Examination of Witnesses (Questions 520
- 539)
WEDNESDAY 8 MAY 2002
MR MICHAEL
LEADBETTER, DR
CHRIS JAMES,
DR GILLIAN
MORGAN AND
MR J RANSFORD
520. Do you accept the estimates that the NHS
Confederation have put forward to us of 2.2 million bed days each
year?
(Mr Ransford) We certainly do not have evidence to
refute this. I am quite prepared to accept that as a basis for
discussion.
521. One of the witnesses—I think it may
have been in your evidence, but I may be wrong—suggested
that there have been delayed discharges over many years. Why has
it become fashionable to discuss delayed discharges in recent
times?
(Mr Ransford) There are various reasons for that.
Certainly I can attest from my own practice over 30 years that
this is not a new issue. Two matters dominate. One is that a whole
series of other accommodation arrangements for people have simply
disappeared, certainly for older people over the years: convalescence,
different sorts of non-acute arrangements have disappeared, particularly
from the health sector over the years. Second, there is no doubt
whatsoever that partly as a result of policy, partly as a result
of resources, services became more efficient. The acute phase
has become more efficient, there has been more attention to performance,
more attention to turnaround of scarce and expensive resources.
That has understandably concentrated on people who are using resources
which could be used for other purposes. There has been a penalisation
of that process, which perhaps was not there in earlier years
when the approach was more relaxed.
Sandra Gidley
522. Mr Leadbetter, in your submission you are
quite keen to suggest, understandably, that not all the blame
should be laid at the door of social services and that there are
many other factors over which social services have little control.
Could it be that the fundamental reason or weakness is that the
social care funding formulas do not cope with the system the way
it is?
(Mr Leadbetter) This also links to the point Mr Ransford
was making. Funding for health has been significantly above the
rate of inflation, also higher than the funding for social services,
for a number of years. The recent budget went some way to remedying
that. If you are getting increased activity in the acute sector,
increased accident and emergency admissions. This increased acuity
puts additional pressure on SSD. We know that 70 per cent of the
people who are accident and emergency admissions are the ones
who are in a situation of delayed discharge. The other factor
we must take into account in looking at that—and I think
it is a question of analysis rather than blame; we really have
to move our terminology away from who is to blame to what the
problem is and how we can solve it—is that prior to 1993—and
it is a statement of the obvious, but it is sometimes a timely
reminder—people who could not afford were funded by the
social security system and that was demand led and it was increasing
like this and the budgets were passed to social services and we
directors described it as a poisoned chalice. It was a chalice
mostly welcomed, but it made the system of assessment and rationing
inherently wrong.
523. My understanding is—and I am happy
to be corrected if I am wrong—that currently it is a pot
of money, no account is taken of an elderly population in some
areas, social indicators, deprivation indicators, all of the other
factors which could have an impact on how many people social services
are having to fund. Would you like to see any change in the way
that money is allocated to social services? I know that we would
all like more money and you might get more money for some areas
if it were done more fairly.
(Mr Leadbetter) We clearly need a look at the system
of allocation. Most people would recognise that the current system
is something of busted flush. There is a problem with any system
of allocation. Locally we have looked at various systems in the
course of resource allocation, index, analysing the numbers over
75, analysing the incidence of sickness. However you look at it
there is an argument from some quarter that somebody is disadvantaged.
Any system has implicit weaknesses. I do think the current one
needs a review as it does not give an accurate reflection. It
is not as easy as the funding for education, for example, where
you just look at pupil numbers. It is a lot more complex. I know
I am stating the glaringly obvious, but there are no easy answers
to how you allocate the money. It is hugely difficult.
524. You must have some ideas. If you were given
an audience with the Minister tomorrow, what would you suggest
be looked at?
(Mr Leadbetter) Over-75s, morbidity, softer issues
like performance of GPs, level of referrals, incidence of consultant
referrals. Let me take a step back and explain this with a story.
In Essex one of the trusts came to see me asking for more money.
