Examination of Witnesses (Questions 140-159)
10 MARCH 2005
MR JOHN
PYE, MR
MARTIN GREEN,
DR JACKIE
MORRIS AND
MS JO
PECK
Q140 Chairman: Have you experienced that?
Dr Morris: There is a perverse
incentive to discharge people before they have reached their maximum
potential. I have always practised health care such that I would
like each individual to really achieve their maximum potential,
and that is our ethos. On the other hand, if you are short of
beds and there is a flu crisis and there are queues in the medical
admissions unit and A&E departments, you might want to precipitate
the early discharge of somebody who is not fit for discharge.
Q141 Dr Naysmith: I would have thought
very small numbers of people get the proper geriatric assessment
that you are talking about.
Dr Morris: I would like to put
this question back to you. I think that we need to know. We do
not know. I would suggest that we need to ask you to audit how
comprehensive geriatric assessments are carried out in this country,
because it is a very difficult thing for us to do but it could
be part of the national framework.
Q142 Dr Naysmith: You are saying that
this should happen, and it should not just happen when people
are going for assessment for care; it should maybe happen regularly
by general practitioners who can identify people who are ready
for a geriatric assessment.
Dr Morris: Yes. It should be a
dynamic—
Dr Naysmith: So given the number, it
would require a huge increase in the number of geriatricians before
it could even become feasible.
Q143 Dr Taylor: Is it not the comprehensive
geriatric assessment part of the single assessment process?
Dr Morris: It is supposed to be.
Q144 Dr Taylor: You are saying it just
does not happen.
Dr Morris: It does in some places
and does not—it is a postcode lottery.
Q145 Dr Naysmith: We were told in an
earlier session there would be a social worker there, a nurse
and someone from the PCT.
Dr Morris: Yes. In areas I have
been in touch with recently, some people have panels involving
a clinician, which review the paperwork. Some people do not have
panels. So even in small areas of London and outside there is
a tremendous variation in how this is performed. The other thing
is that we welcome the NHS improvement plan for managing long-term
conditions, but we would suggest that there is a need for a case
management process. Geriatricians cannot do it all, as you said,
but we need a case management system to work with the nurses and
the primary care trusts, to set up a system whereby vulnerable
older people can be tracked through, to identify reversible problems,
to make sure they can access acute care when appropriate and access
rehabilitation when appropriate, and for their medications to
be reviewed.
Mr Green: Dr Morris has mentioned
lots of issues which certainly from the independent sector I want
to pick up on. She mentioned the way in which assessment was carried
out, and particularly that there were other factors around assessment,
and often they were about whether or not there was a crisis in
beds rather than whether there was patient need. I also think
there are some really big issues about the continuation of medical
support when people are discharged to either a nursing home or
a care home. Actually, the ability for that care home and those
medical staff and care staff to be able to function appropriately
is often about having a clear understanding of what the medical
need is and also some ongoing supervision of the case, because
as Dr Morris said, cases change and people rehabilitate; they
develop and change in terms of their dependency. We need a better
interface between the acute services and those in the nursing
home services so that people can be really clear that actually
we are all about a resource that is there for the patient need.
That is one of the things we have lost. When people get discharged
from the acute sector, the Health Service often, particularly
when they go into a care home or nursing home, think, "that
is our job finished". Actually, it should be about continuation
of care for the patient right across the board. The other thing
I wanted to pick up on was something Mrs Pointon said. The definer
of whether or not it is medical care or whether it is a social
care should not be who delivers it; you do not need to have a
nursing qualification, but you need some ongoing support from
somebody who might have a nursing qualification. There are moves
towards that, and our colleague from the RCNN said that, in some
other areas of care, for example in children's care. You have
a situation where people are doing quite high-level medical interventions
but they are doing them because they are being well supported
by their community clinician. That does not happen so much when
people are in residential care, and we need a clearer interface
between the role of the acute services, the role of the community
services and the role of residential services. We need to have
that much more clearly defined, and we also need to look at how
that impacts on commissioning. We talk a lot about the outcomes
and about patient need. We do not see a lot of intelligent commissioning,
the commissions for outcomes. In terms of the way in which we
need to have commissioning, it needs to be really focused on outcomes.
We need to make sure the incentives are about enhancing people's
independence. So a lot of that good work that goes on in the residential
sector, either nursing homes or care homes, that rehabilitate
people and give them more independence at the moment is not validated.
Often that is because people commission a process of care based
on current medical position rather than saying "actually
the medical assessment says the potential of the patient is X,
and if we commission intelligently and flexibly, if we get to
a point where they are increased in independence, we need to have
incentives in the system to secure that".
Q146 Chairman: The incentives are completely
against that from what we have been told.
Mr Green: Absolutely they are.
Q147 Chairman: It is ridiculous.
Mr Green: Absolutely, because
the incentive is to keep the patient at the higher dependency
level. The other issue is that often there are not proper re-assessments.
