Examination of Witnesses (Questions 440
- 459)
WEDNESDAY 24 APRIL 2002
SUE ADAMS,
MR BARRY
HASSELL, MR
TONY RICE,
MR BILL
MCCLIMONT
AND MR
BOB LEWIS
440. It struck me, when I was looking at the
system in Bristol, that there were two things that were very important;
one was flexibility, not necessarily filling in lots of forms,
and obeying certain rules, and things, and to get jobs done quickly,
you know, there are these operators who could be `phoned up and
24 hours later, or maybe even sooner sometimes, they would be
round at somebody's house just installing a handrail, or something
like that. So what are the lessons we can learn from that?
(Ms Adams) The lesson that I have picked up from looking
at these small handfuls of projects is, where there is a will
there is a way. Now, Bristol, you have got social services and
housing and health pooling money, and a willingness to just fast-track
systems, and for occupational therapists to accept that they do
not have to assess everybody, and to trust the people that are
going out and doing the grab-rails and handrails, that they will
come back to them if there is a bigger problem. In terms of the
Leeds scheme, the lesson there, again, is finding a completely
fresh way to pool budgets, and to give a lump sum, and capacity
planning law is being used here. Last year, the Leeds project
did 1,900 small adaptation and repair jobs, and it is very simple,
the OT at the hospital literally writes down what they think they
want and what the person says they want, it is faxed through,
it is done within 24 hours, with their directly-employed operatives.
And so what you have wiped away is estimating by two or three
builders, you have wiped away lots of home visits and you are
churning through masses, at very, very low cost; that scheme is
saving the local hospital about half a million a year, even on
a very conservative estimate, by getting people out of hospital
24 hours faster than otherwise would be the case.
441. Is that what contributes to the eight months
delay you were talking about in people getting what they asked
for in the first place?
(Ms Adams) Those are the small-scale ones.
442. Is this a system of rationing, you know,
the expenditure?
(Ms Adams) No, I think it is using the money a bit
more effectively, really.
443. No, I mean do people do this, allow this
sort of thing to happen, because a lot of people must know it
is happening, just as a way of not expending the money as quickly
as it would otherwise be expended?
(Ms Adams) I think it is a problem, arguing over who
is responsible, as well, like health saying, "That's not
us, it's housing," or social services saying, "That's
not us, it's housing." Giving you some good news stories.
A bad news story, and this is how things are not joined up, one
of the models in the book was the Hackney discharge scheme, and
really working at the sharp edge, very extreme problems in Hackney,
and I have got a good model, works very well, there had been money
for small repairs and adaptations, literally in the last few weeks,
Hackney Council said, "No more money in the pot." And
I rang last night, just to get a really up-to-date picture, you
have got somebody being discharged from hospital to a house with
no heating or hot water, and so you have got housing just sort
of completely pulling the plug there, and that is in a unitary
authority.
Andy Burnham
444. Like Doug, I am a big supporter of what
you do. Can I just ask quickly, what percentage of the population,
of the people at risk, we might say, are you currently reaching,
and other organisations like Age Concern; are you scratching the
surface?
(Ms Adams) Yes.
445. I would anticipate there are many more
elderly people who never get close to the scheme, who could benefit,
is that correct?
(Ms Adams) It is scratching the surface. There are
230 home improvement agencies in the country, so there is not
even one scheme in every local authority area, and I have found
only seven specifically doing hospital discharge work; and, of
those 230, the average is they have got four staff, even in quite
a large area. Bristol is completely different, they have got 40,
and that is an example where the local authority has really taken
it on board and is seeing its potential; they did 30,000 jobs
last year and it is worth £60 million.
446. Can I just ask, in my experience, locally,
it is not just practical improvements, handrails, making the place
safe, there is also an issue about coping psychologically; if
the lawn is cut, if the front is painted, and it looks smart,
people feel that they are coping. Is that true as well?
