Examination of Witnesses (Questions 680
- 699)
WEDNESDAY 19 JUNE 2002
JACQUI SMITH,
MP, MR RICHARD
HUMPHRIES, MS
MARGARET EDWARDS
AND MS
ANNE MCDONALD
680. So within the hospital?
(Ms Edwards) Within the hospital.
681. Which is one of the causes of delay in
any case.
(Ms Edwards) It is one of the causes of delay but
is not a delayed discharge at that point. We have seen the length
of stay go up slightly in the last few years and actually if anything
electronic records will improve the care required for all patients.
682. So even in patient administration systems
we will see some improvements, you are saying?
(Ms Edwards) I think we will.
683. When do you think realistically we can
expect the electronic patient records? To me it would seem to
be one of the most important things. I was amazed, coming down
here by train on Monday, that British Rail could tell me not only
that my own train was delayed but the connection was delayed so
I was going to catch it. It seems to me it is absolutely crucial
to have this sort of information before we can begin to assess
the impact and whether you are making any improvement.
(Jacqui Smith) I think there are two issues here.
Perhaps I could write to you about the details of the technology,
if you like, in relation to the electronic patient records. But
actually I am quite a strong believer that technology is important
but we do not need to wait for technology in order to share information
better than we do. There is a lot in some areas we can do to share
information better than we are already, even before we get to
the point where that is available technologically.
Dr Taylor: Thank you.
John Austin
684. Can I turn to intermediate care development.
Some time ago the Minister in an answer to a Parliamentary Question
gave a definition of intermediate care, and it seems through the
course of this inquiry we have had several definitions and a certain
vagueness about the term. How would you now define intermediate
care?
(Jacqui Smith) I have not got off the top of my head
the definition that we issued in the guidance which I think went
out in 2001. What I am clear about is the sort of role that intermediate
care needs to play and increasingly is playing, both in ensuring
that people have that bridge between hospital and home in terms
of the rehabilitation which is provided for them, and in terms
of preventing some admissions to hospital without intermediate
care which happens in a way which is not necessarily appropriate.
What I also know is, in terms of evaluations we have done of the
development of intermediate care, we are making extremely good
progress in developing beds and places and the number of people
who are benefiting from intermediate care services, and that development
of intermediate care is part of the reason why we have seen the
reductions in delayed discharges that we have had.
685. I note you are referring to the prevention
of admission, because earlier on you were talking about step-down
provision development. Do you think more emphasis needs to be
put in primary care on preventing admissions as a major contributor
to stop beds being blocked by inappropriate admissions?
(Jacqui Smith) I think there is a balance. Perhaps
I could ask Richard Humphries to answer as that is one of the
responsibilities of his team.
(Mr Humphries) One of the early messages which is
coming out of our work with various health and social care communities
is that in some places people are spending too much time having
an academic debate about what intermediate care is or is not instead
of getting on and developing and identifying what services they
need, firstly to keep people out of hospital in the first place
and, secondly, where people do need to be admitted to hospital
that the right facilities are in place when they are ready to
leave. We are encouraging people to focus on the practical things
that need to be done to put those services in place because it
all comes down to local need. Intermediate care can mean whatever
you want it to mean, it can be defined in all sorts of ways, but
the key point is what difference is it making to people who are
going through a health and social care system.
686. I welcome that comment. It seems to me
a lot of talk about intermediate care has been beds, beds and
beds, rather than you definition of developed services. The evidence
we have had is almost all the development of intermediate care
services has been directed into creating more beds but that in
some cases this has been a re-managing of existing services or
a re-designation of things which are already there. One of the
points put to us as well by one of our witnesses was that the
resources which have been earmarked for intermediate care often
have sticky sides, that it adhered to other surfaces, and Age
Concern in particular said it was very difficult to trace where
the resources were going in terms of providing alternative levels
of care which Mr Humphries was talking about. How would you react
to that?
