Examination of Witnesses (Questions 480
- 499)
WEDNESDAY 24 APRIL 2002
SUE ADAMS,
MR BARRY
HASSELL, MR
TONY RICE,
MR BILL
MCCLIMONT
AND MR
BOB LEWIS
Andy Burnham
480. A question for Mr Lewis. In your evidence,
you describe, in anticipation of the expansion in intermediate
care, how Westminster invested in adapting homes so that the full
rehabilitation programme could be provided. Can you perhaps expand
a bit on that and tell us how much the company did invest in expanding
its intermediate care capacity, and whether that was across the
country, and also to what extent it has been utilised, or underutilised?
(Mr Lewis) In cash terms, I could not tell you, I
do not have that information; but an example is in Epsom, where
we were able to make available rehabilitation facilities, we were
able to speed up discharges, we worked closely with the local
group practice and with the local hospital. But, again, it stopped
because of funding issues; and it is a question of prioritisation.
Funding issues/demarcation disputes, was it a social services
responsibility or was it a health responsibility, and we still
have not entirely got over that problem. There are a number of
other examples up and down the country where we were able to make
available resources, where we had a discussion with individuals
but we were not able to get the corporate agreement to make the
thing work. And it is hugely important—
481. If you had to say whether the problems
were with the health side or the social services, where does the
blame lie, do you think?
(Mr Lewis) I hate to get into a debate about blame.
I think that the issue is often one of bringing all the players
together who are actually able to make the decisions. And I posed
to myself the question, I am currently chairing a review in Northern
Ireland, is the solution to follow their road, of an integrated
health and social services, (a" la" ?) the Care
Trusts. And we have been looking at some of the problems that
exist in Northern Ireland, because they have many of the same
challenges that we face in England, and I have come to the conclusion
that it is not that, it is not the actual organisational structure
that is the biggest problem, it is making sure that the money
is in the right places. Because when you broaden the debate it
is housing as well as social services within a local authority,
it is health, and also ensuring that we break down some of the
professional barriers, and that is not just social workers vis-a"-vis
community nurses, it is consultants versus GPs, etc.
482. Is that possible, to break down those barriers,
without that merged organisation though, without fully merging
the organisations, do you think, or will you always get those?
(Mr Lewis) You are always going to have them, to an
extent, but it is a question of how you plan and manage services.
You need expertise, in order to provide, for example, comprehensive
assessments; but, clearly, they should reflect a multi-professional
assessment. Now I know that that is the Government's policy, but
I am not at all sure, at the moment, that it is actually being
practised effectively at a local level.
483. You also say that you would favour much
greater use of intermediate care, both in nursing homes and in
clients' own homes. From your evidence though, I get the impression
that you have never really been truly involved in the development
of those kinds of services; is that fair to say, in terms of capacity
planning, have you ever had that kind of input, would you welcome
it?
(Mr Lewis) We would welcome it, we have not had it,
in most instances; and we keep on qualifying this by saying there
are examples of good practice within local authorities and within
health authorities and trusts, and it would be quite wrong to
deny that there is some good practice. That what we are saying
is that intermediate care is not a bed in a different place, intermediate
care is much broader than that, it is not just about discharge
planning, intermediate care is about diverting people away from
admission to hospital.
484. So when you are talking about care in someone's
home, are you talking about the kind of home care services that
local authorities provide, are you wanting to develop those?
(Mr Lewis) No, not commercially. To answer the Chair's
question, I was suggesting that there is an expertise within the
independent sector which should be harnessed. I think we should
recognise that we are not all experts in everything and that there
are clearly those agencies that are skilled in providing services
within people's homes, there are those agencies that are skilled
in providing the technology and the management of the technology
at a local level. It is a question of bringing all those agencies
together in a meaningful way, both to plan services and deliver
services; and what we are saying is that those processes are not
in place, in many parts of the country.
485. I will finish off with one final question.
Mr Austin mentioned the scheme in Birmingham, and you do also
mention that elsewhere your facilities have not been used as much
as you would like. Do you think that there is a problem, in that
you are often in competition with yourself, in that people may
go into intermediate care, or they may go into nursing care, and
that that is a tension in the system? And if that is always not
the case, would it help if people were guided more to the kind
of capacity they need, rather than, at the moment, left to make
the choice themselves; would that help your . . .
