Select Committee on Health Minutes of Evidence

Examination of witnesses (Questions 110 - 124)



  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.

John Austin

  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.

Mrs Gordon

  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 too.

  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.

Mr Austin

  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 responsibility—maybe 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.

Siobhan McDonagh

  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 of care?
  (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 it.
  (Miss Sanderson) And it is paid for by the insurance company and it is in the insurance company's interest.

Mr Burns

  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.

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