(Jacqui Smith) It seems to me that what you need to
do is actually to focus on what you are getting for your money,
and that is very much what we have done. Incidentally, I tend
to agree with you that there is a role both for the beds and places,
which is why the NHS Plan target focussed on extra beds and on
extra places and particularly on numbers of people who were being
assisted by intermediate care. In our recent evaluations we actually
believe that there are now in place plans to deliver 2,400 more
beds, 6,200 more places, and that is 137,000 extra people receiving
assistance through intermediate care. That is what I am primarily
concerned about: are there the schemes out there that, as Richard
said, are actually making a difference to helping people be rehabilitated
out of hospital and helping to prevent people going in in the
first place, and are we also now beginning to get a point of view
of what intermediate care can do? For example, when people first
start thinking about intermediate care I think it is very easy
to focus on people being rehabilitated following hip replacements,
say. That is a very important role for intermediate care, but
actually we are also seeing intermediate care that is helping
patients with dementia to be more independent. We are also seeing
a whole range of pre-admission schemes, hospital at home, rapid
response schemes, which are helping in a whole range of ways not
only to keep people out of hospital, but also to help to develop
their independence and their skills in the community as well.
So we are seeing that range. We published on the Department's
website—I think it was on 6 June—our evaluation and
some guidance for the future about good practice that is happening
in intermediate care and what is needed to develop it even further,
so we recognise the need to focus people's attention on spending
the extra investment that is going into the system on developing
these additional services. We are evaluating nationally intermediate
care provision, but we are also, through Richard's team and in
other ways, looking at the experiences on the ground about what
intermediate care is delivering in terms of services and what
it is delivering in terms of better outcomes for older people
and so on.
687. Could I jump in here on a hobbyhorse of
mine, since it is National Osteoporosis Month and the All-Party
Group had a very successful session here this week. There is a
fair degree of certainty that anyone who is admitted to hospital
with osteoporotic fracture is likely to be admitted at some stage,
yet we know that those fractures are preventable in many respects,
and yet of the patients who leave hospital having had an osteoporotic
fracture only one in ten gets further treatment on discharge.
Is not that an area which requires fairly urgent attention, given
that it is in the National Service Framework that resources do
not require NSFs? Is not this an area that needs looking at?
(Jacqui Smith) I think I might dispute with you the
extent to which resources follow NSFs. I think that they do. As
you know, in the NSF there is a standard on falls. I have met
with the National Ostoeporosis Society to discuss what we need
to do in order to make sure that services are in place for people
with osteoporosis and how we need to ensure that the considerable
extra investment that is going in delivers in that area as well.
It comes back a little bit, I think, to what we were saying earlier
about PCTs and commissioning. I have spoken to a PCT chief executive
who described the incentive, if you like, when you are a PCT and
you are commissioning, precisely to ensure that those sorts of
services are in place so that when you are responsible for commissioning
the care for an older person, both into and out of hospital, you
have as a PCT a much stronger incentive to ensure that you have
full services, that you have a follow-up for people as they come
out of hospital. We have talked a lot about financial flows and
incentives, but that is a sort of practical benefit that PCT development
and the incentives that are in place there are already leading
to, and are likely to lead to more in the future.
688. My final point on this is that money is
clearly a problem or is an essential for developing those services,
but in my area—and, I suspect, certainly in London in particular,
but the South East generally probably—even if we had the
money, where would we purchase the extra therapists? There is
not an adequate supply. If we are to develop intermediate care
services, and in terms of levels of care, do we not need drastically
to increase the whole range of supply of various therapists?
(Jacqui Smith) You are right that a key capacity constraint
for the NHS and for social care is developing staff, which is
precisely why, as part of the next steps for delivering the NHS
Plan, we have identified the need to recruit even further than
we have in relation to therapists and allied health professionals.
I was searching for information about the success that we are
actually already having in recruiting extra physiotherapists.
689. Is there more training?
(Jacqui Smith) More training places, and attracting
back into work therapists who have left for a variety of reasons.