(Mr Lewis) I think, crucial to individual care is
the assessments, and if you have got the assessment right in the
first place you can make a judgement as to what is the right pattern
of care that that person needs; once you have done that then you
can begin to talk about choice, but until that is done it is irrelevant.
We have got to strengthen our capacity to provide multi-professional,
comprehensive assessments of need, so that care is provided at
the right point in somebody's life. Sometimes, as has been said
earlier, we do not, we wait until there is a crisis, and then
we are into fire-fighting.
John Austin
486. I am conscious that we have actually been
looking at intermediate care purely on the basis of a post-discharge
facility, but, of course, intermediate care, or the facilities
there, can be very useful in preventing a hospital admission.
I cannot remember whose evidence it was in, that talked about
the issue of direct GP admitting to intermediate care units. Would
you like to expand on that?
(Mr McClimont) Yes, absolutely. I was going to come
in there, just to pick up on the intermediate care, in particular.
An example in my evidence, at 7.5.a, chronic obstructive pulmonary
disease can have individual hospitals treating up to 1,250 patients
a year, and 80 per cent of those, in studies, prove suitable for
diversion immediately from Accident and Emergency, where they
usually turn up, directly into home care, where it can cut costs
dramatically. Instead of possibly a month's stay in hospital,
you can look after a person at home, with probably better results,
at a cost of about two to three hospital bed days; and that is
a diversion at the A&E. But, at the moment, for example, it
is fairly rare for A&Es to include the services of GPs; something
like 40 per cent of the people who turn up at A&E would be
more appropriately seen by a GP than by Accident and Emergency
staff. Now, if you can pick up large numbers of those by using
a GP in Accident and Emergency, in the first place, or by using
better `out of hours' techniques, for doctors out of hours, then
you can avoid a lot of the congestion that occurs in the A&E
in the first place, and reduce the wait there for admissions,
because you do not admit them to hospital, you would send them
back to their own homes with support. So direct arrangements for
GPs, whether it is actually in A&E, whether it is on an `out
of hours' service, or indeed during normal hours of GP operation,
if we could give them the capacity to commission, within a framework,
services of this sort, and people along the table all provide
something that would help in this area, there is an enormous capacity
to do that. And the technology can make a big, big difference
here as well, because the capacity to send somebody with a piece
of kit that will monitor them, in some cases, will give a level
of reassurance to people for whom, frankly, the risk is not that
high but it is a reassurance issue, if you can do that you again
relieve some pressure.
487. This takes me back to the exchange with
Mr Lewis earlier, because, in your evidence, you have referred
specifically to the constraints on the development of intermediate
care services, and you pointed particularly to the limitations
of task-based commissioning practices of local authorities. Could
you tell us what you think needs to be done to remedy that?
(Mr McClimont) I think this actually goes across both
intermediate and long-term care commissioning. There is a need
to start commissioning on the basis of an individual recipient
of the service, rather than, at the moment, of coming with a service
that one size has to fit all; and particularly in commissioning
on the basis of an outcome for that individual, rather than saying,
"Okay, until we've got the spare capacity to do another review
for you, this is what you will receive, no more and no less, and
that is broken down into ten minutes of doing that and five minutes
of doing this." Again, care standards will require commissioners,
because providers will not be able to do anything different, to
change their practice in this area and allow that kind of greater
flexibility. We should be moving from a basis of the current system
of combined case and care management, in relation to home care
particularly, to one where case management continues with the
commissioner but the care management is devolved to the person
who is delivering the care, which is a provider, whichever sector
they happen to be in. There are big problems at the moment in
local authorities; you asked whether it was health or local authorities
that were causing these difficulties. In local authorities, one
of the difficulties is that they are used to commissioning these
long-term maintenance services, which are appropriate for some
people but do not fit well with intermediate care; so when they
are presented with a package of care which starts out very high
and tapers away, without their being involved in that tapering
remanagement, they run scared, they just do not know what to do
with it. We had an example not very long ago where a service was
introduced to a joint commissioning scheme and was approved by
them, but the local authority refused, because the home care element
of it was more expensive than their maximum price, so they withdrew
the whole support for the joint commissioning scheme. On the other
hand, health have big problems as well, because the consultants,
in particular, will not let go, or will not think of alternative
means of delivery that do not involve their unit. And we have
an example that occurred in Swindon, not very long ago, where
again the joint commissioning unit came up with a service, voted
the money, had everything set up, but the consultants managed
not to refer anybody, or allow anybody to be referred to it whatsoever.
