Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 282 - 299)




  282. Colleagues, can I welcome you to this session of the Committee, and particularly welcome our witnesses; we are very grateful for your assistance with our inquiry. Perhaps I could ask you each briefly to introduce yourselves to the Committee, starting with you, Mr Webster?

  (Mr Webster) I am Andrew Webster, I am the Director of Public Services Research for the Audit Commission, so I am here to expand upon the written submission that we have already made.
  (Professor Swift) I am Cameron Swift. I have the Chair of the Health Care of Older People at King's College Hospital, and I am President of the BGS; and, like my colleague, I am here to enlarge on the written submission that you have already had.
  (Dr Dearden) I am Andrew Dearden. I am Chairman of the BMA's Committee on Community Care. I work as a GP in Cardiff, and I will chair soon the Welsh GPs Committee, and I am here, again, to expand on our evidence and to answer the questions that you have.
  (Mr Dolan) I am Brian Dolan. I am an emergency care nurse consultant. I work with challenged organisations and trusts, and not least with the winter emergency services team, in places like Bristol, the John Radcliffe Hospital, East Kent and other challenged places.

  283. So, presumably, you have got specifically a nursing background?
  (Mr Dolan) I am an emergency nurse, I am a mental health nurse, I worked at King's College Hospital in the A&E primary care service for a number of years.

  284. Thank you. Can I thank you all for your written evidence, which has been very helpful. Perhaps I can begin by a brief question, before bringing in Mr Burns on some wider points. One of the issues that we have been exploring, in the sessions that we have had so far, has been the actual costs of delayed discharges. I do not know whether any of the witnesses, I am looking particularly to you, Mr Webster, to see whether you have any figures. I was a little surprised that when we had the officials in, at the start of the inquiry, a couple of weeks ago, they did not have an estimate of what the cost of this problem to the NHS actually is. As you may be aware, we have done some calculations, I am not sure whether these calculations are accurate, but based on figures we extracted from the Government in our Public Expenditure inquiry. Do you have any thoughts in this area, have you actually looked at the cost question from your point of view?
  (Mr Webster) We have not looked at the cost across the whole system. If you look at our individual pieces of work, we have looked at the costs in particular areas, so we can, for example, give costs about the difference between someone staying in hospital and getting a decent piece of equipment, or the cost of a package of home care and the cost of a hospital bed; and, from that, you could do the kind of calculation that you have done. But I think that we ourselves are equally disappointed that such an overall picture is not available, and we have found it difficult to produce one, partly because of the definitions of how much of each type of thing there is, and partly because of the basis on which they are costed within the NHS and within social care. So I think we feel similarly frustrated that, in individual cases, individual councils, yes, we could come to a particular cost, but adding them up across the system, no, we could not.

  285. Can I put to you, the figure that we came up with was, as you probably know, according to the information we received from the Government last year, the average cost of an acute bed per year is £120,000; we were told, at the same time, by the Government that there is an average of 6,000 beds blocked, but a calculation of that came to, I think, £720,000 a year in England. Would you differ from that, with your knowledge of the elements that you have referred to, do you feel that is a reasonable assessment, or do you feel perhaps we have miscalculated, we have made certain wrong assumptions, would you question that assessment?
  (Mr Webster) I would question the things that are absent from it, I think.

  286. Tell us what you would question then?
  (Mr Webster) Clearly, there would have to be some other things in place for those beds not to be used by the people that are in them, and you would need to have an adequate costing for those. And I think the whole thrust of our submission to you is that actually identifying the cost of one bit of the system does not really give you the answer, what you have got to do is model the cost of the whole system. And what we have been encouraging individual health communities and local authorities to do is to sit down and do precisely that, look at everything they have got, look at all the costs, map it out, see where the pressures are, see where the payback would be; and our experience is that they find that incredibly difficult to do, because of the difficulties of sharing the information, having consistent understanding of the costs, and because of differences of view about what is in the map and what is not in the map. So I think that you could come to a headline figure that definitely there is money that could be released to do other things, but it would not come to a simple figure like that, because you would have to calculate the cost in the whole system; that would be different in different places.

  287. Do any of the other witnesses have any points to raise, on this, specifically?
  (Dr Dearden) I do not have any specifics about the actual cost of the beds themselves, but what might also be worth factoring in are things like the actual cost of the patient time and the relative time that they have to take off, to take people back to the GP, etc. Also, another significant one is going to be the drug costs; for example, if someone can have a bypass done today then actually they need a tenth of the drugs that they might need over the next 18 months. So one of the additional costs to a bed that is blocked, to use that phrase, is the knock-on effects to the people who cannot get operations done; and then you have got GP time and district nurse time, for example, where the nurses perhaps are seeing people once or twice a week, where, if they could get those things done, they may need to see them then actually only once or twice more. So actually there is quite a community effect and a community cost to each acute sector bed, and, as has been said, that is a little bit more difficult to factor in.

