Examination of Witnesses (Questions 100
- 119)
WEDNESDAY 13 FEBRUARY 2002
MS DENISE
PLATT, CBE, MR
DAVID GILROY,
MR RICHARD
HUMPHRIES, MS
MARGARET EDWARDS
AND PROFESSOR
IAN PHILP
100. Is there any structural reason why assessments
could not take place, not just immediately upon admission, but
even prior to admission? You know what procedures people are being
brought in to experience and given that some cases vary but in
the generality of it it should be possible to start planning then,
should it not?
(Ms Platt) Yes. Where it is known when the older person
is going to be admitted, and quite often we are talking about
people who have come in through an emergency situation, yes, in
some of the work we are doing about choice, where people are waiting
for admission, they will have allocated to them a personal adviser
who will explore all the issues that the person may have to tackle
before going into hospital and coming out and that would be the
point at which the link could be made with social services.
Chairman
101. May I pursue this whole systems issue?
Ms Platt can guess the angle I am going to approach.
(Ms Platt) Yes, I can see it coming.
102. It seems such an obvious point that we
have people in one sector and we are spending more money on them
in that one sector than it would cost to have them in the other
sector. Why on earth do we not do the most obvious solution which
this Committee and others have put forward of integrating the
two organisations and avoiding all this nonsense of this split
system? Is it the real barrier? I have never got to the root of
the objection to organisational integration. Is it the difficulty
we have with one element being under the 1946 Act and free and
the other being means tested under the 1948 National Assistance
Act? Is that the key to it? It just strikes me that we could actually
save money, quite substantial amounts of money, by having a sensible,
integrated organisation.
(Ms Platt) I want to say a number of things about
that. Yes, there are clearly issues around health and social care
as two organisations but in many ways what we are confronting
when we are looking at the issues of delayed transfers is an issue
across the balance of primary care, social care, community health
and the acute sector and the coalition of interest here has to
be primary care, social care and community health. It requires
a different range of resources in those sectors to be developed
and to relate to the acute sector differently across the piece.
The organisational opportunity that the Government has created
across those sectors is the opportunity to have a care trust development
which does give an integrated arrangement, an organisational integrated
arrangement and one set of accountabilities. We have demonstrator
projects which are resolving quite a number of issues for us around
setting up care trusts based on PCTs and that is what we are talking
about in this area of activity if we are looking at services for
older people and delayed transfers of care. We are very grateful
to the demonstrator projects because we had the ideas and the
ways to integrate, but some of the practical difficulties we have
encountered along the way are taking some ingenuity to resolve.
As we go through them, it will become easier for us to encourage
more people to develop care trusts in the long term. I am not
sure I am answering your question as to why we do not just get
on with it at health and social care level. I am pointing out
to you that on the ground we see the coalition of interests and
the collaboration being in the primary care and social care local
government sector and to provide the opportunities to do that.
103. Do you know how many of these demonstrator
care trusts there are?
(Ms Platt) At the minute we have 15 authorities we
are working with, four authorities we are aiming for April; we
are trying to sort out at the minute issues around transfer of
pension rights. As we work with the demonstrator projects we are
identifying some real issues which have to be resolved by other
government departments using regulations before Parliament. Waiting
in the wings we have 30 more local authorities who have expressed
interest in working with us and part of Richard's team is about
helping people develop care trusts where they want to.
104. What about pooled budgets? What is the
extent of use of pooled budgets?
(Ms Platt) We have about 80 different local authorities
using pooled budgets in a variety of ways out there. Pooled budgets
too have the difficulty which you have identified which is charging
for some services and not charging for others.
105. Is that at the heart of the reason why
we cannot move forward to a much more sensible system?
(Ms Platt) It is not the only reason.
106. But it is one reason.
(Ms Platt) It is certainly a complexity which has
to be overcome. It is not insurmountable because clearly those
people who are going to have PCTs where social workers are seconded
in or become full-blown care trusts are having to overcome it.
It is not insurmountable. In all these arrangements if people
are determined to do something then we shall find ways through
and that is what the demonstrator projects are helping us to do
at this minute.
107. Would you accept that the pooled budget
way forward which certainly attracts me as a limited reform faces
problems where you have this discrepancy on the resourcing of
the NHS versus personal social services. My own area is a good
example where one of the local authorities has been bringing about
a £2 million cuts package. No PCT is going to go into bed
on a pooled budget with a local authority in such circumstances.
I suspect that kind of scenario applies elsewhere. Is that a reasonable
point?
