly, as you said, for our generation,
and I am pleased to say, I think the `high touch' approach is
probably more appropriate. But, clearly, there is a generation
gap, and, as Mr Rice has already said, changes will take place.
So I think it is another one of these strategic issues, where
we must have a strategic policy. What I think we are talking about
though really is the use of scarce resources, and it is only by,
I think, the optimal and imaginative use of all resources, whether
they are in the independent sector or the statutory sector, where
we solve some of the problems we have been talking about. For
us, I think, coming back to the main theme, a good bed management
and resource approach, and an holistic approach, to the use of
those resources, and providing the services for people, I think
it is only when we have that sort of approach that we will begin
to tackle some of the problems. We certainly are committed to
working together, to working in partnerships, to try to achieve
those ends, whether it be high tech, low tech, or services we
have not even thought about at this stage.
Jim Dowd
509. It is only just to take Mr Hassell back
to something, I did not want to interrupt at the time, because
I apologise, too, that other commitments kept me away for the
first hour, or so. In response to Mr Burnham, just when I arrived,
you were talking about the nursing fee element, and you moved
on, and I distinctly heard your last response, which was that
there had been other realignments at the time, but that it was
only a small proportion of the increase that was not, the part
that was absorbed by those increases, and (part of it ?) went
on. Would you say that £55, out of a £72 allocation
for nursing care was a small proportion, and Mr Lewis might care
to comment on it as well, because it was a constituent of mine's
mother to whom it happened, in a home run by your organisation?
(Mr Hassell) I think, every nursing home organisation
is an individual business and will make their own commercial decisions.
Clearly, from the example you gave, that is a large chunk of that
particular element, but they are entirely commercial decisions,
which I am sure would have been justified on the basis of local
circumstances. You have an example, I am talking very generally,
and that is the level at which I have to view these things.
(Mr Lewis) We took the view that there were increases
in costs that were being incurred; however, what perhaps is not
fully publicised is the fact that there were a substantial number
of residents in nursing homes run by Westminster where their fees
went down, as well as receiving their free nursing elements. We
undertook an assessment, often working with our colleagues in
the health trust, and we now charge fees that are based on the
level of need of the individual, so that we have three levels
of fee in a home, a minimum of three, and, as I say, some people
were very clear gainers; everybody gained, not a single person
did not gain something.
510. Well, that was the intention?
(Mr Lewis) Everybody gained; some people, their fees
actually went down. What we did not think was appropriate was
that, if we had a flat rate passing on of the fees, we ended up
with the most dependent people, whose care was the most expensive,
paying less than the most independent of the residents.
Chairman: Ms Adams, gentlemen, can I thank you
for a very interesting session. One or two of you have indicated
you would send us further information on certain matters; we look
forward to receiving that. Thank you very much for your co-operation.
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