  288. I think also the economic cost of people who are ill and cannot get access to a bed that is blocked by somebody who does not need it?
  (Dr Dearden) Absolutely.

  289. We have looked at that. Does Professor Swift have anything to add to it?
  (Professor Swift) There is no simple answer to it; a simple end-point is a national rise in duration of stay of hospital bed occupancy by about 2 per cent, and that is a very simple, measurable end-point, which has massive implications, of the proportions that you have been describing. And hospital bed occupancy, if it is inappropriate, unquestionably is the most expensive component of the system. So, I think, as an end-point in itself, it is crucially important; and the trend, of course, is extremely worrying, as well as very frustrating, for those of us who work in the system.

  290. Mr Dolan, do you have anything to add?
  (Mr Dolan) One of the problems with delayed discharge is that actually we do not do enough to avoid their admission in the first place; because it is not going to be delayed if they do not have to come in. And some work we are doing in East Kent hopefully is going to release something around 60,000 bed days, which is the equivalent of 164 additional beds in that health economy, simply by initiating a raft of measures, such as rapid access to endoscopy clinics, so they do not have to wait weeks on end, getting very quick responses to whether they have got a DVT, enabling the rapid response team, so that the nurses can go into the A&E department, if somebody has got an acute chest infection, take them home, look after them for a relatively short period of time. Now there is not going to be delayed discharge, they are not going to get sucked into the system, if we do not have them in, in the first place. And I know all the points my colleagues raised are absolutely right, but I think I would pick up particularly Andrew's point, there is the human cost, which to some extent is not particularly measurable, but its profound social and personal impact perhaps is greater, and it has a knock-on effect to the NHS at large, because it undermines people's confidence in the National Health Service.

  291. In the system you are describing, the alternative system, have you done any calculations as to what it would cost to develop that alternative system, but what it would save in relation to the occupation of acute beds?
  (Mr Dolan) Yes, we have. We are going to pump something like £6.2 million into the local health economy, but that will save around its own cost as well, in the longer term; because what you are doing is making the service a lot more efficient, so people are not sitting in beds for long periods of time when actually they did not need to come in, in the first place. So the back end, in terms of how much it saves, has not been measured up yet, but we have actually got very clear costs; even just 50 emergency slots for a week across that health economy will save something like 7,800 bed days, so a little, even a 1 or 2 per cent difference, can have a disproportionate knock-on effect, which has to be good for patients, more than anybody else.

Mr Burns

  292. Mr Webster, in your 1997 report, The Coming of Age, it was described there was a vicious circle in which too few resources to support people at home meant that older people often were admitted to hospital, increasing the pressures on hospital lists. It also went on to say that the length of stay in a hospital was declining and that that was giving fewer opportunities for rehabilitation and increasing the pressure for admissions to residential and nursing homes. This, in turn, obviously, had a fairly dramatic impact on local authority resources, and then had a knock-on effect on the whole funding mechanism. Would you say that, five years down the line, that is still the situation, or have there been either improvements or a deterioration, or a shift in the problem, as a result of this?
  (Mr Webster) I think that things have changed quite a lot since 1997, and we have been following that work up, through the work that our auditors have been doing and through other studies. And I think there are clearly some areas where there have been significant improvements, particularly the development of the intermediate care, that rehabilitation point about do people get more support to get home. There is more evidence that things are jointly funded and managed between health and social care; in a recent analysis we did of intermediate care, nearly half of them were wholly jointly funded, rather than relying on one service or the other. And there are places where quite radical changes have been made to the distribution of resources, so that there is less pressure in the places that we identified. So I think we can point to a number of improvements. But clearly there are areas where things are still causing difficulties in the way that we described, in that vicious circle, and, I guess, three. One is the prevention point, which some of my colleagues have already made, which is all these costs are incurred only because people get in the system in the first place, and some relatively simple interventions, quite often, could stop that. Secondly, co-ordination, it is still an immensely complex process for people to get through the whole system, all of those stages. And, thirdly, there is evidence that social services budgets are still under very substantial pressure, and the average that a council is spending is 11 and 12 per cent above SSA; lots of them have got overspends on children's services, lots of them are having difficulty meeting their estimates on older people's services. So I think you can identify that the capacity to change as fast as that report suggested was necessary is still quite difficult for people to deliver.

  293. Would it be too simplistic to suggest that if, in the Budget on 17 April, in the Health Service financing, the Chancellor were to concentrate this year on personal social services, rather than on the acute side, because, certainly after year two of this Government, one has seen substantial increases in the money to the Health Service, particularly, which has been concentrated, more or less, in the acute side, if the Chancellor changed tack and started to pump in significant increases in the projected amounts that he was planning to do on the PSS side of the Budget, would that solve the problem, or is that too simplistic and there are still other ingredients that mean there is a problem? Because you do have the situation, as you rightly have suggested, that local authorities are spending significantly over their SSA on social services, you have the care homes complaining that the local authorities are using their dominant position to force down their prices, so there is a situation frequently where the self-funders, in effect, are subsidising the people being funded, or part-funded, by local authorities, and you see care homes closing, because, of course, the value of their property probably greatly exceeds the effort it takes in keeping them open?
  (Mr Webster) I think it would be too simplistic to think that would solve the problem.

