Examination of Witnesses (Questions 40-59)
10 MARCH 2005
MS ELAINE
MCHALE,
MS CATH
ATTLEE, MS
YVONNE COX,
MR MICHAEL
YOUNG AND
MS DENISE
GILLEY
Q40 Dr Taylor: Is that all a toolkit
is, a needs' assessment form?
Ms Attlee: There is a health needs'
assessment and then there are other components that would amount
to it, yes.
Q41 Dr Taylor: If we do move to a single
set of national criteria, which hopefully we will, would you then
support a single toolkit or a range of toolkits?
Ms Attlee: I think that would
probably be a range simply in terms of professionals wanting to
have their own.
Q42 Dr Taylor: That is a range for different
client groups or different professionals within this?
Ms Attlee: There will be different
tools that will add up to the whole needs' assessment. The health
needs' assessment will focus on particular nursing needs, medical
needs, et cetera. You have therapeutic needs, the psychological
needs, et cetera. Normally there will be a number of components
that will add up to the full needs' assessment. There will be
different tools being used by different professionals as part
of the multidisciplinary team to add up to that.
Q43 Dr Taylor: Even with the different
tools, you think you will be able to monitor and make sure that
everybody is being treated equally and fairly?
Ms Attlee: You have to be constantly
validating. It is not a fixed scientific process. There needs
to be constant validation, in the same way as the issue around
developing the single assessment process is not static; it will
be constantly developing. Yes, I think one can do that validation
process.
Q44 Dr Taylor: That is your aim?
Ms Attlee: Yes.
Q45 Dr Naysmith: We have just been talking
about the confusion between the two things. A lot of people have
said that the RNCC framework was useful as a national model. Does
that suggest that a similar approach would be useful for the continuing
care on a national basis? In a way, it is similar to a toolkit
but this would be a national thing.
Ms Gilley: You still come back
to the same thing, that you do need a national framework, be it
for nursing bandings or continuing care or anything else. However,
this is about the application of that. What has never been done
to my knowledge, and I may be wrong about this, a comparison of
how people are banded to see whether somebody who is high banded
in one of our nursing homes would have similar needs to somebody
who was high banded in a nursing home in north west London. Yes,
in essence, use it, but the same thing needs to happen about nursing
home bandings as does about continuing care, which is about monitoring
how they are put in place and implemented.
Q46 Jim Dowd: Could I look at the area
of the retrospective reviews and ask you all what you think the
best mechanisms are for ensuring that the lessons that they reveal
and the past failures that they uncover is incorporated and informs
the development of the national framework?
Mr Young: In north west London
we have identified, through the retrospective reviews, problems
in the past. The key improvement that has already been incorporated
is that by asking our primary care trust assessors to go out and
carry out these independent reviews, under an agreement that we
as the 16 local authorities and PCTs together drew up, there is
a consistency of approach, particularly about involving the carer
in that review. The information from the carer has been incredibly
useful. Many assessors have said to me afterwards that doing it
this way, which for some of them was new, has really improved
the process. I know that some of the PCTs are now sitting down
with the carer and using the assessment tool: the carer has the
assessment tool; the assessor has the assessment tool. They are
doing it together and that is producing a much happier individual
at the end. The individual understands the decision much better
if he or she is involved in the assessment process. For north
west London that has been far and away the most effective outcome
from the retrospective reviews.
Ms Attlee: Some other practical
things have come out. One is the poor practice in terms of information
and record-keeping, as has already been addressed, and which in
a sense is being addressed separately as well by things like the
Freedom of Information Act and everything else. Some of the poor
practice that was clearly in place from 1996 onwards is already
being tackled through a number of things. That needs to be very
clearly built into the national framework: record keeping, assessment
process, involving users and carers in the process, et cetera.
I think those lessons are already being learnt. They need to be
stated within any national framework for review.
Q47 Jim Dowd: When you say "poor
record keeping", do you mean the quality of what was in the
records or the absence of records?
Ms Attlee: Both.
Q48 Chairman: Are we talking in particular
about nursing homes here?
Ms Attlee: Not just nursing homes
but everybody.
Q49 Chairman: That is right across the
board?
Ms Attlee: Yes, not everywhere
but examples across the board.
Q50 Jim Dowd: Are there any examples
of where it has actually led to changes in practice?
Ms Attlee: Certainly in information,
record keeping has led to improvements in practice across the
board, and again that has been addressed by things like the delayed
discharges and the other initiatives that are going on in terms
of record keeping. Yes, I would say there has been a huge improvement.
Ms Gilley: In terms of accountability,
people who are making the decisions jointly across primary care
and social care now feel that they are accountable to the people
about whom they are making the decisions. Being brutally honest,
if you go back to 1996/97, that was not the case. That is why
there may be records of someone's assessment but they tend to
be very clinical about their disease process, et cetera, rather
than actually their needs, and there is very little, if anything
at all, about why they were not eligible for NHS funding.
Q51 Jim Dowd: Why do you think the timetable,
the projections, for completing the reviews has slipped so badly?
Mr Young: Certainly, in north
west London, we did not expect this issue of lack of records or
the difficulty in accessing records. I think we assumed that we
would be able to write off for the records and get them within
28 days. Unfortunately, that has not happened. Cath Attlee raised
this issue previously. That has been a great difficulty. Now everyone
is much more aware that there is this accountability in the process
and the stream going up through the PCT and local authority multidisciplinary
panel, then the SH panel, then the Ombudsman. People are much
more aware that they must keep records and that those records
must clearly explain the decisions they have made.
Q52 Jim Dowd: It is not just a tardy
approach to the reviews; it is really that the reviews have been
far more complicated than was envisaged at the outset?
Mr Young: Yes.
Q53 Mr Burns: Have you completed all
the reviews up to complaints received by March 2004?
Mr Young: All the reviews have
been completed in the first stage. In north west London we offer
people a second opinion if they have been unhappy. All those second
opinions have now been completed as well.
Q54 Mr Burns: Do you know, off the top
of your head, how many cases you have found where there was a
mistake made and so compensation has had to be paid, either to
the individual or to their family, as a result of that mistake?
Mr Young: In north west London,
and I do not have the exact figure, it is just over 100.
Q55 Jim Dowd: Out of how many is that?
Mr Young: Out of about 220-230.
Q56 Mr Burns: As a matter of interest,
what compensation have you paid? If an individual, at whatever
time the wrong assessment was made, had then to sell his or her
home, they could well financially have lost out considerably,
depending on the state of house prices at the time they sold and
now. Have you just paid the cost of the care or has there been
an element of compensation to make up for the knock-on effects
the wrong decision has had on an individual and their financial
position?
Mr Young: The formula we used
is the cost of care plus the retail price index plus inflation.
Q57 Mr Burns: In fact, no compensation
has been paid if people have financially lost out because they
have had to sell their house?
Ms Attlee: We use Department of
Health guidance.
Q58 Mr Burns: Are you anticipating anyone
who might be in that position suing you?
Mr Young: We have not as yet heard
from any of the people to whom we have offered restitution that
that is what they are looking for. I have to say that when I gave
you those figures of 100 plus that does not necessarily mean,
because we have carried out these reviews in a very thorough manner,
that the original decision was wrong. It could be at some point
in between.
Q59 Chairman: The circumstances may have
changed.
Mr Young: Yes, the circumstances
may have changed at a later stage and we have identified that
from that point. Normally what has happened is that these have
been quite small amounts for the individuals because it has happened
at a later stage. There have been very few at five years or whatever.
It has normally happened for the last two or three months of someone's
care.
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