Examination of Witnesses (Questions 1
- 19)
WEDNESDAY 13 FEBRUARY 2002
MS DENISE
PLATT, CBE, MR
DAVID GILROY,
MR RICHARD
HUMPHRIES, MS
MARGARET EDWARDS
AND PROFESSOR
IAN PHILP
Chairman
1. Colleagues, may I welcome you to this first
session of our new inquiry on delayed discharges and welcome our
witnesses and express the Committee's thanks to you for coming
along today. We are grateful for your written evidence as well.
May I ask you each to introduce yourself briefly to the Committee
and say a little about the work you do so that we are aware of
your contribution?
(Professor Philp) I am National Director
for Older People's Services at the Department of Health responsible
for leading the work on rooting out age discrimination from the
National Health Service and for implementing the National Service
Framework for older people's health and social care services and
one day a week I am Professor of Geriatric Medicine at the University
of Sheffield.
(Mr Humphries) Richard Humphries. I have recently
been appointed as Director of the Change Agent Team within the
Department of Health. This is a team which has been established
to provide practical support to local authorities and health colleagues
in tackling problems of delayed discharge.
(Ms Platt) Denise Platt, Chief Inspector, Social Services
Inspectorate, but here also as Director of Older People's Services
at the Department of Health, a responsibility which spans both
health and social care.
(Mr Gilroy) I am David Gilroy, I am one of Denise
Platt's two Deputy Chief Inspectors in the Social Services Inspectorate.
(Ms Edwards) I am Margaret Edwards. I am Director
of Performance for the Department of Health. I am responsible
for managing, monitoring and hopefully improving the performance
of the NHS; recently appointed, my previous background is as a
Trust Chief Executive.
2. Probably the most appropriate opening question
would be: what do we mean by a delayed discharge? Who would like
to spell out the terms we are using so we agree broadly that we
are talking about the same thing.
(Mr Gilroy) We do have a definition. It is a definition
which is best read rather than read out. I will read it out and
if I may I shall give your stenographer a copy of it. I am very
happy to respond to questions on it and I may add a few comments
when I have read it out. The approach the Department takes is
to define a delayed transfer of care as occurring ". . .
when a patient is ready for transfer from an acute hospital bed
but is still occupying such a bed. A patient is ready for transfer
when: (a) a clinical decision has been made that the patient is
ready for transfer; (b) a multi-disciplinary team decision has
been made that the patient is ready for transfer; and (c) the
patient is safe to discharge or transfer. This applies to ALL
patients of ALL ages who are occupying an acute bed. The delay
starts immediately from the time that the decision in (a) and/or
(b) is taken and (c) is satisfied". May I try to interpret
that because that is the bit which is hard to do unless it is
in front of you? (a) is that a clinical decision has been made
that the patient is ready for transfer and (b) is that a multi-disciplinary
team decision has been made that the patient is ready for transfer.
The stuff about (a) or (b) is because sometimes the clinical decision
is taken as a part of the multi-disciplinary team approach and
then (b) is satisfied. Where a consultant makes a separate decision
not joined up with the multi-disciplinary team approach, both
have to be satisfied. That is what that is about.
3. We are interested in the numbers here and
we have some figures from your evidence. You did make some changes
in your methods for measuring delay last April. What impact did
that have on the numbers in question? What were those changes,
briefly?
(Mr Gilroy) We changed the definition basically .
. . . .
4. How.
(Mr Gilroy) To this one.
5. What was it before?
(Mr Gilroy) No consistent definition was in place
which was the problem.
6. So across the country we had different people
being defined as delayed discharges.
(Mr Gilroy) We had many many different health authorities
adopting their own approach to it and that was clearly not making
it possible to have any monitoring of the problem.
7. The change basically was the introduction
of a consistent form of definition.
(Mr Gilroy) Yes.
Mr Burns: What did changing the definition to
the uniform one do to the statistics you kept on the number of
people who were bed blocking? Did they go up or did they go down
as a result of the change in the definition?
Chairman: Or did they vary from area to area?
Mr Burns
8. Presumably they cannot have varied if you
brought in a uniform definition throughout the country. Did the
figures go up or down?
(Mr Gilroy) They went up marginally at a national
level over a period of a couple of months. Regionally and at local
level, they did go up and down because people had either tighter
or less tight definitions beforehand and this definition therefore
impacted on them somewhat differently. There was a marginal increase
nationally during the early months of this financial year.
Chairman
9. You talked about all ages. Am I right in
understanding that the figures we have are just the over-75s or
are they all ages? Are the figures you have given in terms of
percentages in your evidence and the figures we had when we did
our expenditure inquiry, where we got a figure, as I recall, of
an average of 6,000 acute beds blocked in any one day, simply
over-75s or all categories?
(Mr Gilroy) The percentages you have in our memorandum
relate to over-75s. The 12 per cent figure as at September last
year is the rate of people over 75 who are occupying a hospital
bed and who have their discharge delayed. The percentages are
for over-75s.
10. So the real figure of delayed discharges
is higher than the official figure.
(Mr Gilroy) That is correct.
11. Presumably the difficulties in evolving
packages of care subsequent to the acute phase are more acute
where we are talking possibly about fitter younger people.
(Ms Platt) I should just like to say what we understand
the figures to be and then come back to your question.
12. It is helpful at the start for us to understand
that we are talking about the same issues.
(Ms Platt) Absolutely. The figures we get are measured
quarterly in the quarterly monitoring statistics collected by
the NHS. In September 2001 12 per cent of over-75s in acute beds
could have been placed somewhere differently and would have been
more appropriately placed somewhere differently.