(Ms Platt) The difficult issue around pooled budgets
is that it is easy to pool a budget but the difficult thing is
deciding what it is going to be spent on, what the strategy is
for its use and how it is going to be allocated. Even if a local
authority is in dire straits financially it can still have a discussion
with its local health trust about what the strategy should be
and the level of resource to be put into it. It might not be as
adventurous a solution as some other areas because of the difficulties
the local authority might be facing. The difficult bit about pooled
budgets is to agree what the strategy is for its spending. That
is the case in all the partnership arrangements we have; that
would be the case in care trusts too, looking at what the strategies
are which are going to be developed through the delegated powers.
108. Would you accept that it is utterly barmy
to have people stuck in hospital beds at three or four times the
cost of a community placement, which is what we have at the present
time?
(Ms Platt) Indeed, but it is not that easy. There
are immense possibilities through shifting the balance of power
now PCTs have the commissioning responsibilities. Whether that
commissioning responsibility extends to paying a percentage of
what you might pay a hospital for its acute bed and using that
instead to fund a care home placement is a matter for further
debate. You could destabilise the acute sector.
109. Before we move off this whole subject of
systems, do you have any thoughts, Professor Philp, in this general
area? You are semi-detached in respect of the team which is here
and probably have a freer role. Do you have any ideas on how we
might move this one forward, what structures in particular?
(Professor Philp) We fought very hard as a team in
the Department of Health while we were developing the National
Service Framework for Older People not to take a partial view
of the system of health care for older people but to try to get
a whole system, large view of health and social care for older
people, although we did not extend the work into housing and transport
and other issues. We are coming at this, fundamentally looking
at how health and social care work together. Throughout the National
Service Framework mechanisms are being put in place to support
integrated working: single assessment process for health and social
care; development of intermediate care services which have a health
and social care dimension; discharge planning; development of
integrated community equipment supplies; services for people with
dementia, falls, stroke, depression, that take the whole view
and not just health and social care but also the independent sector
and primary carers. One thing we have are service models which
will be pushed out through the country. The other side is winning
the hearts and minds particularly of the primary care leads. I
have been out on the road 32 days in the last nine months visiting
health and social care communities and always wanting to meet
with primary care leads and social services leads in localities.
The mood is different. The mood is one of these leads seeing their
role as taking an holistic view and having to work together. There
are some grounds for optimism there in terms of the leadership
which is developing through primary care. Then there are financial
incentives for joint working and we are looking at developing
performance measurement which will enhance joint working. You
ask me to talk about structures and what the National Service
Framework for Older People promotes, following discussion with
the Local Government Association, is that the unit for strategic
development locally of older people's services should be local
strategic partnerships where these exist and where they do not
exist they should be developed so that it brings all the parties
to the table including the independent sector and representatives
of older people. I think you are pushing me to go a little beyond
that.
110. I am talking about the health and social
care divide which I think is unsustainable and I have thought
so since it developed in the 1970s.
(Professor Philp) It is the biggest fault line that
we have to address in meeting the health and social care needs
of older people. What I have outlined to you is that several initiatives
are being taken, mainly through the National Service Framework
for Older People but there are others which Ms Platt has mentioned
and another which is Care Direct, a system to route people through.
Having visited several countries in the world and looked at their
health and social care systems, including Northern Ireland where
there is an integrated delivery system for health and social care,
there are still fault lines within that system.
111. The resourcing of that system is not integrated
which is the key problem.
(Professor Philp) Indeed. Where you get anything which
promotes better joint working between health and social care that
is a good thing.
(Ms Platt) Here the health and social care divide
is not the main fault line. We have also experienced that there
are divides between primary care and the acute sector and primary
care and community health. There are almost in many ways as many
divides within the NHS system as there are outside it and with
other systems. If you move across the health and social care divide
you still have the housing issue. Many of the solutions we are
looking at with older people's care are more in the housing sector
and housing developments. When we are talking about integrated
care, we are not just talking about health and social care, although
that is clearly a very important part, we are talking about an
integration across the health care system as well as with social
care. The point I was trying to make about the coalition of interest
is that the coalition of interest we see in the community is local
government, community health and primary care coming together
in a very different way now that we have PCTs and we can develop
care trusts out of the PCTs, rather than just putting them all
together and the acute sector still tips the balance of power.
It is the coalition of the commissioning arrangements. The PCTs
are going to be the big commissioners in future and we would look
to them to overcome a variety of divides which can also be between
individual professionals no matter which system they are in. When
we are talking about integration we are actually trying to look
at it in broader terms than just the health and social care divide.
