Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 100 - 119)



  100. Is there any structural reason why assessments could not take place, not just immediately upon admission, but even prior to admission? You know what procedures people are being brought in to experience and given that some cases vary but in the generality of it it should be possible to start planning then, should it not?
  (Ms Platt) Yes. Where it is known when the older person is going to be admitted, and quite often we are talking about people who have come in through an emergency situation, yes, in some of the work we are doing about choice, where people are waiting for admission, they will have allocated to them a personal adviser who will explore all the issues that the person may have to tackle before going into hospital and coming out and that would be the point at which the link could be made with social services.


  101. May I pursue this whole systems issue? Ms Platt can guess the angle I am going to approach.
  (Ms Platt) Yes, I can see it coming.

  102. It seems such an obvious point that we have people in one sector and we are spending more money on them in that one sector than it would cost to have them in the other sector. Why on earth do we not do the most obvious solution which this Committee and others have put forward of integrating the two organisations and avoiding all this nonsense of this split system? Is it the real barrier? I have never got to the root of the objection to organisational integration. Is it the difficulty we have with one element being under the 1946 Act and free and the other being means tested under the 1948 National Assistance Act? Is that the key to it? It just strikes me that we could actually save money, quite substantial amounts of money, by having a sensible, integrated organisation.
  (Ms Platt) I want to say a number of things about that. Yes, there are clearly issues around health and social care as two organisations but in many ways what we are confronting when we are looking at the issues of delayed transfers is an issue across the balance of primary care, social care, community health and the acute sector and the coalition of interest here has to be primary care, social care and community health. It requires a different range of resources in those sectors to be developed and to relate to the acute sector differently across the piece. The organisational opportunity that the Government has created across those sectors is the opportunity to have a care trust development which does give an integrated arrangement, an organisational integrated arrangement and one set of accountabilities. We have demonstrator projects which are resolving quite a number of issues for us around setting up care trusts based on PCTs and that is what we are talking about in this area of activity if we are looking at services for older people and delayed transfers of care. We are very grateful to the demonstrator projects because we had the ideas and the ways to integrate, but some of the practical difficulties we have encountered along the way are taking some ingenuity to resolve. As we go through them, it will become easier for us to encourage more people to develop care trusts in the long term. I am not sure I am answering your question as to why we do not just get on with it at health and social care level. I am pointing out to you that on the ground we see the coalition of interests and the collaboration being in the primary care and social care local government sector and to provide the opportunities to do that.

  103. Do you know how many of these demonstrator care trusts there are?
  (Ms Platt) At the minute we have 15 authorities we are working with, four authorities we are aiming for April; we are trying to sort out at the minute issues around transfer of pension rights. As we work with the demonstrator projects we are identifying some real issues which have to be resolved by other government departments using regulations before Parliament. Waiting in the wings we have 30 more local authorities who have expressed interest in working with us and part of Richard's team is about helping people develop care trusts where they want to.

  104. What about pooled budgets? What is the extent of use of pooled budgets?
  (Ms Platt) We have about 80 different local authorities using pooled budgets in a variety of ways out there. Pooled budgets too have the difficulty which you have identified which is charging for some services and not charging for others.

  105. Is that at the heart of the reason why we cannot move forward to a much more sensible system?
  (Ms Platt) It is not the only reason.

  106. But it is one reason.
  (Ms Platt) It is certainly a complexity which has to be overcome. It is not insurmountable because clearly those people who are going to have PCTs where social workers are seconded in or become full-blown care trusts are having to overcome it. It is not insurmountable. In all these arrangements if people are determined to do something then we shall find ways through and that is what the demonstrator projects are helping us to do at this minute.

  107. Would you accept that the pooled budget way forward which certainly attracts me as a limited reform faces problems where you have this discrepancy on the resourcing of the NHS versus personal social services. My own area is a good example where one of the local authorities has been bringing about a £2 million cuts package. No PCT is going to go into bed on a pooled budget with a local authority in such circumstances. I suspect that kind of scenario applies elsewhere. Is that a reasonable point?
  (Ms Platt) The difficult issue around pooled budgets is that it is easy to pool a budget but the difficult thing is deciding what it is going to be spent on, what the strategy is for its use and how it is going to be allocated. Even if a local authority is in dire straits financially it can still have a discussion with its local health trust about what the strategy should be and the level of resource to be put into it. It might not be as adventurous a solution as some other areas because of the difficulties the local authority might be facing. The difficult bit about pooled budgets is to agree what the strategy is for its spending. That is the case in all the partnership arrangements we have; that would be the case in care trusts too, looking at what the strategies are which are going to be developed through the delegated powers.