They said they needed more money because they had a lot of people
waiting. I told them that our figures showed they were receiving
26 per cent of the budget when on any demographics they should
only be receiving 19 per cent. I asked them to look at consultant
behaviour. They reluctantly agreed. They looked at consultant
behaviour. They found that their consultants, as opposed to those
in other trusts, were telling Mrs Smith when she went in that
she should not worry, she could stay as long as she wanted and
she could have a care package. This was a few years ago but measuring
the softer issues like the behaviour of consultants, the behaviour
of GPs, admission practices and the conduct and practice of social
workers are all matters which need to be taken into account as
well as having a mathematical formula, plus taking into account
the role of voluntary organisations. In the richer parts of Essex
the voluntary support is stronger than in some of the poorer parts.
I am avoiding trying to give a simple answer and a simple formula
to the Minister.
525. There is no simple answer.
(Mr Leadbetter) No.
Julia Drown
526. You say it would be helpful to move away
from the blame culture. Do you think there is an issue at all
in social service departments of playing the victim and not being
as proactive as possible? Could that be a reason why some areas
do very much better than others in terms of performance, for example,
the issue over the loss of capacity, which is a very real issue,
nursing care, residential care? Undoubtedly social services have
a responsibility in trying to manage all those but it seems to
be, from your evidence and what we hear from Directors of Social
Services, there is sometimes an issue of trying to throw the problem
elsewhere. Do you want to comment on that?
(Mr Leadbetter) I do not think by and large social
service departments act the victim. Sometimes we are placed there
and have to defend it robustly. We do it very well. I have a stream
of figures I can go into if it is appropriate where I did a ring
round of the departments and all of them achieved their targets
for capacity. When the £100 and £200 million came, all
of them achieved their targets for reducing capacity. All gave
me a list of very creative initiatives, some different, some extremely
creative, some averagely creative. I was hugely impressed by what
had been achieved: funding of outreach teams; funding of practice
nurses; funding of co-ordinators; transferring money to health;
so many initiatives we could submit in detail indicating a very
proactive response from social service departments; a very high
level of generality, but approximately 50 per cent of the money
spent on increasing fees, 50 per cent on creative schemes. That
does not read to me like social services departments playing victim.
It does read that given the cash there is a lot of creativity
and willingness and very, very strong partnerships emerging from
the care groups.
(Dr Morgan) There is a general issue which is the
nature of the incentive system. This is not about social services,
it is about health and social care. One of the frustrations for
managers in organisations who tackle these agendas in partnership
and very robustly is that at a point we get later in the year
where there are potential problems, the problems and resources
tend to go to the people with the biggest problems. The better
you manage it, the less additional resource you get to lever even
further change. That can be very dispiriting, perhaps not to senior
managers, who tend to work in those organisations in very strong
partnership between health and social care, but often people on
the ground. They see adjacent communities having additional resources
in and they are left to manage with the resources they had at
the beginning of the year.
527. You can understand why the Government does
that. It wants to focus resources where they are needed most.
(Dr Morgan) Absolutely.
528. So what is your alternative solution?
(Dr Morgan) It is trying to find the balance between
the two. To give a little bit of extra money to the communities
who are doing well as a reward would actually drive the innovation
and the leading edge, because then you could really try out some
of the things where you need to have parallel funding in place
to lever out the change. One of the problems for health and social
care is that you are trying to deal with it in the here and now,
put in alternative solutions, nobody trusts the alternative solutions
until they have been up and running, at which point you can withdraw
the old. It is how you loop the thing round and use the communities
who are really demonstrating they can manage it effectively to
be the pilots and the leaders so they have some incentive rather
than seeing all the resources and what they regard as an easier
option potentially in the adjacent communities. It is how we get
that extra bit in; not replace the first but add in something
which rewards good performance.
(Mr Leadbetter) There is a question of sustainable
long-term funding. We welcome the £100 million and the £200
million but that creates a tail, depending on what we euphemistically
call turnover but usually means deaths. The LGA and we estimate
that could be around £160 million; it is a significant amount
of money. Each of the short-term initiatives, whilst welcome in
a limited way, add to the longer-term problems and reduce the
possibility for creativity because you know you have a financial
headache waiting in the wings.
