Examination of Witnesses (Questions 20
- 39)
WEDNESDAY 13 FEBRUARY 2002
MS DENISE
PLATT, CBE, MR
DAVID GILROY,
MR RICHARD
HUMPHRIES, MS
MARGARET EDWARDS
AND PROFESSOR
IAN PHILP
Mr Burns
20. I want to move on to the question of your
monitoring of the length of delayed discharges. Could you just
confirm to me that I am understanding some figures you have sent
to us in advance? Am I right in saying that if you round it up
to the nearest full point, 40 out or every 100 people involved
in delayed discharges are actually kept in a hospital bed for
over 28 days?
(Mr Gilroy) I believe that is correct. I did a similar
sum and came to a similar conclusion.
21. I must say I do find that quite staggering
because 28 days is by any definition a long period of time, given
that whatever anyone says it is infinitely more expensive to keep
someone in a hospital bed financially when they should not be
there than it is to place them in residential care and I suspect
also in domiciliary care. How can it be 40 per cent, actually
the largest percentage group? Just to remind you in rounded figures
23 out of every 100 are fewer than 8 days, 18 out of every 100
are 8 to 14 days and 20 out of every 100 are 14 to 28 days. You
have 40 people out of 100 languishing in a hospital bed when they
should not be there, at great expense and depriving the Health
Service of valuable resources to spend on other forms of care.
How can it happen?
(Mr Gilroy) That point is very well made. It is taken
in the Department of Health. May I say two things by way of response?
The first goes back to the boring definition which I read out.
That definition allows for no time whatsoever to conduct a full
assessment of what a patient's care needs are when they leave
hospital. It must be one of the very, very few performance targets
which gives no time whatsoever to due process once the hospital
based team has decided the patient is fit for discharge. What
has to happen then is that the patient's post-hospital needs need
to be looked at and that is what happens. In our judgement that
virtually explains the majority of people who are delayed for
less than eight days. Delay is an emotive word. It does not have
the emotive context in relation to the way the Department's definition
is applied at that end of it.
22. I must say, with respect, you are beginning
to sound like the Prime Minister at Prime Minister's Question
Time. If that is the case, from the way you are speaking you are
giving the body language that you think this definition is either
wrong or outdated or not a realistic definition because it does
not take into account this period for assessing. Is that a fair
assessment?
(Mr Gilroy) I was merely interpreting the effect of
the definition on the analysis one needs to do on the numbers
of people delayed and making the point that up to eight days that
time is actually being occupied, or should be where local council
social services and health authorities are doing their job properly,
conducting very speedy assessments.
23. If that is the case, then the logic of your
argument, correct me if I am wrong, is that you think that the
definition is not ideal because it does not take into account
this time for these assessments and in fact you should knock eight
days off.
(Mr Gilroy) From the perspective of the National Health
Service the definition is dead right because it actually counts
from the point at which the patient no longer needs to be in hospital.
It is absolutely dead right. The only point I am making is that
it does not allow, before this slightly emotive connotation which
comes with the word "delay" kicks in, for any time to
conduct the post-hospital discharge assessment. I am beginning
to repeat myself.
24. I am glad you are because it is beginning
to become a little clearer to me. I must say I am getting rather
confused by your interpretation of definitions. You did say, did
you not, that the definition was absolutely right because it is
a definition of the number of days when someone is in hospital
when they should be elsewhere.
(Mr Gilroy) Yes, from the perspective of the NHS;
absolutely right.
25. I shall get back to my original question
then because we now understand that. Is it not extraordinary and
why is it that 40 out of every 100 patients are staying in a hospital
bed under your definition, if I have understood it correctly,
for more than 28 days when they should not be in a hospital bed
at all because there is no clinical reason why they should be
there?
(Mr Gilroy) That brings the other point in. That point
is taken. We are seeking to prioritise the use of the additional
resources, the extra £300 million—£100 million
this year £200 million next—to target at that end of
the delay and we have management information which suggests that
it is working, that the biggest number of delays being taken out
of the system is at the heavy end. That is absolutely right. This
policy is not just driven by a policy of moving people out of
hospital, but making sure that people get the right care in the
right place at the right time and are not languishing in a hospital
bed. We are specifically trying to target the resources at the
end you are concerned about.
(Ms Platt) I just wanted to say something not concentrating
on the group you are concentrating on, because I know why you
are concentrating on them. If we look at the reasons why people
are delayed in hospital at any one time, regardless of whether
they are 28 days or eight days, when we looked at our September
monitoring figures and before we put the additional money into
the system, 22 per cent of people were waiting for their assessment
to be completed and that could be for a number of reasons, not
necessarily social services reasons, it could be specialist reasons,
it could be a whole range of reasons. The question to be asked
is whether people have to wait in their hospital beds for that
assessment to take place. 21 per cent of people at that time were
waiting for social services funding. We know that since we have
had the special grant we are making inroads into those reasons.
11 per cent of people are awaiting further care in the NHS, transfer
to somewhere else. 20 per cent of people are waiting for a care
home placement. 6 per cent of people are waiting for a domiciliary
care package and 8 per cent of people are waiting because they
were exercising the direction of choice which allows them to choose
which home they will move to. The question you have to ask again
is whether an acute hospital bed is an appropriate place to wait
while you make that decision. We would say that this is where
we see the development of intermediate care slow stream type facilities
playing a part so that the assessment can take place properly
and in a different environment. People might wait in a different
environment while they are waiting for different solutions so
that we can free up some of the beds which currently people are
in wrongly and probably doing their health no good while sitting
there.
26. You have both said in your answers that
you have evidence that the extra money, the £300 million
over two years, which has been made available is beginning to
make an impact and it has been targeted at the top end of the
problem. Do you have any figures yet to back that up or is it
anecdotal evidence?