We are having success both in terms of extending the training
and in recruiting. In each of those areas—physiotherapy,
occupational therapists—there are more now than there were
a year ago, but there are plans to ensure that there are more
in the future, because I agree with you that recruitment and the
availability of the right sort of staff is a very important contributor
to getting fully into the system what we need across the whole
of the NHS and social care actually, but clearly in terms of therapists
in relation to rehabilitation, in relation to the sorts of services
that you were talking about.
Dr Taylor
690. How are you going to involve the independent
sector in actually planning the development of intermediate care?
(Jacqui Smith) Firstly, intermediate care was one
of the areas of work highlighted in the concordat with the independent
sector as being an area where we felt that there is very important
work that we can do with the independent sector. For example on
the Strategic Commissioning Group that I chair, where there are
representatives of the independent sector, we have discussed,
and will in the future discuss, the contribution that the independent
sector can make to developing intermediate care. In a meeting
that I had with the Independent Healthcare Association a couple
of weeks ago I talked to them about the guidance that they are
preparing around the contribution of the independent sector to
intermediate care. We have, I think, already undertaken work on
developing model contracts around the use of the independent sector,
and with regard to some of the £66 million capital that we
are devoting to developing intermediate care, I think I am right—and
I will correct myself if I am wrong, but I do think I am right—out
of the beds which are being developed through the spending of
that capital, 25 per cent of those additional beds are being developed
in partnership with the independent sector.
691. It is good to hear that you talk to them,
because they were the very people who told us that there was very
little go-between.
(Jacqui Smith) Perhaps that was before my meeting,
Richard!
Dr Taylor: Yes. I am glad to hear that. Thank
you.
Chairman
692. Can I not necessarily bring in a discordant
note, but slightly change the emphasis, following on your question.
I am not sure I entirely agree with that question. I noticed that
in The Guardian this morning William Laing of Laing &
Buisson, the care analysts, was quoted as saying, "For better
or worse, the delivery of nursing and residential care was largely
privatised during the 1980s and 1990s." My question, in a
sense, is, has not the involvement of the market made it more
difficult to plan for strategies such as intermediate care and
to address delayed discharges than if you actually had a system
that largely depended upon public sector or non-profit-making
provision? I was interested in a study that was drawn to my attention
from the West Yorkshire area, which I will be happy to try to
get hold of and pass on to you, which has looked over the past
year or so at the discharge arrangements for patients coming out
of acute beds through intermediate care and the intermediate care
comparisons being used for a local authority intermediate care
provider and the use of private sector intermediate care. The
conclusion that has been drawn from this period of study is that
people tend to remain within the private care home rather than
actually moving on to their own home environment. I think the
concern is that where you are using private care there is a built-in
incentive for people to remain in that private care facility because
obviously the private care home owner wishes to ensure that his
or her beds are filled. The question I would raise is slightly
at an angle from where Richard was coming from, that part of the
question is about the Government's position of involving more
and more the private sector, in that there are in my view clear
conflicts and disincentives to the process of rehabilitation because
of the profit motivation.
(Jacqui Smith) I think you set the context in terms
of what you said at the beginning about the nature of social care
providers. For whatever reason, we are in a position—and
I do not necessarily share your concerns about this—where
a large part of care provision is in the independent sector, in
both private provision and in some absolutely excellent voluntary
sector provision, both in terms of residential and domiciliary
care and contributions to intermediate care. My primary concern,
I have to say, is how do we develop the necessary capacity both
in intermediate care and in long-term care, in order to ensure
that older people have the quality, the choice and the provision
that they need to meet their needs. As to whether the independent
sector has a role that they can play in providing that quality,
I am happy that we should work with them in order to ensure that
that capacity is there. Part of your question, I think, was really
concerned around how we then manage that capacity across a sector
which includes public provision, voluntary sector and private
sector provision. I think there have been concerns, both from
the local authority side and from the independent sector, about
how we develop the sort of commissioning behaviour that ensures
that we have that long-term high-quality provision. It was, of
course, because of that that John Hutton set up, within the Department,
the Strategic Commissioning Group which brings together representatives
of the NHS, local government and, in his day, of independent care
providers. I have recently expanded it also to bring in housing
providers as well, going back to our previous discussion. One
of the first roles for that Strategic Commissioning Group was
to develop the agreement that we published, alongside the extra
£300 million worth of investment, which was about what sort
of good practice in terms of commissioning and working to plan
across the sectors should there be in place at a local level.