529. When you go back to Department officials
on that and ask whether it is going to be a one-off or whether
you can be assured that it will at least be taken up in the next
year's spending round, what is the response you get?
(Mr Leadbetter) Guardedly optimistic and wait for
the comprehensive spending review.
530. Does a responsible authority not take that
as meaning that they can plan on this?
(Mr Leadbetter) A responsible authority takes a risk
because people are waiting in hospital and we all agree that is
not advisable. So we take a risk and we depend on the £200+
million which local authorities spend extra on services for older
people above their allocation. That is what happens.
531. Are you saying it is not advisable?
(Mr Leadbetter) No, my advice as director is usually
to risk it
Dr Naysmith
532. I want to explore something Mr Leadbetter
said about what happened a few years ago when the system was better
because it was demand led and less of a problem. Could you say
a little bit more about that and the transition to the situation
we are in now, how that came about and how it was managed?
(Mr Leadbetter) I am sorry I did not mean to infer
that it was better. It was demand led. I happen to think it was
worse, but it did mean that there was a ready supply of money
in the social security budget. If people were waiting and could
not afford it, they could go into a home. There was a famous study
from York university which indicated there could be up to 40 per
cent of people wrongly placed in residential and nursing care
who could be placed in the home. It was not a better system, but
the advantage was that it was demand led.
533. I just wanted to clarify that. You do not
think that was necessarily a better system.
(Mr Leadbetter) No. That was partly in answer to the
Chairman's question about why this is suddenly an issue. It has
been growing as an issue since 1993 because the capping of the
funding makes it so, because we ration.
John Austin
534. The logical conclusion is that the way
of easing the situation is not by replacing however many thousand
care home places have disappeared, but looking much beyond that.
(Mr Leadbetter) It needs to be addressed in a much
wider context. There is what my health colleagues call demand
management which is really looking at how we can better support
people in the home and minimise admissions. One of your previous
presentations talked about the possibility of tele-medicine with
the possibility of quicker diagnosis. We know sometimes that people
are admitted because of undiagnosed stomach conditions for example.
Quicker diagnosis, more access to diagnosis, community outreach
teams can all prevent people going in to that "front door"
which means they can then become in patients. We also know the
figures. It is that close to 40 per cent of infections can occur
as a result of a hospital stay, so we are all agreed that keeping
people out of hospital is better. The figures for residential
care are constant, which suggests that there has been some success
in keeping people in their homes as well.
Dr Taylor
535. Can we pick up the question of choice that
you brought up? We had conflicting comments on the importance
of this. The Department of Health said it contributed about 8.1
per cent to overall delays. The Independent Health Care Association
really did not rate it as a problem. In the paper from the Association
of Directors of Social Services in the table in paragraph 3.4
it was something like 14 per cent of councils thought this was
a pretty significant thing. What is your view of the choice directive?
How are you implementing it? Is there any way of getting round
it quickly by having interim arrangements so it does not hold
things up?
(Mr Leadbetter) Locally what we have agreed with most
of the trusts is a letter to patients when they go in giving them
the evidence that it is as well for them as soon as they are medically
fully fit to be out of hospital. If their first choice of home
is not available we will place them in a second home and then
get them in the first home quickly. We find that giving that information
to people helps them make a fairly informed choice that perhaps
it is not as good for them to wait in hospital. We think our figures
at round about 14 per cent are sufficiently robust because there
is the situation of the old person in hospital who had expected
to go home being told unequivocally that it would not be safe
and being in trauma; maybe medically fit but does not want to
face the consequences of not going home to a home she has lived
in. Those situations will always be present and we need flexible
and sensitive responses to people in those situations, not a simple
question of counting numbers and counting bed days lost.
536. Will most of your families and their relatives
accept going to their second choice in the short term? Do many
of them stick out for their choice?