(Ms Adams) It is knowing you have got somebody to
turn to. That came up in interviewing people for the book, over
and again, it is actually saying, "Well, you've done this
for me, but I also now feel better because I know I've got you
to turn to if something else goes wrong," which it does,
if you live in a house. And it is not just about repair and adaptation,
it is also about leaving people better able to cope with things
in their house, by doing perhaps income checks; and some are going
further than others on straddling the care. The Warwick is a very
interesting one and it is unique so far, in that they are now
running a seven-day a week, 24-hour home care service, attached
to the repair; so it is very holistic. Because they will get `phoned
up by the hospital, and they will say, "Mrs X needs to go
home, can you go round, can you provide carers going in twice
a day, can you go round and do the adaptations with your worker,"
and they will turn those around within 24 hours. And then the
case worker goes in and tries to rehabilitate the person as well,
so to get them back on their own feet. Because I think one of
the things David said that was interesting was that continual
assessment, if somebody goes into residential care, and the issue
is do they ever come out again. And I think that is quite different
with children and older people, because of institutionalisation,
and you see people go downhill really quite quickly.
447. And that can happen in hospital, can it
not?
(Ms Adams) And that can happen in hospital too, if
they keep them in too long, and I think that is where you have
to look at the bricks and mortar and develop initiatives with
a continuum, as opposed to thinking you can put them in institutional
care for a certain amount of time. The exception to that, I suppose,
is, Doug has had to go now, but we have talked very much about
the small-scale things, there is a need for larger adaptations
as well, and perhaps large repairs, and that does take a bit longer.
And I have come across an initiative in Coventry, where the person
is moving out of hospital, the health authority is paying the
weekly rent on a residential care unit in a housing association
property, it is level access, it has got an accessible bathroom,
people go there for a few weeks while the major adaptation and
repair is being done; and so, instead of paying £300 a day
in hospital, they are paying something like £60 a week. And
it is looking at innovative uses of the stock that we have got
and sheltered housing and thinking about two stages to get people
out of hospital on their way back to their own home.
Chairman
448. Dr Naysmith will return, we assume, he
is having his photo taken with the Prime Minister; for what reason
I am not sure. Mr Hassell?
(Mr Hassell) If I may come back, there has been a
suggestion about the debate being hijacked by residential care
providers. What I think it is important to point out is that many
of my members and many providers in the independent sector provide
not only residential care but they are, of course, providers of
home care, healthcare at home and other specialised services,
services like acquired brain injury, etc. So we have absolutely
no problem in having discussions about innovation and developing
new services at all; the problem is, I think, actually getting
people round the table to talk about the requirements and to talk
strategically about the need for investment in diverse services.
So I think you should take on board that the sector is more than
willing to talk about the development of new services, but we
have to have the right environment to undertake those particular
discussions, and, I am afraid, in the case of many authorities,
it is very difficult to get them round the table to talk about
future needs. If I may, just finally and quickly, as a second
point, I know Bill mentioned National Insurance a moment ago,
we are very supportive of and very committed to working in partnership
with the Government, particularly in helping the Government to
achieve their plans under Delivering the NHS Plan, last week.
We do have problem, of course, though with the tax on care, the
1 per cent on employers' National Insurance, because that will
add about £75 million to the cost of a sector which, we have
already discussed at length, is having huge financial problems,
so I think that is an unfortunate additional cost.
(Mr Rice) In order to help to explain the complex
nature of the debate, could I position technology against the
care and repair points, all of which I absolutely support. We
have talked about falls and what a load on the overall health
delivery system falls and broken hips impose. Most people do not
break their hip on their first fall. One of the frustrations that
I have is that the technology that is available within the industry
is deployed too little and too late; typically, our average user
has the technology for perhaps 30 months before they move into
intensive care, and, typically, it is after they have fallen once,
twice, or even broken their hip. Now the initial fall does not
typically break the hip. The technology is quite capable of interpreting
the increasingly restrictive mobility of the elderly, the frail,
and actually triggering the deployment of the kinds of services
that Care & Repair offer, in order to prevent a fall and prevent
a broken hip. So when I say that 1,000 to 2,000 beds are occupied
by hip fracture, I think we could actually reduce that number
if we deployed technology which then triggered the right response,
in order to kit the house to make it as near as possible fall
proof; you will not stop people falling but could reduce the incidence
of falls many times though the precise measurement of mobility.
