Examination of Witnesses (Questions 1-19)
17 SEPTEMBER 2003
JOHN ARCHER,
CHRIS APPLEBY
AND GAIL
RICHARDS
Q1 Chairman: Can I welcome people
to the first session of the Committee's inquiry into social cohesion
and can I place on record the Committee's thanks to all those
people who showed us round on Monday afternoon and on Tuesday,
and all those who came to talk to us on Monday evening. In particular
can I express my appreciation to Andy Forbes who fixed it all
up for us. Can I stress to people who may be interested that the
vast majority of the written evidence which was sent into the
Committee, as opposed to background documents which were sent
in, has already been published. It is quite expensive if you want
it in a bound volume, but it is free for those of you who have
access to the internet. Obviously, we tried hard to make sure
that everybody in Oldham had the chance to submit evidence but
if people feel that they did not have the chance there is nothing
to stop them sending in letters, although I have to say that when
we publish our final report there is a limit to the amount of
extra evidence that we can print. Those are the points I have
to make by way of introduction. Can I now welcome the first set
of witnesses and ask you to identify yourselves for the record?
Ms Richards: I am Gail Richards.
I am Chief Executive of Oldham Primary Care Trust and I also chair
Oldham's Local Strategic Partnership.
Mr Appleby: I am Chris Appleby
and I am Chief Executive of Pennine Acute.
Mr Archer: I am John Archer, Chief
Executive of Pennine Care Trust, which is a mental health trust
covering Bury, Rochdale, Oldham, Tameside, Glossop and Stockport.
Chairman: We give you the chance to make
some brief introductory remarks, but more often than not people
are quite happy to go to questions.
Q2 Chris Mole: Good morning. The
Ritchie review, published after the 2001 disturbances, recognised
the significant health problems facing Oldham and referred to
health inequalities within Oldham, particularly those affecting
poorer sections of the community and in particular black and ethnic
minorities. What effect does this diversity in the local population
have on the way you plan and provide health services?
Ms Richards: First, we recognise
that it is crucially important that we get a look at the health
needs information and in particular the recent census has brought
us up to date and shown us the demographic changes. Some of those
demographic changes, both over recent years and projecting forward,
affect different members of our community differently. To give
you a snapshot example, Bangladeshi communities have a higher
increase in young children and also in the older population. We
have that at a borough and a ward level and we use that directly
to shape our planning in terms of where we know we need to target
specific services to meet those needs. Also, and this was recognised
post-Ritchie, some of the issues that I believe your inquiry is
interested in relate to the impact not just on our minority ethnic
communities but also on our white communities, so it is very important
in our plans to take a wider approach as well as doing the targeted
work. In particular for us as a primary care trust it has affected
where we target investment in order to meet the needs of people
who have mental health problems, heart disease, respiratory problems,
all of which are prevalent in a number of our communities across
Oldham, and also in relation to some of the initiatives and projects
that we can say more about if there is time.
Mr Appleby: For ourselves it is
largely around access to services. There are various ways in which
we attempt to do that. We can do it through the traditional method,
which is making GPs aware of services that are available. There
is a problem with that sometimes in that primary care may not
be the best conduit for doing that, so increasingly we do that
in partnership with the PCTs and some of the stuff that Gail has
talked about we work together on. There are outreach services
that are provided from the acute site which go directly into the
community, although increasingly we are trying to tie that in
with community services. It is making people aware of services
and how they can access services for us.
Mr Archer: Much of the work of
mental health services is concerned with challenging stigma, working
with people with low confidence, people who are excluded from
society. All our services are designed to look at people's accommodation,
their activities during the day, their employment, their leisure
networks, their social networks. We ensure that people who come
to mental health have a full assessment of all those needs. One
of the issues is about access and developing services that are
more sensitive to individuals' needs, and we are trying to build
that within Oldham and with the local borough.
Q3 Chris Mole: The opening part of
my question was referring both to ethnicity and to deprivation.
What is the relative importance of each of those to factors when
you are planning health services?
Ms Richards: They are hugely inter-related.
Part of the census information and more recently the area planning
information we are starting to get means that we can drill down
and get information about very local health needs and about all
the other indicators that impact on deprivation, things like the
take-up of free school meals, housing, etc. A number of our communities
from different ethnic minority groups are living in the areas
of highest need and are affected most by things like housing.
There are other parts of Oldham, particularly Failsworth and Saddleworth,
where the ethnic mix is clearly much more different and what we
are doing there now is getting a deeper understanding of where
the pockets of deprivation are and where in some instances the
service provision is much better but not universally available.