  108. Would you accept that it is utterly barmy to have people stuck in hospital beds at three or four times the cost of a community placement, which is what we have at the present time?
  (Ms Platt) Indeed, but it is not that easy. There are immense possibilities through shifting the balance of power now PCTs have the commissioning responsibilities. Whether that commissioning responsibility extends to paying a percentage of what you might pay a hospital for its acute bed and using that instead to fund a care home placement is a matter for further debate. You could destabilise the acute sector.

  109. Before we move off this whole subject of systems, do you have any thoughts, Professor Philp, in this general area? You are semi-detached in respect of the team which is here and probably have a freer role. Do you have any ideas on how we might move this one forward, what structures in particular?
  (Professor Philp) We fought very hard as a team in the Department of Health while we were developing the National Service Framework for Older People not to take a partial view of the system of health care for older people but to try to get a whole system, large view of health and social care for older people, although we did not extend the work into housing and transport and other issues. We are coming at this, fundamentally looking at how health and social care work together. Throughout the National Service Framework mechanisms are being put in place to support integrated working: single assessment process for health and social care; development of intermediate care services which have a health and social care dimension; discharge planning; development of integrated community equipment supplies; services for people with dementia, falls, stroke, depression, that take the whole view and not just health and social care but also the independent sector and primary carers. One thing we have are service models which will be pushed out through the country. The other side is winning the hearts and minds particularly of the primary care leads. I have been out on the road 32 days in the last nine months visiting health and social care communities and always wanting to meet with primary care leads and social services leads in localities. The mood is different. The mood is one of these leads seeing their role as taking an holistic view and having to work together. There are some grounds for optimism there in terms of the leadership which is developing through primary care. Then there are financial incentives for joint working and we are looking at developing performance measurement which will enhance joint working. You ask me to talk about structures and what the National Service Framework for Older People promotes, following discussion with the Local Government Association, is that the unit for strategic development locally of older people's services should be local strategic partnerships where these exist and where they do not exist they should be developed so that it brings all the parties to the table including the independent sector and representatives of older people. I think you are pushing me to go a little beyond that.

  110. I am talking about the health and social care divide which I think is unsustainable and I have thought so since it developed in the 1970s.
  (Professor Philp) It is the biggest fault line that we have to address in meeting the health and social care needs of older people. What I have outlined to you is that several initiatives are being taken, mainly through the National Service Framework for Older People but there are others which Ms Platt has mentioned and another which is Care Direct, a system to route people through. Having visited several countries in the world and looked at their health and social care systems, including Northern Ireland where there is an integrated delivery system for health and social care, there are still fault lines within that system.

  111. The resourcing of that system is not integrated which is the key problem.
  (Professor Philp) Indeed. Where you get anything which promotes better joint working between health and social care that is a good thing.
  (Ms Platt) Here the health and social care divide is not the main fault line. We have also experienced that there are divides between primary care and the acute sector and primary care and community health. There are almost in many ways as many divides within the NHS system as there are outside it and with other systems. If you move across the health and social care divide you still have the housing issue. Many of the solutions we are looking at with older people's care are more in the housing sector and housing developments. When we are talking about integrated care, we are not just talking about health and social care, although that is clearly a very important part, we are talking about an integration across the health care system as well as with social care. The point I was trying to make about the coalition of interest is that the coalition of interest we see in the community is local government, community health and primary care coming together in a very different way now that we have PCTs and we can develop care trusts out of the PCTs, rather than just putting them all together and the acute sector still tips the balance of power. It is the coalition of the commissioning arrangements. The PCTs are going to be the big commissioners in future and we would look to them to overcome a variety of divides which can also be between individual professionals no matter which system they are in. When we are talking about integration we are actually trying to look at it in broader terms than just the health and social care divide.
  (Ms Edwards) I would agree with that. This shifting of the balance of power arrangements does give us quite a unique opportunity because the statistics, but also my own personal experience, show that one of the big issues is often discharging from an acute hospital into a community hospital and different structures. By having the PCTs actually responsible for providing the primary care and increasingly going to be providing the community care, but also commissioning the secondary care, for the first time we are going to have one organisation looking at the whole pattern within the NHS and making that judgement. Because of the size of the PCTs, I feel they will also be much closer to the ground in terms of being coterminous with local authorities. We are not all the way there in terms of a total integration but we are so much further than we were perhaps a year or two years ago in terms of what we have from 1 April when we go fully live with all the PCTs. It is going to be very interesting to see how commissioning develops.