488. These are the problems?
(Mr McClimont) Yes.
489. So what needs to change to make that appropriate
commissioning happen?
(Mr McClimont) Some of what I said is the presumption
of home care, that I said earlier; the other main issue is an
outcome-based commissioning. The two elements.
Julia Drown
490. Just to follow up. You said in your evidence
about the payments by outcomes, but you also said about how you
thought that the financial regime should change, to get financial
disincentives to encourage patients home, and indeed to make sure
that you penalise inappropriate discharges, and looking also at
trying to encourage the discharge of services by financial means.
Can you say a bit more about those?
(Mr McClimont) I am hopeful that we have seen the
green shoots of that in the announcements last week; but, as I
said earlier, there needs to be a balance on the social care side
with what I hope is going to occur on the healthcare side. We
need to incentivise people to look at other options. At the moment,
a hospital is paid for while a patient is in hospital; the moment
they go out that bed is refilled and they have still got that
cost, but they are picking up an additional cost, for which most
of the time they do not perceive they have the funding.
491. But providing there was the penalty for
inappropriate discharges, you would support such a scheme?
(Mr McClimont) Absolutely.
492. Can you just say a bit more about the payment
by outcomes scheme?
(Mr McClimont) It needs to be done on both a population
level and potentially an individual level, because it is no use
having population statistics without judging what happens to an
individual. So you have to look at commissioning on the basis
of "We want this person to reach independence within six
weeks," that might be a target; or your target might be maintenance,
in some of the longer-term areas, but for intermediate care you
would be aiming at a particular level of success. And one of the
contracts that I am aware of, for example, sets a target for readmissions
and claws back money, rather as the NHS is going to be subject
to the same kind of process, claws back money if that is exceeded,
and claws back money if you do not get levels of patient satisfaction,
and claws back money if you do not hit various targets. So there
are incentives to hit. But then, if you can deliver a quality,
time-limited, effective service, and you happen to do it very
cost-effectively, then I am afraid that, for a little while, until
the next time the negotiation comes through, it will affect and
improve your profits, or your surpluses, and some people will
reinvest that directly into care and others will make their shareholders
cheer; but, one way or the other, the individual user and the
public purse have both got a good deal.
Chairman
493. Mr Rice, you deal with a lot of local authorities,
various elements of the Health Service in different parts of the
country, I would imagine; in your evidence, you talked about a
complex, holistic problem, was a term you used. Bob Lewis was
giving an example of, was it health, was it social services. You
have put forward in your evidence suggestions of a need for this
closer working partnership between the different elements; how
do you see the most appropriate model for that to come about?
From your experience of dealing with authorities throughout the
country, are there areas that you would commend as being possibly
the way forward for others to follow?
(Mr Rice) Yes. PCTs should help immensely, once they
get into their stride, in terms of operation, and they get the
confidence to understand exactly how they should operate to best
effect, because that clearly is a move in the right direction.
There are some local authorities who are very forward-thinking
already, in terms of an holistic approach to the issue of healthcare
provision, West Lothian would be one, County Durham would be another,
Sedgefield, who have schemes which offer an integrated package
of healthcare which covers preventative healthcare in the home,
deployment of technology, deployment of home help, or whatever,
right through intermediate into the acute sector.
494. Now is that on the basis of their common
budget, or are they still separate budget heads that we are talking
about here?
(Mr Rice) At the moment, it is on the basis of split
budgets, because we are too early into the new regime for them
to have a single combined budget, and clearly it has only been
operating for a matter of weeks. But they have anticipated, if
you like, the future budgeting process, because clearly you do
need to have a single pot of money that is capable of allocation,
in a sensible way, to the various elements of the healthcare package.
I would argue that you need to ring-fence certain pieces, because,
given the pressures on the healthcare system these days, it is
all too easy to divert money away from some of the longer-term
issues, like preventative care, where the cost goes up at the
front end but actually then comes down dramatically, one, two,
three years in, as you have fewer people going into intermediate
homes, fewer people going into acute beds. But it is very easy,
rather like cutting training budgets in a recession for an industrial
company, to attack those kinds of budgets, in order to address
the fire-fighting issues which occur fairly regularly, more at
the intermediate and acute end of the healthcare sector. But certainly
I could send the Committee examples of an holistic approach in
operation, in three or four locations, which would be a model
for roll-out on a broader scale.
