Examination of Witnesses (Questions 380
- 399)
WEDNESDAY 20 MARCH 2002
MR ANDREW
WEBSTER, PROFESSOR
CAMERON SWIFT,
DR ANDREW
DEARDEN AND
MR BRIAN
DOLAN
380. Right; so you see that as a key element,
from your point of view?
(Professor Swift) I was going to go on to say that
I think the way forward, for the present, might be to look at
some of the models that we have discussed, intermediate care is
a good example, and try to build into that a retrieval of best
practice, in which, as I have suggested, you have a common organisation,
with a common plan, which defines the need, which identifies the
finance and delivers it together with shared accountability. Whether
care trusts would help to achieve that I think remains to be seen,
I think they might, actually, but one is aware of the sensitivities
around care trusts. If that were the way to budget for a single
intermediate care service, which is corporately owned across the
divide, then I think that could be very effective and could deliver
a lot into the system. My definition of the whole system, by the
way, is not the whole NHS, or the whole of social services, or
an acute trust, but is the total group of services, from the point
of view of my field, which are focused specifically on the needs
of older people, so that includes the hospital-based service,
it includes GPs, particularly those with specialist skills training,
it involves the social work staff and social services staff, for
whom that is the complete remit, it involves obviously across
the professions. That is the whole system; and it has this element
of specialism about it, which sits alongside the generality of
practice, which obviously is important to maintain. But not every
GP wants to have an a priori accountable involvement and
commitment specifically for services which have to do with the
needs of older people, they may prefer, some of them, to develop
skills in other specialities. And we would argue, from our field,
that there is a specialism which has to drive the leadership of
this group of services.
381. I am exploring ideas, as we listen to evidence,
and discussion has already touched on the fact that some of us
were very interested in the case manager concept that we saw in
North America, and I have been wrestling with the role of the
nurse, in this possible process, or the role of the social worker,
and I am very interested that you have seen the decline of the
hospital social worker as a factor perhaps in some of the problems
that we have now.
(Professor Swift) I think, many of the things that
you would identify currently as case management, particularly
family counselling, those sorts of things, and negotiation, were
undertaken by professional social workers.
382. Absolutely. I was going to move on to Dr
Dearden, for a GP perspective, a family care perspective, to ask
you about your views on care trusts, as they may relate to the
drawing together of the relationship between health and social
care, and also taking account of the point that Professor Swift
made about the role of the social worker, whether, in fact, you
have, in your practice, an attached social worker, whether you
see any merit in a social worker being attached to a GP, and that
social worker possibly following the entire process through as
a case manager, in the way we have seen it in North America? And
I will come on to Mr Dolan in a moment or two.
(Dr Dearden) I think, from our point of view, we would
certainly agree with what was said previously, that a pure organisational
change is unlikely to achieve what we actually want, and it is
very much about how people work together; and where it has actually
worked well now, even with the split that exists, is where the
people have actually got together, established a need and worked
together actually to meet that. Now the option of having single
budgets and single commissioners and single arrangements is certainly
something that is helpful and we feel would be good; not exactly
certain that another organisational change will actually reach
or change that what is sort of a learned behaviour. Locally, in
Wales, we are actually trying a social experiment, which is our
primary care organisations are co-terminus with local authorities;
elected members will soon be on there, social workers, department
heads, etc., are in our primary care organisations, and their
input is very helpful at that kind of level. But, on the other
side of the coin, we did actually try to institute social workers
being attached to primary care, and, interestingly, they did not
get any social workers applying, or not enough, because they did
not feel it was a good use of their time. And so there certainly
is a change in the way that all sides need to look at it; the
primary care team is certainly developing, and I think the vast
majority of people are now beginning to accept that social work
input is actually vital to that kind of thing. And I think part
of that, from a GP, is self-interest, because more and more people
coming through the door do actually have social, housing, employment,
benefit concerns, and they are coming into the general practice
either because it has health side-effects or because we are the
first person they think of when they come in. So the NHS is being
accessed by lots of people, and if we could expand that team to
bring in the counselling-type side, the social work-type side,
I think most of us would be very much supportive of that kind
of idea.