(Mr Leadbetter) One or two but very few if it is approached
properly. There is a question of context. If you are a small urban
authority, there may be ones, but if you are a big county people
who live in a small village know they will have to travel a long
way to find a home. There is a question of where you live, where
you sit and what your expectations are.
(Dr Morgan) The service would see is as patchy. There
are places where choice is being effectively managed between health
and social care. I must stress that this has to be seen as a joint
issue. In other places it is still something which often nurses,
often social workers, find very difficult to encourage people
to accept a short-term placement. There are some very good reasons
why clinical professions are not in favour of that. We know that
for elderly people, multiple moves are not a positive health outcome
for them and it leads to harm in itself. You often have people
who have some very good reasons for not encouraging people to
think about a short-term option. It is patchy, because there are
some very good protocols across the country, and Essex would be
one, where people are managing this in a fairly dynamic way and
managing to satisfy both patients and their families. Families
have a terribly important part to play in here because choice
is often not about the individual. They are often more flexible
than the families and we find that very often. The family want
to do the best for their parents, their mother, their father,
are often far more concerned about things being just right than
the individual themselves. It is a very complex thing but you
need both high level agreements about how to manage it, and you
also need something to help clinicians make effective decisions,
clinicians and social workers.
537. Are you as a Confederation pushing that
these sorts of protocols should be adopted all over the country?
(Dr Morgan) We would not be pushing in that sort of
way. What we would be pushing very hard for, the important bit,
is to have proper local agreements of what is going to work in
local areas. Rather than push a one-size-fits-all, it is much
more about having the right type of relationships and a whole
systems approach. The answer here is not just focusing on choice
at the end, it is focusing on prevention, stopping people getting
in, focusing on admission, how you put alternatives into admission.
It is then focusing on appropriate planning once people are in
hospital and only then do you get to the point of discharge. There
is a whole lot of things which need to be done in a coherent joint
way and the balance in any community is going to depend on a whole
set of local factors. It is putting those local plans together
which are relevant rather than saying there is a mantra which
will solve something which is a complex problem.
(Mr Ransford) It is very significant and it is bound
to be patchy be definition. It will depend on relative capacity,
depend on a whole series of things. The two points which it is
absolutely crucial to emphasis are: you raised the question of
getting round, dealing with it imaginatively yes, but usually
in these sorts of circumstances people come up with ideas like
holding centres as a way of moving people away from acute facilities,
waiting for the place of their choice. As has already been explained,
multiple moves and treating people with less dignity and respect
than they deserve usually increases the problem. The real answer
here is to ensure that there is capacity and build a system that
can deal with multiple needs. I am a strong advocate of these
matters being part of local government. That is not solely based
on the organisation for which I work. Local government's wider
community leadership role should ensure that there is capacity
built in communities to deal with a whole range of needs to create
a healthy society and to make sure that there is sufficient resource
in the area from which to commission, so hopefully we can have
our cake and eat it with the individuals and their families having
sufficient choice and we having sufficient alternatives to make
that choice meaningful. It really relates to an earlier question
about whether we are victims. Whether we are or not does not matter,
because we have to be proactive. It seems to be a mixture between
creating capacity and certainly using the flexibility of resources,
which is now possible under the 1999 Act. We see more of that
coming forward. Where everyone works together to create the right
solutions means the choices are in a better context.
538. It has just been pointed out to me that
we have not received any specific examples of choice management.
Would it be possible, not necessarily now, for the LGA and NHS
Confederation to supply some specific examples?
(Mr Ransford) Yes, we can do that.
Andy Burnham
539. Reading the Confederation's submission,
you talk a lot about factors beyond the NHS's control and beyond
the control of the Health Service. Is it fair for me to conclude
therefore that you see the whole issue of delayed discharges principally
as not one of the NHS's making?
(Dr Morgan) No, that would be unfair. It is a whole
system thing. There are issues around the NHS becoming more effective
at working with local government, putting in effective preventive
schemes, thereby avoiding old people being in a position of having
an acute crisis. That cannot be done either by local government
or health working independently. We have a lot of the information
about who old people are.
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