Examination of Witnesses (Questions 200-219)
17 MARCH 2005
MS TRISH
LONGDON AND
MR COLIN
HOUGHTON
Q200 Chairman: Do you also have any thoughts
on geographical location: where it is that you have received substantial
complaints from? One of the issues we talked about last week was
that some people seemed to be more aware of the issue by various
mechanisms. Easington Working Men's Club seemed to be one organisation
that appeared to assist people in that part of the world. The
word got round. A serious point. Can you identify particular pockets
of problems in certain parts of the country from the information
you have?
Ms Longdon: The information we
have is partial. It is dependent upon a complaint being made to
us, therefore we would not tend to have the whole picture. But
we are dealing with complaints by Strategic Health Authorities
in batches. We have some information about where we have the most
complaints and where we are taking those forward. I am not sure
that we would be able to say there is a causal link between that
and local publicity. The causal link might be between that and
how satisfied people have been with the process that they are
being put through. We can provide information. If you want it,
we could get it to you subsequently by SHA for the number of complaints
we have received.
Q201 Chairman: If you do not mind, that
would be very helpful. The other issue that came up was that perhaps
more middleclass people are aware of this than people who are
less well informed. You probably cannot draw any great conclusions
from the geographical information, but it would be interesting
to see it, so we would be grateful for that.
Ms Longdon: Could I just add that
in our report we draw attention to the fact that anecdotally we
have some concerns about everybody who needed to know having been
captured by the publicity. Anecdotally, we would support the concern,
and we are seeking an assurance from the Department that they
have done what they felt appropriate to identify people.
Q202 Dr Taylor: Going on with the quality
of the assessments, because this is something that really concerns
us: last week we heard that the criteria from Strategic Health
Authorities may be largely similar but that the interpretation
of these at Trust level is variable and really quite unsatisfactory.
That rather matches the statement in your review to us, which
is really quite damning, that: "In more than half the cases
my Office examined we found that the assessments had not been
carried out properly. The problems included poor quality clinical
input to both assessment and decision-making, inadequate documentation,
failure to consider changes in a patient's health care needs over
time, and lack of involvement of, and poor communication with,
patients, carers and relatives." That is awful. That is a
totally damning statement of the way the process is going, and
it fits, again, with witnesses last week who said that the system
is just not working. What suggestions do you have? You say the
services should be expanded—"expand local capacity"—and
obviously improve training. Can you help us to know how that expansion
should be done?
Ms Longdon: If I may start by
saying that it is a worrying picture. The report is there on the
records to address that. But some people are doing much better
than others and therefore there is much good practice from which
to learn. Our suggestions in the report are two-fold: (i) that
you have to have clear, comprehensive criteria that everyone can
understand—that is, professionals and users of a service—and
(ii) that the tools that people are provided with to help them
to do this well—and some people are doing it well—are
shared very publicly and clearly, so that we build on good practice
and get people following that good practice.
Q203 Dr Taylor: I would love to know
what you understand by tools in this sort of circumstance.
Ms Longdon: I will hand you over
to Colin for this.
Mr Houghton: These will be methods
of assessing someone's health care needs against the criteria.
I know it is easier said than done, but, for example, focusing
on such difficult words as: "intensity" "complexity"
and "unpredictability"—which are there in many
eligibility criteria, but where not a lot of work has been done
to try to pull those out and examine them and see exactly what
they could mean for national criteria.
Q204 Dr Taylor: Should it just be a table,
a chart that people fill in?
Mr Houghton: No, more than a tick-box
one. We have had experience of quite sophisticated assessment
tools which, at the end of the day, fall down to a scoring system,
whereby you have to get above a certain number in a certain number
of health care domains in order to qualify. I think it probably
needs a more holistic approach, to stand back and look at it,
and not to decide, "That one qualifies and that one does
not." We do not have all the answers to this. I think a lot
of work needs to be done on this. That is why we are so pleased
that we are getting involved in looking forward to the National
Framework, so that we can contribute to this.
Q205 Dr Taylor: So the aim with the National
Framework would be that there is a single national assessment
tool that everybody should use.