495. That would be very helpful. And, presumably,
there has been, within these particular examples, no dispute about
where the social care element ends and the nursing care begins,
they appear to have overcome the great divide?
(Mr Rice) It is a difficult question to answer, because
everyone wants to do a good job; it is how they see their priorities.
Clearly, from the point of view of the clinicians, we touched
on this earlier, I feel that we have not done enough to convince
them of the benefits of technology, in order to improve the quality
of life for the patient, and improve their own quality of life,
in terms of the stresses of work. The social workers obviously
have their priorities. It is not that they are not trying to do
a good job, but with the funding being in separate pots and funding
and care responsibility often not being in the same place, particularly
with this issue about discharges, then there is a problem. Now
I think the forward-thinking local authorities tend to have high
quality management and they focus on getting the care pathway,
constructed as a whole, and removing those kinds of boundary issues,
and the way they do it is to have the social and healthcare people
talking to each other and having a common set of protocols that
they both buy into and apply.
496. So you will supply us with further information
on this?
(Mr Rice) Yes.
497. Ms Adams, presumably you also link with
lots of different authorities; can I put the same question to
you. What are your views about the way forward, in terms of them
working together in a more effective manner, are there examples
that you have picked up where you have felt that, yes, they have
got the idea, they have got the potential that could assist other
areas?
(Ms Adams) Yes. We have mentioned Bristol already,
where it is the one really clear-cut example where housing, health
and social services are putting their money where their mouth
is. I think we are in a sort of no-man's-land, at the moment,
because there is the transition to Primary Care Trusts, and a
lot of us have got great hopes and a few fears on this one, and
I have made specific little suggestions about the direction and
any directive that can be given to PCTs around prevention. I think
the comment that was made earlier, about PCTs and all sorting
themselves out at the moment, and it is not fertile ground for
anything new, and we have to hope that in the longer term they
will be. And the big worry is whether they will take a preventative
stance, or whether a crisis intervention, completely medical model
will prevail. And I have got some good examples perhaps in Cheshire,
where they are looking at doing accident prevention work across
the county, but then I have got three local schemes, where they
were doing accident prevention, where the money has been withdrawn
for, what you might call, the home-based accident prevention,
tacking down the carpets, removing steps, putting up grab-rails,
and the money has been shunted into a purely medical model accident
prevention service, where people are looking at drug use and fitness.
And, to me, that sort of rang alarm bells, because you have got
the potential for pulling it together, but, with the PCTs and
a medical model dominance, will we lose out on tackling the housing
and the physical environment that people live in. On the issue
of money, I do tend to think that we have to have pooled budgets;
so often, unfortunately, it does boil down to where the money
is coming from and what the priorities are. And my sense is, working
in social services across England, I do not know whether in Wales
and Scotland, I just get this comment over and again, when I am
talking to people about prevention and small-scale stuff in Care
and Repair, and adaptations and small things, it is like, "Well,
we'd like to be doing that, we'd like to be doing prevention,
but it's all fire-fighting." And we have heard quite a lot
about the home care provision; the national analysis of trends
in provision of home care is a downward trend in the numbers of
people getting any help, and a small upward trend in the number
of contact hours. And, again, it is fairly short-termism, because
you are not actually helping the people where small things might
keep them independent for longer and avoid that longer-term crash,
I think that is the worry; but I think the Care Trusts will be
very interesting, to see whether they tackle all of this. So it
is some good news, good examples, you can work together. I would
just like to put, I will perhaps get my chance later, but housing
just does not come up very often in this, and we have heard a
lot about intermediate care and delivering it to people's homes,
and I just do have to say, we have to make sure the homes are
fit to be in, you cannot deliver these things if those homes are
unfit and in a very poor state, on lots of fronts. You are not
going to send workers in where the electrics are up the shoot;
it is very simple.
Dr Taylor
498. What I really want to ask is not what I
am going to ask, because I want us to get on to Tunstall and to
hear about the innovations; but, before that, just very quickly,
we have already heard about GPs and admitting to intermediate
care, I gather, from the Independent Healthcare Association, that
before 1993 GPs could admit direct to nursing homes. Is that so,
that that stopped in 1993, and why did it stop and why cannot
it start again?