383. I think one of the reasons why some of
us are attracted to aspects of the Northern Ireland model is that
certainly we have been to health centres over there where you
go through one door and you could access all that sort of level
of advice, you would have social workers, you would have nurses,
you would have community midwives, CPNs, as well as GPs, under
one roof, effectively; and it goes back a little bit to my experience
of pre-`74, where we had something broadly similar in England?
(Dr Dearden) One of the difficulties now in primary
care is actually space, it is premises space, because what goes
on in primary care has expanded so much; for example, I actually
do not have a room in my surgery now, which is a three-storey,
large, Victorian house—
384. You see your patients in the car park then,
do you, some days?
(Dr Dearden) My patients see me in the car park, yes,
but that is an entirely different story, that one. It is very
much that I actually do not have a room now, a consulting room,
that is not busy, or not being used, for less than an hour a day;
every room is full. Only, literally, lunchtime, when my staff
are off, doing other things, are my rooms not being used. So I
would love to have the midwife based with me, and the social workers
based with me, under one roof. I simply do not have a room that
I could actually give them. So that is part of the problem. Now,
in certain areas, I do not know what is going on in Northern Ireland,
apart from when I talk to GPs, and I think I can report to you
that they are very unhappy with what is happening, generally speaking,
in the area, and I do not think they see it as they are in the
best place to be.
385. I am not suggesting it is a panacea, but
it is a different approach?
(Dr Dearden) Without doubt, it is a different approach,
and I think we would agree that the split that has occurred has
gone way, way, way too far; and, to be fair, over the last few
years, it has been starting to coalesce again. Whether an organisational
change will achieve that, or whether we need to be looking at
incentives to help people work together; a simple example, if
you actually had health services and social services coming together,
with a single budget, to commission a certain service, and that
was then pump-primed with additional money, that would help. One
of the problems with having a single budget is, if both sides
have an overdraft what you end up with is a single overdraft,
and that is a very poor reason for getting together and working.
So if that attracted other things then that would be an incentive
to get them to work together, and people would start to see the
benefit of it.
386. So, if it is not structural, what kind
of levers do we need, what incentives do we need?
(Mr Dolan) I would return to the point about cultural
behaviour and organisational practices, which sometimes, inadvertently,
run counter to best practice and sometimes hinder the patients
through the process. I do a reasonable amount of work in the north
of Ireland, and one of the reasons why GPs are unhappy among it
is that they have had a health services review and they are still
not making any decisions about their health service configuration;