Mr Houghton: That is what we are
proposing—with appropriate guidelines.[1]
Q206 Dr Taylor: Going back to the quality
of assessment, in some places you say it is really being done
very well. Can you point to any group of staff which is better
at doing it, which it is essential should be involved? Are there
any lessons from the places where it is done well that we ought
to know about?
Ms Longdon: The start is that
this is a multidisciplinary assessment, and therefore you have
to make sure you have involved in the assessment the people you
need to have involved in that assessment. For us that is a decision
that is not always taken at the outset, so an assessment might
be made by an individual from one specialism rather than making
sure that it is multidisciplinary and reflects the needs of the
individual. Therefore, I think an important start-point is to
make sure you have involved in the assessment the people you need
to have involved in that assessment.
Q207 Dr Taylor: The areas from which
the complaints came, was it fairly obvious they did not have the
right representation on multidisciplinary teams? Or is that a
simplification?
Mr Houghton: In some cases it
became obvious from looking at the nursing notes or the care home
notes, that there were, for example, regularly occurring psychological
needs. With the best will in the world, a single nurse looking
alone at these may not be able to pick these up or may not see
the significance of them when seen in a pattern of behaviour.
Q208 Dr Taylor: Are the members of a
multidisciplinary team laid down anywhere, as to who should be
on it? Or is it left to the trust PCTs?
Ms Longdon: The difficulty in
that is that who should be there is so dependent on the needs
of the individual. Individuals with a variety of needs are being
assessed under these criteria, and therefore it is a matter of
judgment, clinical judgment in many cases, about who should be
represented in any individual assessment. It is not possible to
say, "The answer must be X." People do have to exercise
judgment and be flexible and tailor that to the individuals concerned.
Q209 Dr Taylor: Would absolutely clear
criteria reduce the need for training? Or is the need for training
still absolutely paramount?
Ms Longdon: There are a number
of areas of training to which we have drawn attention in our report.
One is, overall, the fact that this is an area in which there
was not a lot of knowledge and expertise. Indeed, the work that
has gone on over the last few years has developed that hugely,
but there is a lack of real understanding of these issues at many
local levels. So there is a general issue of capacity; there is
a specific issue around certain of the elements of the assessment
that need to be undertaken; and then there are other general issues,
for example around communication, which are very relevant to the
way people understand what is going on.
Q210 Dr Taylor: Finally—and I do
not really understand this—how does the single assessment
process fit with your idea of a national assessment tool?
Mr Houghton: I think if the tool
was to form part of the single assessment process—which,
as I understand it is not universal across all trusts, all Strategic
Health Authorities, at the moment—then I think that single
assessment process, with the appropriate tool as part of it, would
be a help.[2]
Q211 Dr Taylor: So it is part of it.
Mr Houghton: Yes.
Q212 Mr Bradley: In terms of the multidisciplinary
team where there is good practice, is it clear who is responsible
for pulling that team or those individuals together? Are there
different people in different trusts responsible for taking the
lead on determining who should be involved in that wider review?
Mr Houghton: It varies, I am afraid,
between the trusts. In some cases, certainly where there is an
appeal tier with a Strategic Health Authority, there is a clear
lead given and a clear person who brings it all together. In other
cases, there is not a second tier at all and it goes straight
into the complaints procedure. So it does vary a lot. Certainly,
as part of the National Framework, we can contribute the areas
where we see that it appears to work very well, and I think we
could pull something out of that.
Q213 Mr Bradley: Do you have a view of
who should take that critical lead?
Ms Longdon: That is a matter to
which we would certainly want to contribute, but I am not sure
we are saying that we think we have the answer as to that way
forward.
Q214 Chairman: One of the issues, following
on from what Keith said, came out last week. We were talking about
demarcation between health and social care and health and social
care professionals, and it was apparent from the evidence of Ms
Kath Atlee, who I believe works in Hounslow PCT, that in their
area they have joint commissioning arrangements, so that is working
multi-professionally in a collective way. But that was not the
case in other parts of the country from which we sought evidence,
including my own part of Yorkshire. Do you have any thoughts,
in looking at the feedback you get from complainants, as to whether
the way in which people operate professionally at local level
has a bearing on the outcomes that might be presented to you?