We made it actually a condition of receiving hot-spot funding
from the £300 million that agreements and strategies based
on that agreement should be part of the deal for receiving that
hot-spot money. I certainly have been pleased about the progress
that has been made in local commissioning, in bringing together
the various different sectors to make sure that we have got that
provision where we need it.
693. Can I be more specific? Forgive me for
interrupting you, but the point I am making is not necessarily
a dogmatic, anti-private-sector point.
(Jacqui Smith) Heaven forbid!
694. Exactly! I can actually see merit in some
more appropriate provision by the private sector. As a Committee,
on Monday and Tuesday we have looked at some of that provision.
My concern is that following on from Laing's comments in respect
of the privatisation of the system (which are his words, not mine),
it certainly struck me that that was what was going on in the
1980s and 1990s, and we now have a market established, a very
vociferous market, that is skewing at the entire direction of
the market by their demands on the issue of ensuring that the
care home sector and nursing home sector has a future. My concern—and,
as I say, it is not dogmatic—is that I can see solutions
being offered by the private sector which are more appropriate.
Certainly talking to, for example, Tunstall who were looking very
imaginatively at telehealth solutions, and to companies like that
and others that I have talked to, it seems that the care home
sector are driving the debate in a very narrow direction and a
very backward direction and, in a sense, the Government are largely
responding to that backward debate in that we are not moving like
other countries away from the institutional model of care, but
simply going along with saying that yes, we need more care homes,
we need more places. They are saying that there is insufficient
money coming forward. Should we not break away from that debate
and move off in different directions, whether it be with the private
sector, or non-profit-makers or local authorities?
(Jacqui Smith) Actually I think what we have tried
to do is to develop a view of capacity that says we need to put
the needs of older people, and what it is that they are telling
us that they want, at the centre of designing our services.
695. Not care homes though. I have never met
one single older person, having worked for not far off 20 years
in social services, who made a positive choice of entering a care
home, not one single person.
(Jacqui Smith) If your argument is that we need to
develop alternative ways of caring for older people, including
much more development, for example, of intensive home care packages,
much more of a development of the sort of housing care provision
that we were talking about earlier, I would agree with you. I
think there is already evidence that the 6 per cent increase to
September 2001 in the numbers of intensive home care packages
being offered suggests that there is progress being made in diversifying
provision. I would not go as far as you in saying that no older
person would want, or that for no older person would it be appropriate,
to have residential provision.
696. No, I did not say that. What I said was
that in 20 years I have never yet met an elderly person who made
a positive choice that that was their wish. Quite frequently they
have had to go in, because they have recognised there is no alternative.
My argument is that you need an alternative, and the alternative
there would be not to go into a care home or a nursing home.
(Jacqui Smith) Where I agree with you is that we need
to have a range of alternatives, and that is where the stronghold
of both local and national commissioning strategy I was talking
about earlier is very important. Where I might, I suspect, disagree
with you is on two things. One, is that it is not possible to
envisage a person's choice of going into residential care, although
I accept what you are saying. I have forgotten the second item
on which I disagree with you. I know the second issue was, I think,
a sort of allegation that the Government was in some way or another
responding to the concerns of private sector care home providers
as well. To the extent that we have recognised that in many areas
there need to be better working relations in terms of commissioning,
that the emphasis that we are putting on quality needs to be reflected
in terms of fee levels, yes, we are responding to the care providers,
but what we are also clearly saying is that the design of the
overall configuration, if you like, of services for older people
has to be based on an understanding about what older people want,
what is right to promote their independence, and that is the basis
on which we need to plan our services.