it is an unsettling time there, and clearly that does not lead
to good staff morale or working relationships. Speaking about
relationships, both relationship and partnership keep getting
used as terms, and I am struck that a relationship is when you
know about the other people, you know about their problems, and
in a relationship you share the successes, but a partnership is
when you share the risks. And in Coventry, for example, where
the social services had a many million pounds overspend, so did
the trust, the trust gave the social service department £1
million, effectively to fund nursing and residential home beds
over the winter period. Now, in broad health terms, if you could
buy 200 beds with £1 million in social services, you might
only get 50 beds in that time in the hospital, for that length
of time, for that sort of money; they had a vested self-interest
in working in partnership with the social services. I think care
trusts are a very good thing, because one of the things is about
you have got one budget, you have got one organisational structure,
you empower individuals to make decisions; and, in relation to
social workers, for example, in Hope Hospital A&E department,
they have got Age Concern, who come in, working quite regularly
in that department. And a lot of the patients' needs will be broadly
called social work needs, when, in fact, what they are is how
they find out about Citizen's Advice Bureaux, how do they get
unemployment benefit, how do they get social service access; and
that is about information. And I would not say, for a moment,
that is what social workers do only, but a lot of that need is
about information; and care trusts, if they are integrated, are
ways of working more effectively as a service and more efficiently,
as services. Ms Drown used to work at the RI, I used to work in
the John Radcliffe, in Oxford, and was a very effective Finance
Director,—
Mr Burns
387. How much did you pay her?
(Mr Dolan) Not enough. The bottom line is, she had
an opposite in social services. Now would it not be much better,
in terms of cost, which clearly Mr Burns quite rightly is worried
about, if you only were paying one person for that sort of work,
who could make decisions but also could delegate budgets; it makes
sense to give money to ward sisters on the ward so they can determine
what patients need. And I worked in mental health, patients could
not go home because they did not have clothes. I work in A&E
departments, they cannot get home because they have not got any
clothes, we have had to cut them off, because they have had an
injury, not because of masochism or sadism. And the fact is that
you have not got the money to do it; so sometimes we have had
whip-rounds for patients. Now would it not be nice to have a budget
which percolated through a care trust to enable these relatively
simple things to happen; which goes back to the heart of your
issue, which is about delayed discharges. One final point I would
make is, looking, if you like, beyond social services and health
services, Surrey Ambulance Service have got an Intranet service
with a real-time link to all of the nursing and residential homes
and A&E departments in the whole county, so they can tell,
in real time, what beds are available, what A&E departments
are under pressure, what departments actually could go onto divert,
so it will take some of the pressure off them. And using IT in
a very effective way is a very good use of resources, but also
what it is doing is empowering the Ambulance Service to direct
patients appropriately to an area where they can get their care
met expeditiously, as well as appropriately. So may I suggest
the Committee looks beyond simply just the NHS and the social
care, but looks at Ambulance Services and looks at a whole integrated
package, because that seems, to me, a way that works, as long
as it does not become a multi-headed, monstrous bureaucracy, which
is sadly what pre-`74 led to.
Chairman: I am conscious we have had you here
before us for two hours, but we have a number of questions left,
and having asked a long and rambling question myself I am going
to appeal to my colleagues to be crisp and sharp in their subsequent
questions.
Mr Burns
388. Chairman, before we ask them, may I just
correct something. I was not actually being rude enough to ask
how much you got paid in a professional capacity, I meant how
much were you paid to make those nice comments about Ms Drown?
(Mr Dolan) Still not enough, Mr Burns.
Dr Taylor
389. A very quick one, to Professor Swift, on
integration. Is not the geriatrician in the ideal position to
push forward the integration; geriatrics, since its invention,
has been largely a hospital-based service, and is not now the
time geriatricians should be moving out into the community, really
to weld together primary care and the hospital service? I know
of one community geriatrician, in the middle of Wales, who is
that because she does not have a hospital at all.
(Professor Swift) Geriatric medicine, as a specialty,
started way out there in glorious isolation in the back of beyond,
where it was not accessible to anybody.
390. I think I was around before it started.
(Professor Swift) Then it moved into various precursors
of intermediate care, in order to get in on the act a bit earlier,
and began in that process to become a community-orientated service,
which, nevertheless, had to be an advocate for patients in the
hospital system. And, as a result of, apart from anything else,
the resource efficiency of that approach, but also the element
of unmet need, this specialty moved very much into mainstream
hospital practice, where it now sits; and, in fact, if you want
to look for a general physician, nationally, you are more likely
to find one who is practising in our specialty than any other.
But that does not mean that the remit of the field no longer continues
to cover all aspects of need, across the community divide, up
to and including continuing care, and forward actually into preventative
medicine, a lot of us are doing joint work with our colleagues
in primary care on the best ways to screen and prevent disability
in later life. So the answer is that, if we are doing our job
properly, we have never been out of the community anyway, but
we have been in the hospital, to have an important clinical role
but also an important empowerment and advocacy role on behalf
of a group of patients; and I think both of those things need
to continue and be kept in balance. There are a number of new
posts of community geriatrician, and some of them are coming along.
There are no where near enough consultant posts generally but
some new posts with a community emphasis have been established
on the back of things like intermediate care, as an initiative.