One of the things about technology is it has moved on a lot in
the last five to ten years, on the back of mobile telephony and
wireless technology, and we have very sophisticated technology
available now in this country that can help; typically, it is
not used in that way, but it is part of the solution.
Julia Drown
449. Can I start by going back to Independent
Healthcare Association, and the issue on capacity. You said in
your evidence that the financial cost to the NHS, and that is
the taxpayer, of what is essentially a chaotic and fragmented
system, is profound, and you were just speaking there about the
wish to get people around the table to discuss ways forward. In
your evidence, the focus was very much on the need to raise the
level that is funded for residential care places. Do you actually
think there is a structural problem bigger than that, and is there
a particular structural change that you would recommend, for example,
national planning, rather than local planning, national planning
of fees, or other issues?
(Mr Hassell) I think it is difficult. I think you
probably need both. I think you need the national steer, clearly,
which is what the Government is doing with the NHS Plan and Delivering
the NHS Plan, and I think that is to be welcomed. But, I think,
likewise, of course, you must have that local planning, because
you do not need me to tell you that the circumstances from the
North East to the South West are totally different; so I think
both are needed. I think the Government clearly put in place the
national framework. I have certainly noticed over the recent years,
and covering the entire spectrum of our members' services, from
acute hospitals through to home care services, that there is a
lot more openness and involvement with the Government, we find
it much easier to talk to the Government than we ever have done
with any previous Government. So I think it is to be welcomed;
but I think we need that national planning, but, of course, the
implementation has to be locally-based. And, certainly, I think
that we welcome the new role for PCTs, because I think that again
will help to focus the delivery of local services. And, from the
point of view of the main thrust of your inquiry on delayed discharges,
although, as we have suggested in our evidence, there may be what
I am now calling best value savings, by using the independent
sector, as opposed to beds being blocked, I say that because,
of course, of the churning nature and use of facilities. Where
I think there are some real economies to be made are actually,
and it is a little like Tony's comments a moment ago, that in
the prevention of admissions to hospital, in the first place,
and whether that be through technology, Care & Repair, or
indeed placements in homes, I think, if we can get in place, which
I am hopeful the PCTs are more likely to do, the rapid use of
alternative methods of providing for people's needs, it will help
to reduce admissions, and therefore help in terms of the bed-blocking,
the delayed discharges.
450. There are some delays to discharge that
occur because of the choice directive, because a particular individual
wants to go to a particular home where there is not a place available,
and it seems that a number of independent homes are not keen to
take people temporarily, while they are waiting for a home of
their own choice. Can you tell us a bit about why there is not
the enthusiasm from independent homes to take residents on that
temporary basis?
(Mr Hassell) I would suggest that some homes actually
do take people on a temporary basis. But I think, philosophically,
some people feel that it is perhaps wrong for the person who is
leaving the NHS, in that they are actually being moved, at a very
difficult time in their lives, from one environment to a temporary
environment, to their final home, that that is destructive on
their lives. Equally, of course, for people who are resident and
have made it their home, it is not a good idea having people constantly
go through. But, certainly, I think the reasons are philosophical
rather than anything else, because certainly I am not aware of
there being any; in fact, quite the reverse. I would suggest that
probably, financially, it is more beneficial; but if you are going
to go down this route then I think one needs to develop proper
transitional models. It could be argued that intermediate care
is one of those transitional models, it is rehabilitation-specific,
it is time-limited for six weeks, it is one way of viewing it,
but it is a transitional model, until the person's assessed needs
are provided elsewhere.
451. It certainly is a frustration of some hospitals
that they feel it would be in a person's best interests to move
into a nursing home or residential home; is your group doing any
work on this, to try to come up with the protocols that you are
talking about?
(Mr Hassell) I am not aware of it. We will certainly
give it some thought, and I will certainly talk to my members
about it. You may be interested to know that I think there is
about just under 9 per cent of the people who are in beds in the
NHS awaiting discharge, just under 9 per cent of them are there
because of their own choice requirements; about 24 per cent of
the beds that are blocked are, in fact, people who are awaiting
nursing or residential care home places. So the choice issue is
a relatively small one.
John Austin
452. You said the 9 per cent are there because
of their own choice?
(Mr Hassell) Sorry; because they are using their rights
under the choice directive to choose their own home.