(Ms Edwards) I would agree with that. This shifting
of the balance of power arrangements does give us quite a unique
opportunity because the statistics, but also my own personal experience,
show that one of the big issues is often discharging from an acute
hospital into a community hospital and different structures. By
having the PCTs actually responsible for providing the primary
care and increasingly going to be providing the community care,
but also commissioning the secondary care, for the first time
we are going to have one organisation looking at the whole pattern
within the NHS and making that judgement. Because of the size
of the PCTs, I feel they will also be much closer to the ground
in terms of being coterminous with local authorities. We are not
all the way there in terms of a total integration but we are so
much further than we were perhaps a year or two years ago in terms
of what we have from 1 April when we go fully live with all the
PCTs. It is going to be very interesting to see how commissioning
develops.
112. Do you detect any resistance from local
managers in social services and health? I had a PCT Chief Executive
say to me recently that he felt he was being asked to marry the
Director of Social Services before they had even started courting.
I said that if it was up to me they would be in bed together and
would have been for years. Is it an issue from your point of view?
(Ms Edwards) Your comment that they should have been
talking before now is a valid one and it would be worrying if
we were bringing together people who were not already together.
We will have new relationships because of the individuals being
appointed but in terms of the principles and the roles, those
discussions should have been going on and what we are doing is
making sure that they are going on in those places where they
are not.
(Ms Platt) We should not underestimate the amount
of turbulence that there is in the system as we do move to the
new structural organisation in the NHS. I visited one authority
recently which had a very good track record of relationships with
health services, with many joint services developed together.
However, the Director of Social Services was having to get to
know nine new chief executives with whom he had not worked before.
Some of those relationships have to be re-established and we acknowledge
that but we are encouraging that and we are also encouraging the
new strategic health authority chief executives who are all in
place now to ensure that the proper strategic relationships are
made and that proper joint working is set up right from the start
in the new trusts. This is an opportunity we have not had before.
Sandra Gidley
113. Most of what I wanted to ask has probably
been touched on because my questions were around shifting the
balance of power and the development of the primary care trusts.
One comment which was made does concern me and I should like to
pursue exactly what was meant by it. The comment was that if we
go to full budgets we could destabilise the acute sector. Could
you elaborate on that?
(Ms Platt) I was responding to what I thought was
the question that if you spend £120,000 on an acute bed and
you had a full budget across health and social care, you could
spend the money on a cheaper care home bed in circumstances where
I heard you say the local authority was strapped for cash so the
largest part of that pooled budget might actually be the health
bit. What you would therefore be looking at would be a transfer
of resources in the pooled budget across from the NHS sector to
purchase a community care, social care provision. That could have
been a resource which the acute sector was relying on in terms
of its occupancy, its activity. We have to be very careful around
setting up pooled budgets to be clear what they are for and what
is pooled. I think at the minute the acute sector does have problems
in responding to all the waiting list issues which it has to respond
to and all the issues about accident and emergency. If the argument
is that you can take a bit of it and pay for this person to go
to a care home to help out the local authority because they are
in financial difficulties then that could be a problem.
(Ms Edwards) We have talked about occupancy rates
and the modelling and the university-type analysis which has been
done actually shows that a hospital should be running at 82 per
cent to virtually avoid—you could never be 100 per cent—long
trolley waits for emergency admissions and cancelled operations
on the day. We know that over half our hospitals are running well
over that and some considerably more than that. One of the things
we would want to see as we reduce the delayed discharges would
be that actually helping to lower occupancy rates. There is a
whole issue then about how you do that and simultaneously shift
the money. One of the things we are working through in the spending
review is what we need to lower the occupancy rates and what we
need to do to delayed discharges but not necessarily assuming
that there is a completely equal relationship. All we will do
is to continue to run our hospitals with slightly fewer patients
because we have moved the delayed discharges but running them
just as hot. What we actually want to do is cool some of the hospitals
down in terms of their occupancy rates. That is the sort of modelling
we are doing nationally and we are asking each local economy to
do that: how are you going to get 82 per cent locally and within
that what contribution would delayed discharges make and what
contribution would intermediate care? Quite a lot of work is going
on to make sure this is all planned systematically and all the
streams are brought in, not just the delayed discharges.
114. Have you identified any advantages or other
disadvantages or concerns in shifting the balance of power particularly
in relation to the impact on the existing patterns of joint working
other than the potential funding?
(Ms Platt) One of the things I touched on is the organisational
change and the change of personnel which is going on at the minute.
That has had a short-term impact on the quality of joint working
just because of people not knowing who it is they have to talk
to even to set up the arrangements we are talking about. As those
people are now coming into post and as the strategic health authority
chief executives are now all in post, we can start to make the
right connections and get the joint working off the ground properly.
