Examination of Witnesses (Questions 180-191)
10 MARCH 2005
MR JOHN
PYE, MR
MARTIN GREEN,
DR JACKIE
MORRIS AND
MS JO
PECK
Q180 Dr Naysmith: Does that happen?
Mr Green: I will not say it is
happening now, but it will happen in the future. It probably is
happening. I cannot quantify that, but I do not think it is happening
to any great extent. I do think it may happen in the future, and
particularly as we are in a situation where we know the demographics
are going to change. We know there will be increased numbers of
people with very high dependency levels, some of which may be
able to be supported in supported housing or through community
care packages, but some of which undoubtedly will need residential
or nursing care. If we do not get our planning structures right
now, we will have a great shrinkage in that available resource
and greater competition for those beds.
Q181 Dr Naysmith: It must follow then
that there will be some residents who have been assessed for a
level of care that is below what you would anticipate they would
need when they are in your members' homes.
Mr Green: Absolutely. The problem
is that often as well assessments are, whatever anybody says,
resource-bound. For example, if you had little in your budget
then you would spend much longer justifying your lower level band
because you had to justify it to yourself and others, whereas
if there is more budget you know you might be more flexible. There
needs to be far more re-assessment on a regular basis, and that
needs to be multi-disciplinary re-assessment because the reality
is that the dependency levels are such that often people are placed
in their end-of-life placements, and at that period in a patient's
journey there is a lot of change, and sometimes quite rapid change.
We need a commissioning process and a resourcing process that
can build flexibility into the system so that people can have
their care needs sometimes turned up but conversely sometimes
turned down. There is a lack of flexibility at the moment and
lack of re-assessment.
Q182 Dr Naysmith: You may have heard
me refer to a couple of cases I have where people were not properly
assessed but were admitted to residential homes on a contract,
and when they were subsequently assessed properly the money that
came just resulted in the home putting the fee up so that it was
of no benefit to the individual at all. Can you tell us how this
can happen and what your members' official attitude to this is,
if you have one?
Mr Green: I think it happens because
of under-funding at the initial stage and because the way in which
there is a monopoly commissioning approach via either health trusts
or local authorities means that homes cannot survive without those
contracts to fill the beds. So they are forced to either make
self-funders pay more in order to cover gaps, and then when an
opportunity arises because there has been a re-assessment of the
need—and what has happened is the need has not changed but
the assessment and the acknowledgment of the resources required
has changed—so the individual would expect to benefit from
that, but the reality is that the care needs are being now more
properly assessed in terms of their resources. That leads to a
very unsatisfactory position for everyone.
Q183 Dr Naysmith: You can understand
why people would be very unhappy about this.
Mr Green: Absolutely.
Q184 Dr Naysmith: Because the letter
comes to them saying "you are getting so much more money
from the Government" and it is—
Mr Green: Absolutely, and everybody
is dissatisfied probably with the exception of people like the
commissioners, because nobody ever comes into direct contact with
them, so they are not the people in the firing line, and this
was about probably inappropriate assessment at the start we need
to get this assessment process really clear so that there is a
robust and accountable approach for both the care needs but also
what those care needs cost.
Q185 Dr Naysmith: How often does it happen
that you get this late assessment?
Mr Green: I think it is happening
less often now, but certainly in the past it happened quite a
bit. Part of the problem is the variability of assessment and
the fact that people have not got clear assessment criteria which
is a national one does not help. Of course, you also get people
who cross-reference around their own families. For example, the
mother-in-law has one assessment, and they think they are in a
much higher care band, but they get probably more money than somebody
else who they perceive as being in a lower care band; then they
get differential approaches. That does not help the process and
it leaves people, particularly carers and older people themselves
quite dissatisfied. It also leaves providers dissatisfied because
they have to deal with the understandable upset that that causes.
Dr Morris: I totally agree with
everything Martin said. My concern is that previously in the panels
there was a perverse incentive for the Health Service to get the
social service departments to pay for everything. This has expanded
into the fact that the acute sector wants to shift everything
on to the PCT and makes it more the responsibility of the PCT.