  112. Do you detect any resistance from local managers in social services and health? I had a PCT Chief Executive say to me recently that he felt he was being asked to marry the Director of Social Services before they had even started courting. I said that if it was up to me they would be in bed together and would have been for years. Is it an issue from your point of view?
  (Ms Edwards) Your comment that they should have been talking before now is a valid one and it would be worrying if we were bringing together people who were not already together. We will have new relationships because of the individuals being appointed but in terms of the principles and the roles, those discussions should have been going on and what we are doing is making sure that they are going on in those places where they are not.
  (Ms Platt) We should not underestimate the amount of turbulence that there is in the system as we do move to the new structural organisation in the NHS. I visited one authority recently which had a very good track record of relationships with health services, with many joint services developed together. However, the Director of Social Services was having to get to know nine new chief executives with whom he had not worked before. Some of those relationships have to be re-established and we acknowledge that but we are encouraging that and we are also encouraging the new strategic health authority chief executives who are all in place now to ensure that the proper strategic relationships are made and that proper joint working is set up right from the start in the new trusts. This is an opportunity we have not had before.

Sandra Gidley

  113. Most of what I wanted to ask has probably been touched on because my questions were around shifting the balance of power and the development of the primary care trusts. One comment which was made does concern me and I should like to pursue exactly what was meant by it. The comment was that if we go to full budgets we could destabilise the acute sector. Could you elaborate on that?
  (Ms Platt) I was responding to what I thought was the question that if you spend £120,000 on an acute bed and you had a full budget across health and social care, you could spend the money on a cheaper care home bed in circumstances where I heard you say the local authority was strapped for cash so the largest part of that pooled budget might actually be the health bit. What you would therefore be looking at would be a transfer of resources in the pooled budget across from the NHS sector to purchase a community care, social care provision. That could have been a resource which the acute sector was relying on in terms of its occupancy, its activity. We have to be very careful around setting up pooled budgets to be clear what they are for and what is pooled. I think at the minute the acute sector does have problems in responding to all the waiting list issues which it has to respond to and all the issues about accident and emergency. If the argument is that you can take a bit of it and pay for this person to go to a care home to help out the local authority because they are in financial difficulties then that could be a problem.
  (Ms Edwards) We have talked about occupancy rates and the modelling and the university-type analysis which has been done actually shows that a hospital should be running at 82 per cent to virtually avoid—you could never be 100 per cent—long trolley waits for emergency admissions and cancelled operations on the day. We know that over half our hospitals are running well over that and some considerably more than that. One of the things we would want to see as we reduce the delayed discharges would be that actually helping to lower occupancy rates. There is a whole issue then about how you do that and simultaneously shift the money. One of the things we are working through in the spending review is what we need to lower the occupancy rates and what we need to do to delayed discharges but not necessarily assuming that there is a completely equal relationship. All we will do is to continue to run our hospitals with slightly fewer patients because we have moved the delayed discharges but running them just as hot. What we actually want to do is cool some of the hospitals down in terms of their occupancy rates. That is the sort of modelling we are doing nationally and we are asking each local economy to do that: how are you going to get 82 per cent locally and within that what contribution would delayed discharges make and what contribution would intermediate care? Quite a lot of work is going on to make sure this is all planned systematically and all the streams are brought in, not just the delayed discharges.

  114. Have you identified any advantages or other disadvantages or concerns in shifting the balance of power particularly in relation to the impact on the existing patterns of joint working other than the potential funding?
  (Ms Platt) One of the things I touched on is the organisational change and the change of personnel which is going on at the minute. That has had a short-term impact on the quality of joint working just because of people not knowing who it is they have to talk to even to set up the arrangements we are talking about. As those people are now coming into post and as the strategic health authority chief executives are now all in post, we can start to make the right connections and get the joint working off the ground properly. Local authorities want to work in a different way with these new arrangements. They have been part of PCGs. Social services personnel have been sitting on primary care groups and this is an extension of that. I do think they want to continue that joint approach.