It is really about looking at those and I think they are inter-related.
Mr Appleby: I think the deprivation
thing is very much about having to look at all the agencies. You
become aware of it in terms of your own particular sphere but
it may manifest itself in other agencies and that is where the
agency work becomes more important.
Ms Richards: One major contribution
that we recognise we have to make as an NHS collectively is that
we are one of the town's biggest employers and there are issues
of employment and access to ethnicity and deprivation.
Q4 Chris Mole: We shall be coming
to that shortly. Perhaps I could ask Mr Archer how mental health
services in particular respond to both the needs and cultures
of different communities.
Mr Archer: I submitted some information
to you. Our information tells us that minority ethnic cultures
have very low access rates to mental health services. The number
of people sectioned under the Mental Health Act, for instance,
in Oldham is average but the number of people who are admitted
to the wards who are in direct receipt of care is low. That tells
us several things. It tells us that our services are not yet sensitive
enough and it tells us that mental health services are not attractive
to minority ethnic people for a variety of reasons. However, what
has not been found to work is developing specialist services just
for people from ethnic minorities. What we are going to do is
make our mainstream services more attractive and more accessible.
We are doing that through the use of interpreters, through supporting
a whole range of initiatives that the PCT and the social services
department are engaged with. We have established a need for black
and ethnic minority workers. We are looking to recruit more black
and ethnic minority workers into our services and there is a whole
list of other initiatives which I have here and which I can leave
with you.
Q5 Chris Mole: Coming to the concept
of parallel lives, we have been struck by the degree to which
geographical separation in black and ethnic minority communities
exists in Oldham. What particular challenges does that create
for your services?
Ms Richards: In terms of direct
front line provision, I do not want to sound flip but it is actually
less of a challenge. I think we can make a tremendous contribution
because it is a bit like schools: everybody accesses health services.
We have one major hospital in the centre of Oldham which everybody
across the borough attends and over 90 per cent of our community
do get that hospital care from there. In relation to our health
centres, whilst they are in huge need of improvement and development
we have sent evidence in on the LIFT initiative we are taking
forward. Through that initiative and using resourcing to create
new kinds of buildings—integrated care centres, primary
care resource centres—and looking very carefully at where
they are sited and the range of services that are provided through
them, mental health and social care as well as medical care, I
think that we are able to contribute in order to enable people
to come together as well as outreaching to the community. In that
sense therefore I think it is less of a challenge.
Mr Appleby: There are some areas
where you can see good practice. Maternity services is a good
example of that where the whole community accesses maternity services.
If we look at the way in which we provide maternity services,
it is a fairly diverse service, both at home and in hospital,
and is widely supported and well used, so there are some examples
of good practice which we can use.
Q6 Mr Clelland: Mr Archer touched
on the use of interpreters. In what situations is it necessary
to use interpretation and translation services to people with
limited or sometimes no English? How extensive is the need for
these services?
Mr Appleby: It is quite extensive.
We all have fairly sophisticated services for dealing with interpreting,
both formal and informal, in the hospital.
Q7 Chairman: Can you just describe
what happens at Oldham?
Mr Appleby: The formal set-up
is that there is a central point for contacting interpreters or
a mixture of externally employed interpreters and internally employed
staff, and each ward and each department has access to that list.
The first port of call is to ring Mr Bloggs who can speak Punjabi
or whatever it is. If that is not the case there is a lady whom
I believe you have met, Andrea Biggs, who co-ordinates that and
will contact people externally. As far as I am aware that works
well. There is also, if you like, an unofficial system in that
people know within the department that so-and-so happens to speak
a particular language, so often they will say, "Can you just
pop in and explain to this lady ..." or whatever. There are
different layers of how the system works and I think it works
reasonably well. It is not something that seems to crop up as
a problem. It is something that we check regularly and I think
it is a reasonable system.
Q8 Mr Clelland: That is in the normal
course of events, but what about emergency situations where you
need quickly to have consent to perform an emergency operation
or something like that?
Mr Appleby: The first port of
call will often be relatives. Often you are able to resolve the
issues through relatives. Relatives will come in and they may
come in deliberately because they know there will be a language
problem.
Q9 Chairman: But there is a problem
on occasions using relatives, is there not, particularly using
young relatives who may have a pretty good command of the language
but do not really quite understand the medical implications and
therefore they are not really giving the parents in many cases
informed information?