Those individuals reflect that spectrum of commitment. And there
is a balance; some of them will have the majority of their time
based in the community but will still have access into the acute
hospital sector; and we believe, in the BGS, that that is crucial,
that that `across the divide' principle is maintained. But we
do think we have lost our community remit; to some extent, we
have lost it through the sorts of mechanisms that have affected
professional practice, across the community hospital divide, as
a result of structural change, and geriatricians, to some extent,
feel disenfranchised by that. So we are looking to retrieve it,
but not at the expense of the vital role that we believe we have
to play in the hospital, where so much of it has to be driven,
because that is where there is a big focus of need; and it worries
me, when we talk about getting it right in the community, but
not actually getting it right in the acute hospital.
Dr Naysmith
391. I am at the stage of picking up one or
two things again that were in your evidence, Mr Webster; in fact,
there are one or two things I think we already touched, just before
I went out, I had to go out for a few minutes, so I hope you have
not been asked one of them already. Basically, in your evidence,
you talked about resolving the problem of delayed discharges requires
a new approach, which puts the older person at the centre; now
could you tease that out just a little bit and just say exactly
what you think that would demand of the partnership between ages,
changes in attitude, that sort of thing? How is it likely to be
brought about, how can this transformation happen?
(Mr Webster) If I can pick up on the points that were
just made, I think the average older person listening to this
conversation would be staggered at the suggestion that, in order
to buy them some clothes, we had to restructure the NHS. But I
think that is symptomatic of a general issue, that we translate
people's simple needs and simple requests into things that are
immensely complicated for us to discuss, and then forget to deliver
what the person wanted, in many instances. So I think we are talking
about quite a profound change in professional attitudes, where
the primary responsibility of all the people is the delivery of
the person's specific individual requirements; and I think that
maps to a much wider change in culture, about being responsive
to the individuals who use the service, rather than the people
who run it. And I think there are really positive examples of
that happening, right across health and social care, where people
are much more empowered to speak up and to get things differently
and to choose. And I think one of the things this Committee could
do would be to refer continually to the evidence that you have
had from people who use the service, as a benchmark.
392. Let me just put it to you, you yourself
said things are a lot more complicated than they used to be; the
people who are dealing with older people, with all respect to
Professor Swift, who specialises particularly in geriatrics, I
understand, a lot of the professionals that are coming across
have other responsibilities as well, they are dealing with not
just older people, social workers, although they tend to specialise
a bit, they are not supposed to specialise as much as they used
to, and that kind of thing. How do you get all these people to
collaborate, when it is not necessarily the only thing that professionally
they are supposed to do, is to look after older people?
(Mr Webster) I think it relates quite closely to the
preventive discussion we were having before. The first question
that any of them need to ask is do they actually need to collaborate,
or could they resolve this themselves; because in many cases,
the reason for collaboration is to share a risk, rather than to
effect an outcome.
393. When we had that discussion earlier on,
the Chairman was muttering, "The one thing they don't want
to share is their budgets," and I think, in a sense, that
is true; so how do you get—
(Mr Webster) Most of the front-line professional staff
do not have a budget to share, or not share, in this system; most
of them operate within a system that requires their line management
to share budgets. So I think one of the things that clearly could
change would be that, I think the example from Coventry is a positive
one, an example where you know, as a front-line worker, that flexibility
will be displayed by your organisation, in its dealings with others,
in the way that the budgets are managed. But that requires the
sorts of incentives that I was describing earlier, where, as a
manager in one of those organisations, you are encouraged and
rewarded for taking that risk with your budget, rather than that
being presented as something which is unacceptable and likely
to lead the organisation into some problem that it might otherwise
have avoided. So I think there are some messages that need to
come from the top; but I think we are also pointing to some real
changes in professional attitude and professional boundary management.
394. I think one of the other things in your
submission was, you talk about the active management of long-term
conditions; now what does that mean?
(Mr Webster) There is a lot of literature now about
disease management, and the proper pathways that people should
follow through the healthcare system that is familiar to lots
of people who work in healthcare. Good examples of that would
be people with respiratory illnesses being checked much more frequently
in the winter, when they are quite likely to end up in hospital;
so, rather than waiting for them to arrive in A&E, someone
is actually doing the checking before they arrive. There are many
diseases now, the chronic diseases like diabetes, which we have
studied in depth, for example, or risks, like the risk that people
will fall over and fracture their hips, many of those things can
be actively monitored before the symptoms arrive in the system,
and most of our work would point to real benefits for those people,
in not suffering, and real savings in the system by not having
to treat them, from much more active attempts to make sure that
people are safe.
