Examination of Witnesses (Questions 40
- 59)
WEDNESDAY 13 FEBRUARY 2002
MS DENISE
PLATT, CBE, MR
DAVID GILROY,
MR RICHARD
HUMPHRIES, MS
MARGARET EDWARDS
AND PROFESSOR
IAN PHILP
40. How often does it happen that a multi-disciplinary
team meets and then decides that the individual is not ready to
leave hospital? Does that happen very often?
(Professor Philp) I meet with my multi-disciplinary
team every week and many of the people we are discussing have
extremely complex problems on average taking six or seven drugs
each of which reflects a serious problem with complex problems
in their home environment, who is going to look after the dog,
the state of repair of the home and so on. The role of the team
is to think creatively about the problems that person has but
recognising we want to ensure that older people do not have to
stay in hospital for longer than they should but their needs are
not going to be met by a simple move to long-term nursing-home
care. Most older people want to resettle back home. We are developing
this range of intermediate care services which bridges the gap.
People going into intermediate care services from hospital have
to have regular multi-disciplinary assessments of their needs,
so for these people who have complex problems throughout their
passage through the system, both within hospital and following
discharge, until a suitable long-term solution is found to meet
their needs and their condition has stabilised, until that has
taken place, there needs to be regular multi-disciplinary specialist
review of the needs.
41. You are not answering my question. I understand
what you are saying. You are telling me that it is complicated
and that people have prior knowledge, they get together, not just
to discuss discharge but to discuss other things as well.
(Professor Philp) It is standard good practice. The
short answer is yes, it does happen.
42. How frequently?
(Professor Philp) The frequency in hospital for an
old person with complex problems is usually on a weekly basis.
43. So if someone has their situation assessed
one week, then it is seven days before it can be assessed again.
(Professor Philp) No, because the care management
of the individual is ongoing. The team needs to co-ordinate their
relative contributions to the person's care and ideally will be
based on the older person and the family's views and priorities
about what they need and want as well as the professional perspective.
That is a stock-take meeting. In between times there will be people
who are taking the lead in the person's care and carrying through
the management plan and revising that in the light of changing
circumstances.
44. You say it is good practice and I am sure
you are very much associated with good practice but I bet there
are lots of places where practice is not quite as good as where
you operate.
(Professor Philp) We know that, because we have an
ageing population and older people are now the majority users
of hospital services, two thirds of hospital beds are occupied
by older people with complex problems, it is not enough simply
to have a specialist multi-disciplinary service for older people
in hospital doing good practice. Every hospital in the country
will have a specialist multi-disciplinary team, every general
hospital doing good work. The key challenge is to spread the good
work so that all practitioners in the hospital setting have the
skills and competencies to manage people well which includes the
team meetings. The answer to your question is that not every general
ward has a weekly multi-disciplinary meeting of the relevant specialists
and they should. We are moving towards that as part of the implementation
plan for the National Service Framework for Older People general
hospital standard, which is standard 4.
Dr Taylor: My immediate concern has been answered
by the discussion because Mr Gilroy's original answer to Mr Burns
rather implied that discharge planning did not start until the
multi-agency team got involved when it should start the moment
the patient goes through the door, which I think we have been
reassured about. May I just come back to Mr Burns' point about
Shropshire? It is not only Shropshire. In Worcestershire I have
had many letters from extraordinarily angry farmers who think
they are going to be expected to look after intermediate care
patients in their bed and breakfast places.
Julia Drown
45. You are saying that if people in the interim,
before the meeting comes up, could be discharged, problems could
be resolved. But are you telling us that there will be some issues
where you do need the multi-disciplinary approach and if that
meeting was on Fridays and an issue came up on Monday they would
be waiting for most of the week before it could be resolved?