(Mr Hassell) It happened up until 1993 because of
the funding arrangements at that stage. Without going into a lot
of detail, from 1993, when the NHS and Community Care Act came
into force, the responsibility for purchasing new places moved
to local authorities, and therefore the right to place and fund
was with local authorities. Hopefully, with PCTs, we will see
them beginning to purchase a wide range of services, many of the
services we have been talking about today, not only residential
care but intermediate care, and indeed I think it is critical
that PCTs understand the importance of purchasing intermediate
care. I think one of the other services which we have not touched
on today, which is relevant both to partnerships in providing
services in the community and delayed discharge, of course, is
the mental health facilities, because it is another area where
there are huge opportunities for delivering better services. If
I may say, Dr Taylor, just commenting on intermediate care, one
of the reasons why some of the schemes that I outlined earlier
have succeeded is because they managed to transcend the normal
barriers, and, in fact, that health authorities and trusts, local
authorities and independent sector actually manage to sit down
together and work together. And I think our vision probably for
the future is that we will see more of that sort of working, plus
the assessed needs of people, giving us some form of seamless
services, which would be beneficial to everyone.
499. Thank you. I am desperate to go on to Mr
Rice and really hear about all these innovations in monitoring
in the home that we should be supporting, because I do not know
that many of know what is available?
(Mr Rice) The basic technology that the social alarm
business is built up on was either a personally-triggered alarm
or a fall alarm triggered by, what we call in the aerospace industry,
an uncontrolled descent, i.e. software that interprets the fall
and therefore can appreciate that the person falling is probably
unconscious, or certainly going to be hurt, and can trigger an
automatic alarm. Now that technology was the base for the business
of Tunstall and the base for the other social alarm providers
in the UK, it has moved on a lot from there, it has moved into
two areas. It has moved into the area of providing total care
support in the home; so, currently, the technology can provide
support, for example, against flood, against build-up of heat,
fire, intruder alarm, panic button, it can arm an intruder alarm
behind someone going up to their bedroom, or whatever. And when
you talk about the psychology of the elderly, of course, it is
not just about them actually not being well, it is also about
their perception of threat. So the technology is capable of offering
a very complete protection package to the elderly, which keeps
them at home, keeps their confidence up such that they can stay
at home, which clearly, from our point of view, because hospitals,
as you know, are very unhealthy places too, it keeps them at home,
it gives them a high quality life and keeps the will to live high,
which I believe, although we cannot prove this statistically,
extends their life. The other area in which the technology is
developing, and it is developing fast, is in what we call Telemedicine,
or Telehealth care, which is vital signs monitoring and disease
management; now this is where we can relieve the load on the acute
and intermediate healthcare sector even more profoundly, and that
is by measuring the vital signs of a person who is vulnerable.
And it is not necessarily someone who is elderly, there are 1.2
million people with diabetes in this country, and we think there
will be four million by 2010, it is a serious condition, with
acute episodic attacks and an overall, gradual deterioration,
which very much lends itself to Telemedicine care in the home,
to minimise the extent to which care is required in intensive
care units. But, equally, hypertension, with nine million sufferers,
asthma, with several million sufferers, there is a tremendous
number of conditions that do not necessarily affect the elderly,
with which technology can help to relieve the pressure on the
healthcare system. So that is why, when I look at the statistics,
I do not think the statistics on bed-blocking are wrong, but they
are measuring a fairly precise definition of bed-blocking; there
are things that technology could do to free other beds in the
system. Now what do we need to do to deploy it successfully; I
think we have a major job in educating and selling the benefits
of that to the clinicians, because, quite rightly, the clinicians
take great pride in direct and intense control of their patient
relationships and have a reluctance to embrace new technology.
That is no fault of theirs, I think we really have not communicated
it well enough, and that is the job that we need to spend a lot
of time on over the next three to four years. It also needs, I
think, support at Government and local authority level, because,
properly encouraged, I suspect, it can have a very profound effect
on the pressures on the Health Service, in terms of reducing admissions
and minimising the need for additional investment. I am not saying
there is not substantial need, for new hospitals but we can help
to reduce the need. Building hospitals is not necessarily the
only answer, in our view, it is deploying techniques, technologies
and practices that reduce the need to use hospitals.
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