  294. So what would be better then than simply increasing significantly the money to PSS?
  (Mr Webster) I guess it is worth pointing out, there has already been quite a substantial increase to PSS.

  295. I am taking that as read; but—but—on the other side of the coin, those in the sector, and certainly those in local government, in social services, who have the responsibility for providing social services, would argue that that is not the case in reality, whatever the figures are, it is nowhere near enough to meet the ever-increasing demand?
  (Mr Webster) I think I would go back to saying, where is that demand coming from, because still there have been more people placed in care homes every year, over the last few years, so there has been a continuing growth of people going into those homes; there has been more focus of home care on the more vulnerable people, so there has been more attention paid to the people who might be presenting those kinds of pressures. And I think that it would be much more constructive to produce a stream of funding that required particularly community health care and social services to be looking together at how they deploy resources, rather than thinking that if you pumped a lot of money into one bit of the system, because it is really the kind of opposite side of the coin to if you had more beds there would be a solution, well, if you had more beds in an acute hospital, some people could stay in them longer, if you had more beds in care homes, some more people could get in. We have looked at some councils where they have managed to reduce the number of people going into care homes, prevent people needing that care, have not placed any greater pressure on the acute system, and have got better outcomes for the people; a lot of work has been done, for example, in Hammersmith and Fulham, to completely re-engineer that whole system. And, I think, if you were going to put money in, it should be directed at enabling people to do that, rather than put more money into care homes.

  296. Just one final question, because it is rather interesting, from something you have just said, have you done any work to assess the comparative costs between providing someone with a domiciliary care package and someone being put into a residential home, to see if it is noticeably cheaper to keep someone in their own home with a care package?
  (Mr Webster) We have done comparisons, but I think it is difficult to come to a conclusion that it is going to be cheaper for any individual, because it depends very much when you do it. A preventive package of care for somebody at home could be very cheap and save you a lot of money later, but you may be in the position where somebody could get a better outcome staying at home, with a lot of frailties, that is more expensive than going into a care home. So if you wanted to get best value for money all our studies would point to prevention, aimed at the times when people were most vulnerable.

Sandra Gidley

  297. Another question to Mr Webster, if we can move away a little bit from prevention. You suggest in your submission that some of the delays are as a result of the fairly cumbersome procedures within the hospital, and you actually suggest some ways of streamlining the procedures; a couple of them I thought were tinkering at the edges slightly, I was going to say `departure lounges' but you recommend `discharge lounges', that beds are freed earlier, but, more interestingly, I thought, you suggested planning discharges earlier and involving key people on the critical path, and introducing discharge co-ordinators. And this was something that was so much in evidence when we went to visit the States, in particular, to such an aggressive degree that there were actually fines in place if people spent too long in hospital; obviously, if they developed another illness that was taken into account; but the financial pressures concentrated the mind wonderfully. First question, what evidence is there that, these processes and procedures, a sort of solution is being adopted in the UK; and how do you feel about some penalty system?
  (Mr Webster) There is evidence that discharge co-ordinating and earlier planning definitely yield results; the figures that we have highlighted in our submission, at St Mary's, they show that the number of delays has fallen very, very substantially, the number of days lost has been half to a third what it was before, so certainly it is possible to smooth that process in a way that yields real results. And there is no reason to believe that that would not be true in lots of hospitals, because the processes, conceptually, are relatively similar. And there is certainly evidence that the incentives in hospitals are not organised, in the way that it works at present, there is too much of an incentive to pass the responsibility to somebody else in the hospital rather than to ensure that the patient moves to another, more suitable place. It would be a big culture change for the Health Service to have financial penalties associated with those things. Though I think you are touching on something that we do highlight in our submission as probably a major deficit in the health care system, which is, there is not anyone who manages the whole process of somebody's care, and so there is not anyone who has an incentive to see that the whole thing works. And I think what you are describing is probably one of the tools that those sorts of people use, in American health maintenance organisations; so introducing the tool, in itself, probably would be quite easily absorbed by the complexities of the Health Service, but introducing—

  298. Sorry; can you put that into plain English, do you think it would not work, or it would?
  (Mr Webster) They would find ways of it not working, is what I am saying; whereas, if you give somebody the responsibility for making sure that it does work, they would have to have a much wider remit and range of tools than just attacking a particular point in the process.

  299. But they do not attack a particular point in the process, that is the point, they analyse the process very specifically from A to B.
  (Mr Webster) We are making exactly the same point. They manage care through the whole system, rather than manage a little bit of each person's care.

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