395. What do you think of that, Professor Swift?
(Professor Swift) We did a piece of research at King's,
which was published in The Lancet at the beginning of 1999,
showing that, if you looked consecutively at older people who
came to A&E who fell and you randomised them into two groups,
one was given what Brian will remember as the standard practice
of referral back to GP and fracture clinic, "Your patient
attended; sustained the following injury," etc. The intervention
group was seen afterwards, on an index occasion, by a physician
who did what I would call a decent medical check, or the nearest
thing to a comprehensive assessment, of the individual's intrinsic
risks, and they were seen by an OT, who, as a model of interdisciplinary
practice, looked at the home, did a safety check. And the results
of the trial showed that in the intervention group you reduced
the total number of falls in excess of 60 per cent, and the total
number of people who fell by about 50 per cent; that has massive
implications for bed occupancy, for fractured femur, and is one
of the reasons why the NSF, I think, quite rightly, has a section
on falls as part of it. And falls is actually a wonderful model
of the totality of care that Andrew talks about, because it follows
an individual through from primary prevention, through the risk
criteria and right through, where necessary, to rehabilitation
after fracture, and indeed through to continuing care.
Chairman
396. Can I just butt in on that, because it
struck me, I am trying to remember, somewhere, whether it was
on a visit we did to the States, we came across a scheme where
they had actually taken proactive sort of attempts to prevent
falls.
(Professor Swift) This is Mary Tinetti's work.
397. Is it; nailing carpets down, dealing with
floors, it was very interesting?
(Professor Swift) It was very similar; it was multi-dimensional,
it involved health checks for the individual's intrinsic risk
factors, and also a look at the house. It was actually fairly
expensive. And the beauty of our sample was that there was an
opportunistic look at a group of people, actually, largely, very
healthy, they were mostly fit, independent people, at an early
stage, who happen to have fallen, and it was a way of picking
up people at early risk and preventing further problems.
Dr Naysmith
398. I know, in a sense, we have been round
this already this afternoon, in a couple of different ways, but
how do we get it to happen, does it need more resources, or what
does it need, what does it need to get this sort of thing to happen
much more, because I am sure we would all agree, would we not,
Dr Dearden, that that is the way we should go?
(Dr Dearden) Picking up the point, there is evidence
that you can say the same thing about falls, but also heart failure,
those issues, and COPD, the sort of respiratory illnesses; and
there is evidence that, where you actually set those schemes,
if you like, it is a halfway step between the primary care type
and the acute hospital type, in the middle there is a special
list, or special input, into the kind of routine management, monitoring
and treatment, which is more than crisis to crisis to crisis.
399. We are all agreed that it is a good thing,
but how do we get it to happen?
(Dr Dearden) In Cardiff, they have actually made an
application for this, and the application involves some equipment,
like (Echos, ECOs?) and things like this, which will be community-based,
also community facilities to see those people, because the hospitals
do not have the room; also there will be one or two specialist
nurses who will be trained up, as we have asthma nurses and diabetic,
parkinson nurses, who will have the role of the monitoring, they
actually do that, but with consultant and senior registrar input.
So, to some degree, it is about a place to do it, it is also with
the equipment you need, because, of course, it is a little different
from primary care, where you might have a stethoscope and a lung
function, it is actually much more about the sort of equipment
you need, but also then you need someone with enough specialist
knowledge to actually be able to do that on a non-crisis, routinely
monitoring kind of thing. So this does come back to some resources,
some new resources and some new personnel; but some of it can
be diverted from the hospital. If not so many people are going
into hospital then obviously you will free up, you have got to
get it there in the first place to reduce the admissions to free
up the people; so, again, it is a bit of pump-priming and getting
it there in the first place.
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