Would this joint commissioning model perhaps assist in addressing
some of the problems that you face in other parts of the country?
Ms Longdon: I do not think we
have the evidence to back up a view on that. We have some examples
but I do not think we have a considered view about joint working.
Mr Houghton: Where there are examples
of that joint working and it has been set out clearly to the carers
and relatives: these are the people who are going to make the
decisions, this is the process—and, even more, when they
are invited to be part of the process—then we get less complaints
from those people because everything is set out. A lot of the
complaints we get are (a) "We think it is a wrong decision"
and (b) "We do not understand the system."
Q215 Chairman: So you do feel that the
way people operate locally has a bearing. It may not necessarily
be in terms of joint commissioning, but including users' families
in the process is helpful.
Mr Houghton: Yes.
Ms Longdon: Absolutely. We are
very clear that including the families/the carers is very helpful
and would certainly represent good practice.
Q216 Dr Naysmith: To probe a little further,
what you are saying is that you know of examples of good practice,
they are probably different in different places, but you do not
want to recommend any particular one until the whole thing has
been examined a bit more closely. Is that really what you are
saying? You want to look at these places where there is good practice
and see what you can draw out of that to recommend more widely.
Ms Longdon: Certainly. That is
because we are well aware that our knowledge depends on people
having complained in that area. There will be some areas that
we do not know about and they may have wonderful practices that
we do not know about, so our view is that we would want to contribute
what we know in order to inform a better way of doing things but
we do not pretend that we have all those answers or all the information.
Mr Houghton: One of the things
we did when looking at this whole area was to take a reality check
and make sure that we are not setting some gold standard for these
assessments that no-one can achieve. But we have seen excellent
examples throughout the country of the way assessments have been
carried out, so we know that it can be done. I would like to go
on record as saying of all the Strategic Health Authorities that
they all have good points that we can pull out, and, although
in our report we put down lots of examples of not so good practice,
none of those are all concentrated in one Strategic Health Authority.
There are pockets and areas in all of them where there is practice
that we think is great, and if we can replicate that and bring
that together then I think there is good hope for the future.
Q217 Mr Amess: Primary Care Trusts could
not have greater powers and bigger responsibilities, as they appear
to have at the moment, and there could not be any greater challenge
for them than deciding who exactly would be eligible for NHS continuing
care. Your good organisation has made proposals about these panels
and what they should be composed of and how perhaps their decisions
be challenged. Could you elaborate a little bit on what your proposals
are actually trying to achieve.
Ms Longdon: We are interested
in good administration of a clear framework, which actually delivers
across the country the right answer for the individuals that are
going through this process, in a way that takes account of their
differences—because people who are seeking this support
are very different—but in a way that also ensures that people
are treated consistently across the country.
Q218 Mr Amess: What are you proposing?
Ms Longdon: We are proposing that
there should be a National Framework, a single set of criteria
that are applied across the country which needs to be developed.
We will contribute to that development, but that is clearly something
that is a matter of policy for the Department of Health to lead
on. Within that, there should be examples of how you can undertake
this process well in your local context. We also want to work
with others, in sharing our knowledge of what works with others,
in order to come up with examples of what works so that people
can use that. Those are the two key changes we are proposing.
Within that we are saying there must be more training, there must
be better documentation, and there does need to be some clear
monitoring of what is going on so that everybody is clear as to
what is working and what is not.
Q219 Mr Amess: Who do you specifically
think should sit on these panels? Who should appoint them? What
should their backgrounds be?
Ms Longdon: What we can do is
to share some of the details that we have of good practice. We
could let you have those subsequently, as examples of where we
can see things working in detail—not saying that it should
be the way, but that this is a way that we have seen working as
good practice to contribute to your deliberations. Would that
be a helpful way forward?
Chairman: Thank you.
1 Note by witness: There should be a single
set of assessment tools, as set out in the Ombudsman's retrospective
report on continuing care. Back
2
Note by witness: The Ombudsman's report recommends a set
of assessment tools, not just a single assessment tool. Back
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