Examination of Witnesses (Questions 160-179)
10 MARCH 2005
MR JOHN
PYE, MR
MARTIN GREEN,
DR JACKIE
MORRIS AND
MS JO
PECK
Q160 Dr Taylor: So we have the participants.
Who actually makes the decision about the health and social care
components? How is that decision arrived at? Who makes it?
Ms Peck: At Lewisham it is made
at a panel meeting, and the panel is made up of members from the
PCT, social care and health and the acute trust; and they ratify.
Q161 Dr Taylor: The multi-disciplinary
team that has done the assessment would then report to this panel.
Ms Peck: Yes, they submit the
paperwork and then the panel make the decision about where the
most appropriate destination for the patient would be.
Q162 Chairman: Is this a panel similar
to the one we had described to us in the earlier session?
Ms Peck: I assume so, yes.
Q163 Dr Taylor: Has the introduction
of the single assessment process made any difference?
Ms Peck: No, because we are not
using the single assessment process across the board yet. Actually,
we have just had a case that went to panel this week in Lewisham
that had the single assessment, and it was deferred because the
assessment was not deemed appropriate; so they have now got to
go back and re-assess under continuing care.
Q164 Dr Taylor: Turning to the registered
nursing care contribution, is assessment for this viewed as a
sort of ladder, that you start at the lowest and work up; or do
you start at the top and work down? How does it work?
Ms Peck: I am not sure.
Mr Pye: I do not think it is either/or;
I think it is based upon the information provided to the nurse
undertaking the RNCC, who looks at the criteria within each band.
Q165 Dr Taylor: Would you agree with
previous witnesses that there is very little distinction between
the highest band and continuing care?
Mr Pye: The wording is the same—"complexity;
intensity"—they are both within the high band of continuing
healthcare. Again, it is down to interpretation.
Q166 Dr Taylor: Is there a space for
a very closely defined group in between those, or do you think
the merge is so inevitable that they ought to be regarded as one?
Mr Pye: I think they practically
are one. There are some real difficulties in identifying a difference
between the two. Again, it is down to local interpretation at
a specific time.
Q167 Dr Taylor: Would that go for all
of you?
Mr Green: I certainly do not think
there is much difference between the two, and I think it is down
to interpretation. I think there are lots of other factors that
come into play here which are not mentioned, which are sometimes
about the amounts of people you have at any particular time needing
that particular resource. Nobody comes out and says that but that
is the reality.
Dr Morris: No, the reality is
that colleagues of mine have said, "we are keeping this patient
in because we think they need hospital care and we are not putting
them up to the panel, and they are very frail and very vulnerable
and we think they need to be in hospital". They have not
gone through any panel; the consultant has made a decision that
that individual needs a lot of care. Another consultant however
might say, "I am sorry, we have got to have the beds, and
put them up before the continuing care panel."
Q168 Dr Taylor: There is a limitation
on resources available outside.
Dr Morris: Yes.
Q169 Jim Dowd: On assessment, do you
talk to the relatives?
Ms Peck: Yes. They are involved
in that process, almost from the very beginning.
Q170 Jim Dowd: They are involved when
you said four people together, making reference to a panel. At
which stage are they involved?
Ms Peck: They are certainly very
involved with the social services component of it, and they will
contribute to the nursing.
Q171 Jim Dowd: But are they actually
present when the meeting takes place, making the decisions?
Ms Peck: No, because each individual
does their assessment on their own, and the form is completed
but each person fills in their relevant bit. Sometimes it will
be done at the team meeting, or elements of the form, but sometimes
it will be filled in by separate individuals on separate occasions.
Q172 Jim Dowd: Do the relatives see the
report before it goes to the panel?
Ms Peck: Not normally, no, not
in acute trust.
Mr Pye: It is worth saying, Chairman,
that the panels do not operate in every area.
Q173 Chairman: I picked that up from
Mr Hill because I had a good idea it did not happen in my area.
I had never heard of it.
Mr Pye: No, they do not have panels;
they have individuals who make decisions.
Q174 Chairman: Does it in your area?
Mr Pye: We do not have panels
in Cheshire.
Q175 Chairman: Is it a north/south kind
of thing because we get the picture that they seem common in London.
Dr Morris: It is not common in
all areas.
Q176 Jim Dowd: Lewisham, which I know
very well, is a relatively small DGA, about 450 beds. On average
how many assessments are you doing in a month?
Ms Peck: The panel normally hears
between six and 10 cases each time it meets, and it meets twice
a week, on a Monday and a Thursday, but that is not just patients
in Lewisham Hospital; that is patients already in care homes or
patients in mental health trusts, or patients who are in hospitals
outside the borough but are Lewisham residents.
Q177 Jim Dowd: So it is about 20 a week,
or up to 20 a week.
Ms Peck: Yes, up to 20 a week.
Q178 Dr Naysmith: Mr Green, is there
any evidence that when a home takes residents from more than one
primary care trust area there is likely to be an inconsistency
of assessment?
Mr Green: Very definitely. It
is very interesting when we talk about things like assessment
processes, which are supposed to be based on individual need,
and then we see block contracting from local authorities and health
trusts about the delivery of a service. If you were thinking about
this in relation to individual needs and you were going through
an assessment process which said a person has given needs, you
would then look at your resource package appropriate to those
needs and a placement appropriate to those needs. So there is
great variability in the system, and certainly in relation to
how the individual interpretation happens in different places.
That is where we have not got much standardisation, and in fact
we have postcode lotteries coming in through the back door.
Q179 Dr Naysmith: That must give rise
to problems where you have some patients in some of your members'
care homes, where some people are being well funded and others
hardly being funded at all, but with the same needs.
Mr Green: Absolutely. As the demographics
change, and particularly as there are more people with very high
dependencies because of Alzheimer's disease and dementias, there
will be even more pressure on beds. The inconsistencies inherent
in the processes around assessment will then lead to some people
saying "no, I am not going to have your patient in this establishment
because somebody else does a better assessment process and is
prepared to pay more for more intensive care".
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