Mr Burns: I have a very quick question, and
a yes or no answer would be more than sufficient. As the Minister
for long-term care, would you personally ever make a speech and
describe pensioners as "banged up in care homes"? Would
you? I want an answer.
Chairman: We will give that one a miss, to be
fair.
Mr Burns: No, I would like an answer.
Chairman: That is a term that I would not use.
It was not me who used it, but I would not use it.
Mr Burns
697. Let the Minister answer.
(Jacqui Smith) That was not, of course, made in a
speech, that was made in the heat of parliamentary debate, the
sort of pressure you are putting me under now.
Chairman: I would suggest the Minister would
not use that phrase.
Mr Burns: I would like to hear her say so.
Chairman: At that point, let us move on. Sandra,
we said we would come back to you on the incentive issues. I know
you wanted to come in here. There are areas you wanted to explore
on that which we may not have covered.
Sandra Gidley
698. I apologise for not being able to be here
earlier, and I hoped to make this part of the session. Certainly
if we refer to Delivering the NHS Plan, which seems to
have moved on from Wanless, in that the Government seems very
keen to go ahead with cross-charging for social services, what
I would like to do is to explore a little bit as to whether any
conclusions have been reached as to how this will operate in practice.
For instance, will there be a period of grace before any charge
against social services is implemented, or if social services
cannot place somebody who is fit to go home straightaway, will
they be charged from that date or will there be a sliding scale?
When does the Minister envisage that these charges will come into
being?
(Jacqui Smith) Firstly, I think, to a certain extent
your question implies part of the problem potentially with the
system at the moment where it is not working properly, and that
is that we do not actually start thinking about where people should
be going when they are discharged from hospital until some way
well down the track, when actually we should have been thinking
about it a lot earlier. So the way that I would envisage the system
working is that firstly I think we need to make much clearer that
social services need to be notified as soon as possible after
an emergency admission, and potentially, of course, well before
an elective admission, by the hospital, of a patient who is likely
to need social care after they are discharged. Then I think it
would make sense to put in place a short focussed period of time
in which to make a discharge plan. I do not know if you were here
earlier when I was discussing the difference between a discharge
plan focussed on what would happen to a person on leaving hospital
and a sort of ordinary assessment, but I think there can be a
very tight focus of period of time in which, social services being
aware, there is time to develop a discharge plan. Then, of course,
we would also need to have a decision made by a clinician within
the hospital, that somebody is better and safe to be transferred
out of the hospital. Then it seems to me that having in place
a discharge plan and having that decision, that is the point at
which it is the responsibility of social services, and I shall
come to that in a moment. That is the appropriate point, given
what I was saying to Mr Burns earlier about funding available
to social services, to take responsibility for those people ready
to be discharged from hospital; that is the point at which the
responsibility either to find an alternative to remaining in hospital
or to paying the costs of somebody remaining in the hospital could
kick in. However, in relation to your earlier question, we have
moved back the responsibility for planning that discharge much
earlier on into the system, which is good for the system, but
most importantly, I think, it is good for the older person. The
next decision, if you like, that needs to be taken, for the implications
of what happens after that, depends on who has responsibility
for that care. Clearly there are going to be some people where
what is needed is ongoing NHS care or care for which there is
an NHS component, and it clearly would not be reasonable to charge
a social services department where effectively the responsibility
had not transferred to them because there was still an ongoing
responsibility for the NHS.
699. Would that be proportional? For some people
there is some nursing care needed, but not 100 per cent hospital
care, so it seems perverse in a way that the person might be fit
to be discharged from hospital but is probably not fit enough
to live unaided at home. There is a whole grey area there inbetween.
I am unclear as to where the responsibilities for them lie.
(Jacqui Smith) That particular example I do not think
is very grey. That sounds to me like social services' responsibility
to put together a package to support that person to live at home.
If the only thing that is stopping a person coming out of hospital
is having the necessary support at home, that sounds to me like
social services' responsibility.
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