(Professor Philp) It is certainly bad practice if
the team meetings get in the way of the efficiency of using the
hospital bed and an older person moving on. It is good practice
to have regular reviews and to anticipate problems. What would
happen between a team meeting, if it was thought that an older
person could go home within a couple of days of admission to hospital
and if they had complex problems but going home meant going to
an intermediate care service at home, that would be perfectly
acceptable, provided there was further ongoing multi-disciplinary
review. We are looking now not as a simple, "This is your
hospital package and this is your community package". We
are trying to integrate things by having the single assessment
process as a way of integrating assessments, recognising that
people's needs are transparent and their care is transferred from
one place to another. The principle is that you do get ongoing
multi-disciplinary review until the person reaches the next stage
in their care needs.
46. You said what you want to do is spread that
best practice nationally. How long does it take to spread this
practice?
(Professor Philp) We have set quite challenging milestones
in the National Service Framework for Older People. We are looking
up to 2005-06 to implement best practice across all the domains
in the National Service Framework and we have particular milestones
relating to the general hospital standard about establishing the
key interfaces, ensuring that effective discharge planning procedures
are in place from the beginning of a hospital admission for old
people. Someone can give me the figures as to when these particular
milestones are, but they are set out year on year up until 2005-06.
47. Can anybody else who is working on this
say when we might expect best practice to be across the country?
(Ms Platt) The Health and Social Care Change Agent
Team which Richard is leading at the minute is here to start the
promotion of best practice around planning, working together,
joint working together and getting the system better together.
It is a team which has a core team working at the centre with
Richard and a lot of people who are practitioners in the service,
who know what they are talking about, who are best practitioners
who can be called in to help others. We have funded Richard's
team until the end of the year in the first instance and then
we shall review how far we have got. Some of this is big cultural
change around attitudes and all the things you have been talking
about, about the hospital system getting in the way. It can be
not just when the multi-disciplinary team meets, but when the
pharmacy is open, when the ambulance gets arranged. All sorts
of systems operate in institutions which people get used to and
part of the role of the Change Agent Team is to get in there where
there are difficulties and to try to help people unblock their
own systems so they are not holding up the patient from getting
out.
48. But we may all have to be delayed a long
time before we get the answers.
(Ms Platt) I hope not, because some of us are getting
closer to retirement than others and would quite like it to be
sorted out.
49. You did outline and in the evidence are
some of the main reasons for delays. Could you say a bit more
from your perspective about where the main frustrations are, where
you think the quick gains could be and where some of the more
longer-term gains are?
(Ms Platt) The issues which different parts of the
country face are different. In the South East the problems which
are faced by councils in the South East are the care home capacity
and the level of fees. Much of what those councils will be doing
is reviewing their fee structures and their fee policies. In other
parts of the country the issue is a lack of capacity of staff
because many of the care workers we are talking about in home
care services or care assistants who work in these facilities
are often on very low wages, so are attracted into other parts
of the economy. That plays itself through again into a local authority
commissioning strategy and how much the fees are. In other parts
of the country it is because the range of services we are talking
about in intermediate care is inadequately developed so people
may be going too quickly into residential care when with the proper
rehabilitation facility they may have gone home with the very
minimal type of care package. We have identified a variety of
reasons in different parts of the country, which is why some of
this is a very local issue and why we want to go into very local
systems to work out what it is we need to unblock.
50. You said in your evidence that one link
identified by the national beds inquiry was high levels of acute
bed provision with more problems and also that where there are
inappropriate patterns of service for social services these are
often the results of the historic availability of surplus care
home capacity at low cost. Both of those seem to suggest that
more beds actually could result in more problems.
(Ms Platt) It is certainly the case that where there
are beds people are very anxious to fill them. That might not
be the best in the long term and it is easy to do without a proper
assessment. We do know, in talking to older people, that they
do want to go home and to be supported at home while it is safe
for them to be so. Because we have not had the investment in intermediate
care and rehabilitation, in the past it has been quicker and easier,
if the facility has existed, to place people in an environment
where, when they have been there for a bit and their house has
been sold, it is very difficult to move out even if their level
of functioning has improved. We come back to where I started really
that you can tackle in some very crude ways the issues of delayed
transfers of care but actually this is about a proper service
development for older people, so they are in the right place,
getting the right care at the right time and that should be our
longer term aim. We have some short-term strategies which can
be driven and hit all those targets, but if we want to get some
sustainability in the system we have to develop a new pattern
of service for older people which gives them more choice and independence
and a variety of care where they want to be.
