Examination of witnesses (Questions 110
THURSDAY 15 MARCH 2001
ADAM and MS
110. Why do you think it is then that evidence
earlier today from other people suggested that it was not the
best thing since sliced bread and that your response just now
has caused some amusement behind your back?
(Dr Adam) Can I have a go at that question? I think
this is an incredibly difficult area to research in. That is probably
the reason Warwick did not provide the neat answers that perhaps
when it was initially set up it was hoped that it would. We are
talking about people with complex needs, with diverse needs. The
ideal approach in a research project is to have a reasonably homogeneous
group of patients, who can be randomised and we can make direct
comparisons between different types of interventions. People who
have had brain injury do not fit into this type of research design.
To my mind it is not surprising that the project did not prove
the hypothesis it was set up to prove. I do not think it was a
waste of money, if that is the follow-up question that is coming.
Mr Burns: No, it is not, relax!
111. You have been here before!
(Dr Adam) I think the messages were quite high level.
They do not give us the detailed information that we were hoping
for. They do not provide the basis for clinical guidelines for
rehabilitation. What they do provide (which is what we have then
promulgated to health and social services) is a set of high level
principles that we would expect services to follow, but I do not
think they take us too much further along the road than that.
(Miss Sanderson) The other problem with the Warwick
study was that it was set up in 1992 and we were not quite so
focused on things like clinical evidence in 1992 as we have become
over the past decade.
112. I found the last answer particularly enlightening
because it seemed to go slightly against what you were saying.
(Miss Sanderson) What I am saying is the Warwick Report
revealed all sorts of useful messages about the management of
head injury. What it did not reveal was a lot of information about
what is clinically effective in head injury rehabilitation. Were
we to set it up now we would set it up in a different way. That
is always the way when you have a long-term study. Things changed
in the course of the study and with the wisdom of hindsight, of
course, it would have been done differently.
113. Could I come back to the issue of the impact
on family and particularly children, particularly if it is a parent
or maybe if it is a sibling as well, the impact on the child,
and what was suggested in earlier evidence was a lack of a co-ordinated,
preventative approach in support of the children.
(Yvette Cooper) When you say impact on the child,
you mean a child who has had a head injury or a child in a family
where someone has had a head injury?
114. A child whose parent or sibling has had
a head injury and the impact on them, whether there is a suggestion
that perhaps the agencies are not sufficiently co-ordinated in
seeing to the needs of the child in that case.
(Yvette Cooper) I think there is a general issue about
how you co-ordinate properly support for the family. Some of the
cases where you clearly have concern about people falling through
the net or people not getting the support they need, are people
going back to family settings without the support there that they
need, other family members who do not understand what is happening,
and other family members, either as carers or other members of
the family, whose needs are not being met as a result. I would
certainly say that is one of the areas. There may well be some
excellent practice happening in some areas but we are also very
well aware there are problems, and they can be quite serious problems,
faced by particular families when this happens. I think that is
one of the things that probably should be picked up by the NFS.
If you have taken particular evidence that shows quite an extensive
problem around children in those families that would be very helpful
information to feed into the national service framework discussions
as they take place.
115. Minister, earlier you mentioned about the
guidance that has gone out, which includes something about the
voluntary sector, which is reassuring, perhaps you can expand
on that a bit? The evidence that the Department gave to the Committee
does not mention the voluntary sector at all, and yet we have
heard this morning how absolutely vital groups likes Headway are
with the recovery process and with supporting the families? I
would like to know your view and how you see the role of the voluntary
sector, especially the work they do within the community, and
how they can be helped?
(Yvette Cooper) The work that I referred to before
was the initiative on rehabilitation and employment, that is a
joint initiative between the Department of Health, the Department
for Education and Employment and the voluntary sector. I certainly
recognise that there is a huge amount of work done by the voluntary
sector, particularly as you get out into a community setting,
and where it comes to family support as well. One of the things
that we would be very keen to do within the National Service Framework
process, as we set up the external reference groups, in the same
way we have done with previous frameworks, is make sure that the
external reference group includes voluntary sector organisations,
includes representatives of patients, carers and the families
of those involved. It is something that I think has been extremely
important and was a very successful part of the National Service
Framework on Coronary Heart Disease, for example, which included
the voluntary sector, patient organisations and patient groups.
That is something that we would certainly be very keen to build
in from the beginning of the National Service Framework on the
long-term neurological conditions as well.
116. Headway mentioned earlier that there is
a problem with all of the charities and voluntary organisations
that they are usually after short-term funding, and this does
inhibit what they can do, and them are planning ahead. If they
want to take new initiatives there is very little help they can
get for that in developing new ideas. They mentioned Section 64
funding and said at the moment that is a very small pot of money.
Is there any room to increase the amount of money in that fund?