Local authorities want to work in a different way with these new
arrangements. They have been part of PCGs. Social services personnel
have been sitting on primary care groups and this is an extension
of that. I do think they want to continue that joint approach.
115. Someone expressed a concern to me, a great
reluctance really to go down this route, generally coming from
social services, that they feel they are going to lose control.
Is this a valid concern or is this something which is gradually
being addressed?
(Ms Platt) The whole reason for the changes we are
putting in place is so that the service can make the most effective
response to individual people living in communities. The control
we would want to see is the person using the services having control
over the way in which those services are delivered, having an
input into that. If professionals are saying to me that we are
losing control, I might say good because maybe the control ought
to be in a different place. Some of the concerns I have heard
social workers say is that this is an overtaking of a social model
of care by a medical model of care. I actually think that if you
look at what the changes are which we are trying to deliver in
the NHS at the minute in terms of a patient focus and an NHS focused
on patient needs, and the services moving round the patient and
not the other way around, that is a very good description of what
a social model of care is probably about. A social worker's experience
in developing that model can be an enormous contribution in a
primary care setting as primary care is trying to set up new commissioning
arrangements and new service arrangements in communities. What
social services know about is purchasing packages of care for
individuals, which is a very different sort of commissioning from
a block purchase of a number of beds. It is about having the block
purchases there but looking at the person's individual needs.
The system can benefit very considerably by the social services
contribution in these new integrated arrangements. I am continually
saying to social workers that they should not be timid in these
circumstances about what they have to offer but go for it because
together the system can put the person who needs the service in
better control of what is going on.
116. I would agree with you in practice but
the reservations have come from senior managers rather than social
workers on the ground which says something. Do we not need those
people on board and signed up to this if it is going to work at
all?
(Ms Platt) Yes; exactly. I agree and we need to get
out and about and say some of the things I have just said, which
we do.
Dr Taylor
117. I am delighted there is so much stress
on integration, particularly between primary and secondary care
and the community. One of the bits of written evidence we have
had from the Stroke Association comments that medicine for the
elderly is still largely hospital based. Do you see, with the
development of PCTs, taking on the physicians who are looking
after the elderly and defining part of their time as working in
the community, in people's homes, in care homes? It always struck
me as completely ridiculous, before I retired, that as a physician,
not for the elderly, I was called to do domiciliary visits to
elderly care homes when they should have had a geriatrician looking
after that specific care home. Any comments?
(Professor Philp) The analysis is a very important
one. May I just give a very short history of the development of
the specialty of geriatric medicine? There are three phases. The
first phase was the development of the service outside the main
centre of the system, taking over the old fever hospitals, largely
a domiciliary service. The second phase was the incorporation
of the specialty into the heart of the general hospital and into
the centres of the corridors of medical power so that the specialty
is now very powerful but it lost some of its reason for existence
in that process in that it disengaged from some of the community
and longer term aspects of care for older people for which it
has an historical mission and purpose: to meet the needs of frail
and vulnerable older people in whatever setting they are in. For
that reason, I spent the last year as a very high priority working
with the leadership in the specialty of geriatric medicine thinking
about the challenge of moving into this new world where much care
is going to be delivered in the post acute setting in the community
and that geriatricians need to be engaged in that, not as the
dominant leaders but as contributors to the delivery of care outside
hospital in partnership with others and that a specific example
of what we are doing in that area is that the British Geriatric
Society and the Royal College of General Practitioners are now
engaged in a bilateral to develop a job description for a general
practitioner with a special interest in older people's services
to work as part of the specialist service to help with the specialist
service to discharge medical responsibility with an intermediate
and long-term care for older people. That would be a key development
for improving medical care of older people in this country.
118. That is very interesting. Most of the specialties
are looking to supplement their numbers with general practitioner
specialists. Is there an expectation that all social care will
be commissioned through care trusts within five years?
(Ms Platt) There is no such target as that. The care
trusts are still voluntary arrangements as systems settle down.
As people get used to new arrangements and see new organisations
coming into being and see benefits, this is a journey we should
like all local authorities to explore actively. They may decide
that they can deliver the same sort of integrated outcome without
organisational change and it would not be our wish to force organisational
change if they could. The emphasis must be on a different outcome
for the person and a single system of care; even if not a single
structure of care but one system.
Chairman
119. I understand that 1 March is the end date
for health authorities and local authorities to agree the eligibility
criteria for continuing care. Am I correct in that and is that
programme on course?
(Ms Platt) Yes, as far as we know.
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