13. Could you express that in terms of numbers?
(Ms Platt) Not off the top of my head. Somebody behind
me might pass me a note.
14. If somebody could pass you that at some
point that would be very, very helpful.
(Ms Platt) 12 per cent of over-75s in acute beds were
inappropriately placed in September. That figure has come down
progressively since 1997. We are making inroads into this problem
although very slowly. 6 per cent of acute beds—not people—were
occupied by people of all ages who could have been moved somewhere
else. Yes, there might be trickier and complex resource issues
about younger people, because we are very often in the arena of
people who have had severe accidents, head injuries, those sorts
of issues. Our concern about the over-75s is that the delayed
discharges here are a symptom that we need to do something about
the totality of the system for older people. Actually just homing
in on the issue of delayed discharges is concealing that there
is a systems issue. That would be our concern.
15. Can we look at the cost here? I am interested
in the welcome initiatives announced by the Government in October:
£300 million for councils, building up care capacity through
cash-for-change grants. In December there was the additional £425
million which takes us to £725 million. Interestingly, we
did a calculation, and it may be a back-of-the-envelope job and
I cannot guarantee how accurate it is, but from our expenditure
survey, the figure we extrapolated from the information given
by the Department of Health was that the average cost of an acute
bed per year was £120,000, that according to the information
we were given then—and I believe it was for October—6,000
beds were blocked. Multiplied that seemed to be roughly the amount
of money that the Government had put in to deal with the problem.
Would you accept that?
(Ms Edwards) I am sorry, I missed part of the question.
16. We are trying to establish first of all
the definition. Mr Gilroy has given us some very helpful information,
so we understand what we are talking about. The figures relate
partly to the over-75s and partly to all ages. We understand the
distinction there. What I am concerned to establish in an attempt
to look at the best use of our resources is what it is costing
the Health Service to have these people blocking beds. The figure
we came up with, a rough calculation from what was provided by
the Department in October/November on our expenditure survey,
was that at that stage 6,000 beds were blocked, the figure given
was that the cost of each bed was £120,000 per year, multiplied
that comes to roughly the amount of money the Government has put
in to deal with the problem. My concern is, and we are looking
at the best use of resources, that it is costing a significant
amount of money not to unravel this problem. What I am trying
to establish—and I appreciate you may need to take advice
on this—is the Department's estimate of the cost of this
problem. If we work out the costs, I would humbly suggest the
solutions might possibly be a good deal cheaper.
(Ms Edwards) The principle you are putting forward
is correct in the sense that this is not an appropriate use of
NHS resources. It does not necessarily always follow in our experience
that the actual alternatives are cheaper. What we are working
through at the moment is some quite interesting work looking at
as you build up intermediate care, as you build up alternatives,
the costing not being the main driver. The main driver is appropriateness
of care. The biggest issue for us is that we do not want to be
creating additional elective capacity and emergency capacity in
acute hospitals to keep people who should not be there in them.
It is not a financial issue at the moment. Our plan is estimating
at the moment a cost neutral shift on the whole of moving these
patients into other facilities. What is important is making sure
that we get the right facility so we do not build additional acute
beds when we do not need them.
17. I do not want to over-generalise and I fully
take the point you are making that there are very different costs
involved here. In my area one of the two local authorities I cover
has a maximum £250 per week home care package, so we have
people stuck in hospital beds because the local authority are
not prepared, without all sorts of deliberations, to pay more
than £250. We are paying more through the public sector for
them to be stuck in hospital. Frankly to me that does not add
up. I think we need to do some serious calculation about how we
are utilising our money.
(Ms Edwards) Yes; I accept that.
18. We may come onto the common budget question
in due course. If you are able to come up with some figures, I
should be very interested, even if it is after this session.
(Ms Edwards) Yes, we can do that.
(Ms Platt) We know the money we have put into social
services from the building capacity grant is only tackling the
symptom of what we currently have. It was only for two years.
As part of the spending review, we clearly have to negotiate for
a broader range of resources which can generate the capacity in
all local communities, which is not forcing people into boxes
just because they exist, but is providing a range of services
which support their very different needs. Some of those resources
might be utilised to prevent people getting into hospital in the
first place. We are doing some of that work in the Department
at this minute as part of our spending review proposals and are
just finalising them with the Secretary of State. If you asked
whether the Department of Health knows how much resolving this
problem will cost, we would say to you at this minute that we
could give you a variety of models of care which would resolve
it, but we know that to resolve it will generate demand for more
resources across community health and social care. If you are
talking about pooled budgets and looking at money which is locked
up in the acute sector at present and redeploying it differently,
part of another problem we are trying to solve is by getting older
people—and we are talking predominantly here older people—in
the right place at the right time we release occupancy in the
acute sector which is necessary to deal with the admissions through
A&E, the cancelled operations and all those sorts of problem
which are elsewhere in the system. It is not "if you take
it from here and put it there you do it differently", it
is quite a complex whole systems issue.
19. We understand that. What we should like
to do is really lift the debate a little bit on what the full
costs are because I am certainly well aware, in fact I have scribbled
down on my notes here, that there is an economic cost of a waiting
list. Here we are talking about people occupying beds and preventing
others coming into hospital, preventing people earning a living,
we understand fully that the economic cost has to be estimated.
(Ms Platt) That is absolutely right. May I just say
something about the economic cost to the local authorities that
you know very well? An episode of care can be a short period in
a hospital in the acute sector. A package of care, whether that
is in the community, domiciliary care, residential care or whatever,
can be a package which lasts two or three years. Actually the
investment you are asking the local authority to make is not just
a unit cost on the day and those are the things we are needing
to look at.
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