(Ms Platt) It is not anecdotal. What we have is that
councils are monitoring their spend very carefully and we have
access to their monitoring figures. We shall need to wait for
the quarterly monitoring return following on from September to
know what that real inroad is.
27. You will be aware in another field that
local authorities, when they have problem cases they have a statutory
duty to house, if they do not have housing stock, they possibly
put them into bed and breakfast accommodation. Right?
(Ms Platt) Yes.
28. Do you think it would be appropriate to
put patients who are bed blocking, for want of a better phrase,
into bed and breakfast to free up NHS beds?
(Ms Platt) I suspect if people were fit enough to
cope in bed and breakfast then we could find a solution based
in their own home to support them, that they would need more care
than you would get in a normal bed and breakfast place. The whole
reason they are waiting is because they do need more support in
their own home. If they do not need any more support or they can
cope in a reasonably independent environment, which bed and breakfast
accommodation is, then they should be at home.
29. Basically it is not an ideal alternative,
not a panacea.
(Ms Platt) No, not without other facilities put in
place.
30. Given your role as Social Services Chief
Inspector, would you care to comment on what I believe is happening
in Shropshire, where this is happening?
(Ms Platt) I do not think it is happening in Shropshire.
Shropshire social services have had an interesting offer made
to them that farmers who are looking to diversify their business
at this difficult time might offer accommodation to people who
are in hospital in beds inappropriately. Shropshire social services
are of course looking at the option which is being put forward
but are looking at it from the point of view of appropriate care
rather than just getting people into any environment.
31. Can you categorically tell us as of now
that Shropshire is not doing this?
(Ms Platt) I can tell you that Shropshire have had
this offer made to them and I am not aware that they had made
any such placement. If I were aware, I should want to know a lot
more about it.
32. When did you become aware that Shropshire—
(Ms Platt) Two days ago.
33. So fairly updated.
(Ms Platt) I hope so, but it sounds as though you
may know more. If you do, please tell me.
Mr Burns: Members of Parliament tend to be reliant
on other people for information and one has to believe what one
is told. I am very grateful.
Chairman
34. May I just ask about the issue of discharge
planning? The delayed discharge question is interesting. We have
an agreement as to when a person is fit for discharge. What I
want to know is when the discharge agreements begin. If I am going
into hospital to have a double amputation of my legs, surely somebody
will realise that when I come out I shall not be able to dash
upstairs to the loo and to the bedroom. When does the planning
actually start? The definition you have given us appears to imply
that is only when there is this agreement. Does it start before
then and if so when?
(Mr Humphries) In every part of the country there
should be an agreement between the Health Service and social services
about what procedures should be followed about discharge. Good
practice means that in many cases the actual process of assessment
should begin when the person is actually admitted because it will
be clear that, if for example an elderly person is facing major
surgery, they will not be able to be discharged without some sort
of care or support. These days we encourage colleagues to view
discharge not as an event, but as a process which does require
careful planning and the earlier that starts in the person's stay
in hospital, the better it will be.
35. Presumably it could also be before they
go into hospital in certain circumstances.
(Mr Humphries) Indeed; absolutely. That is even better.
Dr Naysmith
36. Going back to definitions, what is your
definition of this multi-disciplinary team which has to be called
in to decide whether people are fit?
(Mr Humphries) It will depend on the particular needs
of that individual, but a typical multi-disciplinary assessment
would involve a social worker, it would involve nursing staff
on the ward who know the patient, it might well involve a physiotherapist
or occupational therapist and it could involve other clinical
specialisms as well.
37. How difficult is it to set up an individual
assessment of that type? Can it take time to do?
(Mr Humphries) It can take time but where there is
a proper multi-disciplinary team approach in place, it all should
begin to happen very quickly. It will be helped by the introduction
of the new single assessment process because one of the difficulties
that does get in the way sometimes is where different professionals
need to do their own separate assessments. All that will be brought
together under the new single assessment process and that should
make things a lot easier and make things work.
38. I was not quite clear when you said that
a single consultant could be part of this process and then the
multi-disciplinary team. Can a single consultant decide on her
or his own that this can happen? When do you call in the multi-disciplinary
team?
(Professor Philp) The key to whole systems working
seems to be in the detail of how care is delivered that brings
a multi-disciplinary response to the needs of the older person.
The National Service Framework for Older People sets out a number
of service models which we know are good practice and are conducted
in parts of the country to level up so that all services have
that standard of care. Within the general hospital standard it
specifies the components of the specialist multi-disciplinary
team for older people by professional group and that is a medical
consultant in geriatric medicine, a nurse, an occupational therapist,
physiotherapist, a dietician and a social worker. The leadership
needs to come from people with specialist knowledge, but good
whole systems working does not mean that every member of the team
in every case has to do his bit of the assessment because teams
need to work in the way that they understand each other's roles
and responsibilities and for a particular patient it may be one
or other member.
39. Are you saying that they do not need to
meet every time?
(Professor Philp) That is a requirement in the National
Service Framework for Older People. The specialist team needs
to meet and needs to establish the standards of multi-disciplinary
assessment throughout the hospital including the requirement to
begin discharge planning within the hospital early on in the person's
care. A point which is important for the Committee to pick up
on that my colleague Mr Humphries was mentioning is that the single
assessment process, which we are introducing to promote whole
systems working, means that information has to be passed on within
the system so that prior knowledge of an older person's needs
defined by the primary health and social care team should be available
to the staff who are assessing the older person on their admission
to hospital. That prior knowledge would include information about
their housing status, their levels of mental functioning and any
physical impairments they may have which would threaten their
independent living.
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