Mr Burns
453. This problem that you have raised are people
who are having their discharge delayed because of choice, because
there may not be availability. How do you think, or maybe you
do not think, that penalising either the NHS or social services
is going to help the situation; is this introduction of penalties
going to improve the situation with regard to delayed discharge,
or is the right of choice and the problem of capacity in certain
areas just going to be an unfair penalty on particularly the NHS?
(Mr Hassell) I do not know whether it is going to
be an unfair penalty on the NHS, quite the reverse; it strikes
me that it is more likely to be a penalty on—
454. Sorry, I mean social services?
(Mr Hassell) Yes, on the social services. I think,
certainly from the point of view of our members, and I think it
is true from the point of view of the Department of Health and
Ministers, that substantial sums of money have been put into social
services, but, of course, Ministers are not able to direct social
services on how to spend that money. There has been a reluctance
to ring-fence money, and I think the issue of cross-charging that
was announced last week, where a local authority does not place
somebody in a care home, is actually, I think, quite an imaginative
way of trying to encourage, some people take the view it is negative,
but, I have to say, nothing else seems to have worked.
455. But if someone in hospital is exercising
their right of choice, you cannot blame social services if they
are not being placed if there is not a bed that fits their choice
available; so it just seems rather, and to my mind, an unfair
and also unworkable penalisation of social services?
(Mr Hassell) We have to wait and see what the details
are, of course; it may be that if somebody is remaining in hospital
of their own choice, because they are exerting their rights under
the choice directive, that may be excluded from the rules. I have
no idea at this stage, I am not sure the rules have been written.
(Mr McClimont) I think we do need to wait for some
detail here. But, looking at the new announcement, it struck me
that it was unbalanced, inasmuch as on the NHS side they are supposedly
going to be given incentives for additional activity and money
to follow volume, balanced by a stick, and if that is the carrot,
balanced by the stick of penalties for emergency re-admissions,
and that seems to me like a balanced approach. From the social
services side, there is the penalty stick for blocking beds and
there is no balancing carrot of any relationship between the money
that is given over to social services and any form of volume counting
at all; there is no actual measurement of the volume of care or
client outcomes from the money that is used, in any of the systems.
So it is very difficult to have that balancing carrot, but it
would be positive if there were one.
Chairman
456. Mr Lewis, you presided over the ADSS at
one point, so you are a man of great vision; what are your views
on this?
(Mr Lewis) Whilst supporting the choice question,
and I think it is an important principle that we stick with, nevertheless,
I think it can divert us from potential other pitfalls. I think
that, if a local authority, and they have finite budgets, if,
in fact, the places are there but not available to that individual
because of the pricing policy of the local authority, the contracting
price that they will pay, then I think that the stick probably
is a useful instrument, because, in fact, they are denying people
the opportunity to move to more appropriate accommodation because
of their contracting strategy. On the other hand, if they have
got a finite budget, then if you have got two people requiring
nursing home care, one is in hospital, one is in the community,
it may well be that the person in the community's needs are far
greater, but the local authority is going to offer the place to
the person in the hospital first because otherwise they enter
into a penalty. And I fear, therefore, for those people who are
not coping at home and who could more appropriately be cared for
in a residential setting being denied that.
Andy Burnham
457. Can I just quickly return a question to
Mr Hassell, on this issue of delayed discharges and the role of
independent homes generally, in managing those. Is it really clear
that some homes which have places available will not take local
authority-funded residents, because of the fees they get; does
that happen?
(Mr Hassell) Yes.
458. Could I then take you on. I understand
the issue of fees, but we did have the example, a few months ago,
of independent homes withholding the fees for nursing care that
were given to them by the Government, the element of free nursing
care, from self-payers, I might add, as a way of getting back
at the issue of fees for local authority-funded residents. Do
you support that action by those homes, and would you uphold their
right to do that, and do you not think that that may have damaged
confidence amongst the wider community, in the actions of those
homes that did that?
(Mr Hassell) It is a complex issue. I think, firstly,
it was unfortunate that the suggestions, incorrect suggestions,
that homes had been withholding money from residents, because—
Chairman
459. Incorrect?
(Mr Hassell) Incorrect.
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