Mr Appleby: Potentially there
is, I agree, although in an emergency situation often you have
to settle for something that is perhaps not optimal. I have to
say that that is used in emergency situations. This interpreter
system that we have within the hospital is 24 hours, seven days
a week, so it depends what you mean by "emergency".
If someone has to be sent for an operation within 15 minutes then
often it will be the relatives. If there is a two-hour time frame
then we are able to contact somebody externally.
Ms Richards: If I may just come
in from a community perspective, we have access to the ethnic
health team based in the hospital. We have recently completed
a review of that service and I have the report if you would be
interested. I think we have much further to go in the community.
We have people from 46 different countries; 52 different languages
are spoken across Oldham. We get by some of the time with access
to the ethnic health team which is under tremendous pressure to
provide the outreach into the community service. As you said,
you have highlighted the issues about relying on either the health
care staff themselves and GPs or family, which is far from satisfactory
when you are looking at some of the more sensitive issues and
certainly some of the women's issues. Then we fall back on Language
Line, which is a three-way telephone support line, and we are
waiting for the launch of NHS Direct which I think is going to
provide a much improved service. This work, now in partnership
with social services and the council, is to build and strengthen
a community based provision creating employment opportunities
and looking at not just interpreting but advocacy and people who
are able to explain what is happening, not just interpret what
is being said. This report sets out a proposal to take that work
forward and we are committed to doing that but it will take two
or three years before we are really meeting the need.
Mr Archer: Mental health services
have access to all those facilities. However, it is compounded
further when there is a mental health issue. Some of the nuances
around someone's problem plus some of the stigma and prejudice
around mental health make the problem even more difficult, and
when you are looking for someone to interpret in those circumstances
it is quite a sophisticated concept.
Q10 Mr Clelland: Can I ask specifically
about the GP services? A lot of the doctors who came over from
the sub-continent in the 1960s and who have language skills are
now reaching retirement age. Is that going to create a problem?
Ms Richards: Yes. We very much
recognise the need to be far more proactive and I always said
from the outset that the position would get worse before it got
better because of predicted retirements which, for a whole set
of reasons, things had not been put in place to address. The current
position is that we have 13 vacancies within Oldham. We have GPs
providing health services to very high list sizes in some cases.
The recommended average is 1,800 patients per GP. Some of our
GPs have list sizes of 3,000-3,300, which is wholly unacceptable.
The good news is that we are beginning to turn the corner but
it will take the next three to five years. Since we have been
in post we have recruited eight new GPs into Oldham, which was
something that had not been happening previously, a number of
whom are females. Of course, a lot of the other GPs were male
so, although they had the language, for some of the issues people
wanted to see a female GP and have choice. Besides harnessing
every opportunity, every flexibility going, one of the things
that changes in GP contracts have brought is that we have developed
out of the primary care trust a salaried GP scheme which is very
flexible and offers more flexible working hours and opportunities
for research, education and development. We have recently recruited
three salaried GPs into Oldham and we are interviewing next week
and we have five very strong applicants for that, so yes, it is
very difficult but we are moving forward in the right direction.
Q11 Chris Mole: Can I ask if there
has been any assessment of the cost of inappropriate referrals
to acute services in comparison to what could be the value of
investment in support at the primary care level?
Ms Richards: A general statement
would be, and you would probably hear this across the north west,
is that Oldham has been under-funded; we have been eight per cent
from our target funding for many years. The recent budget settlement
has begun to address that and over a period of three years we
do see an increase in resource coming in but we still remain considerably
under target. That in turn has dramatically affected not just
whether people are getting the right services but also the investment
across the whole. Historically it is fair to say, and I think
others would agree, that the investment has gone into the hospital
services rather than community based mental health provision.
In terms of specific slots, the only real information we have
is around delayed discharge and we are beginning to gather information
about inappropriate referrals. I cannot give you a cost figure
but in terms of signing up to a target across Greater Manchester
we have signed up to a target that we will hold GP referrals into
out-patients at the current level, so there will be nought per
cent increase, and that is based on the information that we need
to manage referrals differently; we need to get underneath this
and understand the figures and the costings and then use the resources
that we have protected across Greater Manchester to put investment,
initially non-current, I have to say, into community services.
Q12 Chairman: What does a GP do when
he gets a patient come to him and they have some difficulty communicating
to the GP what is wrong with them? Is the temptation not for the
GP to refer them on to a consultant on the basis that the consultant
can sort out the problem, which may be a medical one or may be
a communication one, rather than getting to grips with it himself?
Mr Appleby: I take your point.