Yearly re-assessments in cases of people who are very frail are
not adequate, because they change in their conditions.
Q148 Mr Bradley: You mentioned the tripartite
relationship between the acute, the community and the nursing
home or potential home. In my experience, taking physiotherapy,
if you are prepared to take the person back to the hospital they
might get a physiotherapy service. Relying on the community to
come into the home to do that same thing is extremely limited
and patchy, and unless you do that, then that rehabilitation stops
the moment they come out of the acute setting.
Mr Green: Absolutely. We need
to analyse whether or not those are structural impediments based
on the way in which services work at the moment or whether the
structural impediments are because of workforce issues and lack
of trained personnel. I think it would be useful to unpick those
issues for the long-term planning approach. Too often we might
say that we need to change the structure, but underlying where
the structure is are some issues about long-term planning and
workforce planning particularly. If your Committee does anything,
it could also highlight some of those long-term planning issues
as well as some of the "where we are now" issues and
"where we would like to be issues".
Dr Morris: We emphasised in our
report that in a recent national study published in 2001, they
found that charges were made in 30% of homes for physiotherapy
and 39% of homes for speech and language therapy, so there is
a problem around people accessing appropriate therapy. Our recommendations
in the Royal College of Physicians, whom we are also representing,
in a report we did in 2000 was that we would suggest the introduction
of a more multi-disciplinary approach should be facilitated across
the board in homes to support case managers. As well as that,
I think you need a clinical governance system, and I would support
your suggestion, which looks at outcomes, including death and
mortality. I would be very interested to know whether there is
any information about outcomes from the continuing care panels
about what happens to people, about death rates, readmission to
hospital and so on, about the panels around the country and the
regional variations. That would be very interesting and would
help us.
Q149 Dr Taylor: Can I go back to the
assessment of the patient in hospital for NHS continuing care,
particularly going to Ms Peck, to tie it down and give us the
detail. Who does it? What are their job titles at the moment,
when you are putting somebody through this assessment?
Ms Peck: It is still in the multi-disciplinary
approach certainly in our trust. On that team would be a nurse
from the ward, who has obviously been caring for the patient;
and they would contribute to the nursing side of the assessment.
Q150 Dr Taylor: Would that be a fairly
senior nurse on the ward?
Ms Peck: It could be anybody.
We try and get somebody who knows the patient the best, because
obviously then they can go for the most detailed report. When
the case goes to the panel—and we have a panel in our patch—the
quality of the assessment is vital. Often a lot of cases get deferred
at the panel stage because the quality of the assessment is not
good enough.
Q151 Dr Taylor: So it would be a staff
nurse or a sister, if you still call them that.
Ms Peck: Yes, we do—just.
Then there would be, depending on the patient, physiotherapy,
occupational therapy assessment, depending on what the diagnosis
of the patient is.
Q152 Dr Taylor: So nurse, OT and/or physio.
Ms Peck: Then somebody from social
services obviously to look at the current home situation of the
patient, and then a doctor would also give their assessment.
Q153 Dr Taylor: Who would the doctor
be if not necessarily a geriatrician?
Ms Peck: It would be a physician,
so a medical consultant.
Q154 Dr Taylor: Is that good enough?
Dr Morris: I would question, is
it always the consultant? I would wonder whether the consultant
may designate it to a more junior member of staff. Having sat
on panels for many years, the people who filled the forms in was
variable. I think to be fair it would often be the registrar.
Q155 Dr Naysmith: Just as it is the registrar
or senior houseman who sees patients at a clinic.
Dr Morris: Yes.
Q156 Dr Naysmith: Lots of people think
they are seeing a consultant but in fact they are not. It is the
same thing.
Dr Morris: Yes.
Q157 Dr Taylor: Should one of our recommendations
be that it should be at consultant level?
Dr Morris: I would think—consultant
level filling the form in—as a consultant geriatrician filling
the form in?
Q158 Dr Taylor: It is more and more likely
to be because there are not enough juniors about now, are there?
Ms Peck: We normally have a consultant
that signs the form, but whether the consultant physically filled
in the form—they would normally sign it so their signature
is on the form.
Q159 Jim Dowd: Would that not serve simply
to slow the whole process down?
Dr Morris: I should not think
so.
Mr Green: My issue here is not
about who signs the form and what their particular medical status
is; it is about clarifying what is on the form and how much inquisition
has been gone into in terms of whether or not the patient's needs
have been taken account of. I would not want to go down the road
of necessarily saying it has to be a consultant. It has to be
somebody who has gone through a process, and that again raises
the issue about clarity and standardisation in the assessment
process. We need to have that so that if you had somebody who
is appropriately trained, who knew the patient and understood
what we were trying to get at from the assessment, then it would
not matter whether they were a consultant. I do not try to do
Dr Morris out of a job, but it is just about being clear.
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