  115. Someone expressed a concern to me, a great reluctance really to go down this route, generally coming from social services, that they feel they are going to lose control. Is this a valid concern or is this something which is gradually being addressed?
  (Ms Platt) The whole reason for the changes we are putting in place is so that the service can make the most effective response to individual people living in communities. The control we would want to see is the person using the services having control over the way in which those services are delivered, having an input into that. If professionals are saying to me that we are losing control, I might say good because maybe the control ought to be in a different place. Some of the concerns I have heard social workers say is that this is an overtaking of a social model of care by a medical model of care. I actually think that if you look at what the changes are which we are trying to deliver in the NHS at the minute in terms of a patient focus and an NHS focused on patient needs, and the services moving round the patient and not the other way around, that is a very good description of what a social model of care is probably about. A social worker's experience in developing that model can be an enormous contribution in a primary care setting as primary care is trying to set up new commissioning arrangements and new service arrangements in communities. What social services know about is purchasing packages of care for individuals, which is a very different sort of commissioning from a block purchase of a number of beds. It is about having the block purchases there but looking at the person's individual needs. The system can benefit very considerably by the social services contribution in these new integrated arrangements. I am continually saying to social workers that they should not be timid in these circumstances about what they have to offer but go for it because together the system can put the person who needs the service in better control of what is going on.

  116. I would agree with you in practice but the reservations have come from senior managers rather than social workers on the ground which says something. Do we not need those people on board and signed up to this if it is going to work at all?
  (Ms Platt) Yes; exactly. I agree and we need to get out and about and say some of the things I have just said, which we do.

Dr Taylor

  117. I am delighted there is so much stress on integration, particularly between primary and secondary care and the community. One of the bits of written evidence we have had from the Stroke Association comments that medicine for the elderly is still largely hospital based. Do you see, with the development of PCTs, taking on the physicians who are looking after the elderly and defining part of their time as working in the community, in people's homes, in care homes? It always struck me as completely ridiculous, before I retired, that as a physician, not for the elderly, I was called to do domiciliary visits to elderly care homes when they should have had a geriatrician looking after that specific care home. Any comments?
  (Professor Philp) The analysis is a very important one. May I just give a very short history of the development of the specialty of geriatric medicine? There are three phases. The first phase was the development of the service outside the main centre of the system, taking over the old fever hospitals, largely a domiciliary service. The second phase was the incorporation of the specialty into the heart of the general hospital and into the centres of the corridors of medical power so that the specialty is now very powerful but it lost some of its reason for existence in that process in that it disengaged from some of the community and longer term aspects of care for older people for which it has an historical mission and purpose: to meet the needs of frail and vulnerable older people in whatever setting they are in. For that reason, I spent the last year as a very high priority working with the leadership in the specialty of geriatric medicine thinking about the challenge of moving into this new world where much care is going to be delivered in the post acute setting in the community and that geriatricians need to be engaged in that, not as the dominant leaders but as contributors to the delivery of care outside hospital in partnership with others and that a specific example of what we are doing in that area is that the British Geriatric Society and the Royal College of General Practitioners are now engaged in a bilateral to develop a job description for a general practitioner with a special interest in older people's services to work as part of the specialist service to help with the specialist service to discharge medical responsibility with an intermediate and long-term care for older people. That would be a key development for improving medical care of older people in this country.

  118. That is very interesting. Most of the specialties are looking to supplement their numbers with general practitioner specialists. Is there an expectation that all social care will be commissioned through care trusts within five years?
  (Ms Platt) There is no such target as that. The care trusts are still voluntary arrangements as systems settle down. As people get used to new arrangements and see new organisations coming into being and see benefits, this is a journey we should like all local authorities to explore actively. They may decide that they can deliver the same sort of integrated outcome without organisational change and it would not be our wish to force organisational change if they could. The emphasis must be on a different outcome for the person and a single system of care; even if not a single structure of care but one system.


  119. I understand that 1 March is the end date for health authorities and local authorities to agree the eligibility criteria for continuing care. Am I correct in that and is that programme on course?
  (Ms Platt) Yes, as far as we know.

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