51. Does that mean, if there is a potential
problem with having more beds because they just get filled, that
rather than what most of us did, which was to welcome the 7,000
additional NHS beds, we should instead be rather concerned about
that?
(Ms Platt) I am sure that NHS beds are always valuable
because they can always be used for a variety of circumstances.
What we would want to emphasise is that it is not just beds. You
can have beds in people's own homes. It is actually the best package
of services which enables people to be where they want to be.
52. Trent is the region which is doing best
on the figures at 3.3 per cent. Do you have in your mind that
Trent still has some way to go or is there some nominal percentage
that you would take, given the points Mr Gilroy made, as acceptable,
as what one would expect to have best practice?
(Mr Gilroy) The judgement we are making at the moment
is that there is a figure below which you cannot get it while
the definition is as it is. It is about 2.5 per cent rather than
the 6 per cent it is running at at the moment. Trent, like everywhere
else, has health and social care communities in it which are in
trouble and the worst of the ones on that list, the South East,
has health and social care communities which are doing pretty
well. It is very patchy as an issue. We think Trent got to Change
Agents first probably. They have been running a collaborative
across the health and social care system designed to get the top
managers into showing common leadership rather than parachuting
in where there are problems. We do think they probably got somewhere
rather faster than the rest and part of the background to the
Change Agents initiative is running that sort of approach out
more generally.
53. Mr Burns was talking about 40 out of every
100 patients being there for over 28 days. Is the issue not 40
out of every 100 but 40 bed days out of every 100 bed days and
in fact it is just a few people who are spending a very, very
long time in NHS acute beds? Is that right?
(Mr Gilroy) Yes, that is right.
Mr Burns
54. Can we just check that is right? I thought
it was not.
(Mr Gilroy) It is older people and it is based on
the proportion of the number of people who have their discharge
delayed by this length. My immediate answer was wrong.
55. Yes, it is the number of people, not the
number of beds or the proportion of beds.
(Ms Platt) Yes, for the over-75s we are talking about
numbers of people. 12 per cent of over-75s.
Julia Drown
56. No, no, no, we are talking about over 28
days. It is not 40 out of 100 people. It is 40 per cent of the
bed days are taken by a few people.
(Mr Humphries) No, it is 40 per cent of people who
are over 75 whose discharges were delayed.
57. Right. So percentage of delays is not percentage
of overall delays it is the percentage of the people. I wanted
to clarify that.
(Mr Humphries) No, it is the percentage of the people.
Jim Dowd
58. You have given us six specific grounds and
one "Other reasons" as the principal causes of these
delays. Is there any correlation between different reasons here
and the different segments shown in the delays? For example, would
that be uniform across all those four bands or are there more
particular reasons resulting in longer delays or particular reasons
which can be more quickly resolved resulting in shorter delays?
(Ms Platt) The things which are within our control
quickly are speeding up the assessment and introducing the good
practice reasons that Professor Philp was talking about. Those
things are quicker to get into place. Anything which relies on
new capital development is clearly longer to get into place, which
is why looking at how resources can be differently used is an
important issue here and one of the things we are encouraging
people to do on the ground. A lot of local authorities, for example,
have residential care or sheltered housing accommodation, which
are not used for those purposes, but could be used for a different
model of service if we could staff them up and use those services
differently. We are encouraging people to look very innovatively
at what they can develop. Clearly anything which requires capital
or people to be recruited to expand capacity is going to take
longer than speeding up an assessment.
59. I am just extrapolating at the moment. Although
home adaptations and equipment only account for 6.7 per cent overall
it could well be a much higher figure of that 39.5 per cent at
that end.
(Ms Platt) Yes.
Dr Taylor
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