There is some evidence that some people have been imaginative
and set up systems whereby the acute sector and the PCT work much
more collaboratively to improve the system of delivery to older
people. On building on this, one of the things that has been mentioned
as part of assessment and as part of my experience is the incredibly
poor documentation that homes receive when patients arrive from
hospital. They may have got a very complex assessment, but they
will not have got their previous medical records. They will not
have got their hospital records, their GP's records. They may
if they are lucky occasionally receive a discharge summary, because
the discharge summary will tend to go to their previous GP. The
homes are left with a new patient about whom they know nothing,
and they have to then set up a comprehensive system of care delivery.
Building on that, when I have been into the homes—and I
think it is improving—you often get a system where the GP's
records are in the GP's surgery; the care home plans are in the
care home; and the medication lists are somewhere else. There
is not a holistic approach to providing care, and this needs to
be part of assessment and part of the review assessment, the bringing
together of—
Q186 Dr Naysmith: That is clearly something
we need to turn our attention to. To turn it round, in the previous
session we were talking about the retrospective review, when some
people were complaining about the state of records in some care
homes.
Mr Green: Absolutely. There is
an issue about records generally, and it is a fairly easy issue
to address as long as we get some clarity about what is required
and we build it into a standards regime. One of the disappointments
is that some of these things should be addressed by things like
electronic patient records, which is costing millions and millions
of pounds but probably will not address the very points that Dr
Morris mentioned. So we have an opportunity here which has been
missed.
Q187 Chairman: We are on the case. You
know that, do you not? We have been for some time.
Mr Green: There are some issues
about records, but it is very difficult as well because there
is not any clarity or standardisation about what records need
to keep, and also—
Q188 Chairman: And how long they keep
them for.
Mr Green: Absolutely. Dr Morris's
point is very important, that people are sometimes having to start
from scratch, not knowing the history, when they get a patient
coming through to their establishments. That is not helpful because
you start not knowing what the history was. So even if you keep
the records for 10 years or do them in the best way, you have
probably got 70 years of patient records that you did not get
to before the patient was admitted to your establishment, so there
are some big issues there.
Dr Morris: I have a suggestion,
that you empower the patient and the carer. I suggest a system
whereby the patient carries their own record.
Q189 Jim Dowd: Mr Green used the very
loaded term "postcode lottery". How do you reconcile
your desire for greater uniformity with devolved local priority-setting
by PCTs?
Mr Green: It is a real dilemma
because you need to have local priority-setting, but that needs
to be about real priorities, not about budget-led priorities.
For example, one of the issues I have about local priority-setting
is the accountability of what those priorities are and how you
establish which priorities are going to be for area X, and why
they are different in area Y. I would not have a problem in terms
of the local priority-setting if there was some accountability
and people knew why particular priorities were for particular
areas. The other thing we need to understand is that local priorities
should be responding to local need, but that does not mean that
some people should be getting better quality services than others,
so there has to be a position where you say "this is our
benchmark of what people should be receiving in terms of the quality
of the service" and then you build in the local priorities
on to that benchmark rather than just letting it be a free-for-all,
which it is potentially in my view at the moment.
Q190 Dr Taylor: In a previous inquiry,
the delayed discharges inquiry, we tentatively explored the possibility
of specialist GPs or consultant geriatricians being attached to
care homes. Is there any mileage in that?
Dr Morris: We would support that.
There is an example of this in the north, in Durham, where they
have appointed a GP practice to take over a group of care homes.
They have also got nurse specialists to provide a case management
system to back this up. We are exploring this in Paddington where
I work at the moment. But those GPs have had a comprehensive training
programme, the GPs with a special interest in older people. I
think we now call them practitioners with a special interest.
Q191 Dr Taylor: Are there many community
geriatricians? I know there are very few.
Dr Morris: They are a developing
species. There are community geriatricians and they are a developing
group. What the British Geriatric Society recommends is that the
service that the departments of geriatric medicine provide need
to be comprehensive. Within that comprehensive service there would
need to be a system of community geriatrics, which includes attachments
for GPs and nurses to be trained up, perhaps to teach in nursing
homes and so on; so it is about providing a comprehensive service
which includes community geriatric medicine.
Mr Green: We would support that
as well, and we would certainly support it because it may stop
the practice that happens at the moment that some care homes and
nursing homes have to pay to get GP services, which is an absolute
scandal, because those establishments are supposed to be in the
community, and the residents should be able to access every other
community service.
Chairman: Thank you for a very useful
session. I am sorry we have kept you so long, but that indicates
that we have had a very interesting session. Thank you very much.
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