We have not done any work on the cost is the true answer. What
we have done some work on is inappropriate admissions, which is
not the same thing, I accept, because you could argue that your
inappropriate referrals are getting weeded out at out-patient
stage, but the work we have done in terms of inappropriate admissions
indicates that they are very low. We would have to do an audit
piece of work initially, I think, to see if there were inappropriate
referrals to out-patients. It is not something that I have been
made aware of. That is not to say that it does not exist.
Ms Richards: The rates of referral
do vary across Oldham from practice to practice and we are now
starting to get very detailed information on that. We have introduced
a direct referral centre where everything comes in. At the practices
that seem to have the highest referral I do not believe it is
a language issue but it is also certainly the practices where
they have vacancies in terms of GPs, where they do not have the
health care staff wrapped around the practice, such as nursing.
It is the overall resource provision, I would suspect, rather
than a specific language issue.
Q13 Chairman: Do you think even the
new funding formula, if it is achieved, will reflect the extra
cost of putting in the translation services?
Mr Appleby: No. There is a big
issue with asylum seekers where it is becoming an increasing problem
for us. There is pressure on that at the moment, certainly.
Ms Richards: It is easy to provide
for our more stable parts of the community than the transient
communities, and again we are looking at some work that certainly
I was first involved with across in Huddersfield, where we may
be able to create amore dedicated service not just for the asylum
seeking communities but for the wide range of people we have within
Oldham who are highly mobile, because then it becomes far easier
to meet their language and health care and social care needs,
but it is very early days.
Q14 Dr Pugh: Can you clear something
up for me? There is the issue of self-referrals, is there not?
The Ritchie report said that some ethnic groups have more self-referrals
to A&E than other parts of the community. Is that true and,
secondly, does the explanation for it lie in the fact that they
are not on any medical practitioner's books or that there is a
translation service at A&E or whatever?
Mr Appleby: Yes, it is true. I
think there is an assumption that it is around ethnic rather than
around area because the two are often similar, as you know. It
would be difficult to say whether it was around language or around
lack of access to GPs.
Q15 Dr Pugh: Should you not be doing
some work to find out then?
Mr Appleby: Yes. We are talking
about referrals to out-patients. We know which practices refer
much more than others, for instance, and we know where we get
more self-referrals from A&E.
Q16 Dr Pugh: But you do not know
why somebody shows up at A&E who possibly could have gone
to a pharmacist and sorted out something out for themselves?
Ms Richards: Particularly in terms
of out-of-hours provision we do know why. It is because there
are not the alternative services there. We do not have the equivalent
in Oldham of walk-in centres and we certainly do not have access
to 24-hour services, except in an emergency, right across the
borough. The LIFT scheme I was mentioning earlier, the integrated
care centres, will take time but that will enable us to provide
access.
Q17 Dr Pugh: But if that is the explanation
that indicates that there is uneven primary care provision for
the communities across Oldham.
Ms Richards: Yes, there is.
Mr Archer: May I make a point
on that with regard to mental health? Bearing in mind that there
is a low number of people from minority ethnic communities being
care co-ordinated by mental health services and we have a range
of mental health services out of hours, I would imagine that they
would be more likely to turn up to casualty as they are not getting
that continuity of care. That is very important for mental health.
We are doing some monitoring of people who being care co-ordinated—what
is wrong with them, where they are coming from. We have started
doing that monitoring this year so we will be able to start looking
at targeting that much more and looking at ways of retaining people
from those communities on the books for longer. Continuity of
care in mental health is absolutely crucial. The major problem
in addition to interpretation is about the provision of appropriate
information to allow people to know about alternatives and think
about more self-help. We are not getting that information out
either. That is an area that we need to improve upon.
Q18 Dr Pugh: What about the staffing?
Seven per cent of your staff come from the ethnic minorities but
something like 14 per cent of the Oldham population belong to
the ethnic minorities. That is a strange inversion of the position
you get in many other parts of the country. Why is that?
Ms Richards: From a primary care
point of view obviously it varies across the staff groups. The
GP community is very reflective of some minority ethnic communities,
other staff groups less so. It perhaps just was not prioritised
and the work was not taken forward in community based services
for recruitment and retention. What I can say is that in the primary
care trust it was four per cent when we came into being in April
a year ago and our figures in June this year show that that has
gone up to 6.3 per cent. Again, there is a whole set of proactive
things we have done to encourage recruitment and to support existing
staff from black and ethnic minority communities to have the opportunities
to progress within the organisation.
Q19 Chairman: But it is still pretty
low compared to other parts of the Greater Manchester conurbation,
let alone nationally, is it not?
Ms Richards: Yes.
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