(Yvette Cooper) Section 64 money is funding that goes
from the Department of Health to all kinds of voluntary sector
organisations. We try to focus as much as possible on building
projects and building services and so on and on giving organisations
a chance to develop new projects and new innovative ideas that
can then become self sustaining. There are such a lot of different
projects, that if we became the sole funder from the Department,
we would not be able to fund all other kinds of new innovative
projects as well. I do not know if anybody wants to talk about
the details of Section 64 in this area.
(Dr Adam) At the moment the grants for next year are
currently being looked at and we are aware that Headway have a
bid within that. The other point to make is that, at a local level,
increasingly we are seeing coalitions between local authority,
NHS and a range of voluntary sector organisations. I think, again
sorry to go back to the National Service Framework, that that
can act as a catalyst. Certainly within mental health, setting
standards for local mental health service delivery has drawn people
together and demonstrated more clearly how funding the voluntary
sector is a very effective way of using public sector funding,
within a clearly defined framework. The input from those groups
to the development of the NSF will help develop those opportunities
117. They welcome Section 64 funding, they just
wish there was more of it, I think.
(Yvette Cooper) A lot of people always say they wish
there was more money.
118. In your evidence you refer to the Government's
plans for its job retention and rehabilitation pilots, and it
may not be your area of ministerial responsibilitymaybe
we have the wrong Minister here. Although Headway felt that there
was no doubt there local organisations would be involved in pilots
in particular areas they have not been involved in the planning
process about that programme, is the voluntary sector involved
at this stage at a national level?
(Yvette Cooper) Unless Sheila has particular information
there that may be something that we need to write to you on.
119. I appreciate that.
(Dr Adam) The pilots are still at a very early stage.
We are still collecting ideas, and we will be looking at pilots
running over the next six to twelve months.
120. There appear to be at least two factors
which lead to a multi-tier provision of rehabilitation services
for people with head injuries, particularly people with compensation
receive a different level of rehabilitation service than those
without, and the post-code lottery. Do you have any ideas how
you can make sure that those would not provide different levels
(Yvette Cooper) We have tried to set up, I suppose,
two different sets of mechanisms for addressing the post-code
lottery issue. One is NICE guidelines, and the other is the National
Service Frameworks. So in the area of brain injury what we have
is two quite important ways of addressing some of those post-code
lottery issues are in the process of starting the work and this
gives us considerable scope for the future. On the issue about
compensation, can I ask you to repeat that?
121. Patients with compensation monies receive
a different level of service from those who do not have access
to compensation monies.
(Dr Adam) Because they have more money to spend on
(Miss Sanderson) And it is paid for by the insurance
company and it is in the insurance company's interest.
122. On compensation, are you concerned, not
simply with head injury problems but other areas in the Health
Service, of the plethora of advertising and the development of
a new industry in this country to encourage people to sue for
compensation for everything?
(Yvette Cooper) You will be aware that litigation
for the NHS has been an increasing problem, so it is something
that the Department takes extremely seriously. We also recognise
that individual patients have rights and those rights need to
be respected and recognised. Certainly we do everything we can
to avoid unnecessary litigation and to reduce the litigation costs
to the NHS.
123. Is there not a problem that we are going
to end up like the United States of America, where they have a
compensation culture where you sue almost for the sake of suing
because there might be the odd pound in it. When you say you are
seeking to minimise it, how?
(Yvette Cooper) There has been a lot of work done
in the Department, but it is not something that I am able to respond
to you directly on now.
124. It is slightly out of the area that we
are enquiring into. The issue that Siobhan was concerned about
was the way we have this big discrepancy between those that have
compensation and those that do not. It appears those with money
get a much better service.
(Dr Adam) Now I understand the question, I think that
is right that those with more money can buy additional rehabilitation.
It is not just compensation, it is also people on different incomes
who may have different opportunities. The difficulty we have at
the moment is that the research evidence is still incomplete on
what the right package of rehabilitation is for any specific individual.
If people are in doubt, and they do have personal resources, they
may tend to go for more rather than for less. We are not really
in a very strong position to be able say what the right package
would be for any particular set of problems. This is an area where
we need more research and we need more clarity. Certainly Warwick
did not show a direct correlation between the amount of rehabilitation
and the eventual outcome, even trying to control the number of
variables within that. It is not a simple, "more input, better
outcome" relationship. We do need to get ourselves into a
better position through the development of the research and the
evidence base to be able to say for particular sets of problems,
"This is the sort of rehabilitation, these are the sort of
goals that you should expect to be able to achieve". There
is also something about being realistic for people with head injuries.
Some of those with brain injury will get so far, but as Judy was
saying earlier they are not going to make a complete recovery.
Rehabilitation is also about readjustment, supporting their family
and working within their environment to try and enable them to
return home, but not necessarily to the previous level of functioning.
Chairman: Can I thank you for coming along this
morning. You did mention you would follow up on at least one matter,
we would appreciate that. I hope the report will be of some help
to the Department in this difficult area. Thank you very much
for your help.