Examination of Witnesses (Questions 200
WEDNESDAY 13 MARCH 2002
200. Just a quick follow-up on this point. One
of the performance indicators now is readmission rates. Since
that has become an indicator has there been any improvement in
the rate of readmissions, because presumably that was put there
to deal with this very problem? Are you saying that it has had
(Mrs Robinson) I have not seen anything in the performance
measures that shows that there is improvement in that.
201. Has there been any work done on comparing
before and after?
(Mrs Robinson) There probably has but I am not aware
202. Ms Harding, do you want to come back to
Dr Taylor's points?
(Ms Harding) I will try and pick up your point of
the key causes of delayed discharge. Quite frequently people end
up in hospital when they should not have got there in the first
place because of inadequate social and health care support. The
whole area of helping people gain and maintain a good level of
health is a very important one. It is there in Standard 8 of the
National Service Framework. We have got an awful lot to do to
turn it into a reality. At the moment hospitals are picking up
a lot of people that maybe should never have got to that point
in the first place. Secondly, there is evidence within the hospital
system that there clearly is good practice where discharge planning
starts from the moment that somebody gets into a hospital bed
and that people have a sense, including the person themselves
and their family, of what is aimed at in terms of through and
beyond the hospital experience, but that certainly does not always
happen. Much too often it is a last minute "we need the bed;
you are going to have to leave", and much more functional
and ill-thought through and ill-planned with very little time
for the older person themselves or their family to make sensible
choices and come to terms with what needs to be done.
203. So poor planning still exists?
(Ms Harding) I am sure it still exists, and we need
some more of the good practice. The big area we certainly hear
a great deal about on our helpline and other people's is the whole
business of implementing discharge. People are stuck in hospital
because the services are not there for them to return home. The
social services department says, "I am sorry, we have not
got the money to enable you to have that extra visit a day or
that night cover or to be able to fund that place in a residential
home." There are times when it is literally not dead men's
shoes but dead women's beds it seems that people are waiting for.
There are ample examples of that, that social services departments
simply do not have the funding to enable people to leave hospital.
(Ms Herklots) I certainly agree with what colleagues
have said already, but I would add two or three things to the
issue of before hospital. The lack of preventative services, and
particularly problems around older people living in poor housing
who therefore might be at risk of falling or running into health
problems because their house is damp or poorly heated, is generating
admissions to hospital that should not happen. The whole system
of housing adaptations, which the government is reviewing, certainly
needs to be improved. Once people are in hospital there can be
problems of communication, not just between the hospital and outside
but within the hospital itself. The consultant may make a recommendation
for discharge based on that person's physical condition but it
may be some time before the physio or the OT can get there to
do an assessment to see if they can be discharged home. There
are some issues around communication within the hospital environment
itself. In terms of then implementing the decision, one of the
key factors in delayed discharges is transport. There have been
three studies that have shown this. Age Concern London did a study
looking at the experiences of older people in London and both
the Audit Commission and the National Audit Office have looked
at the issue. The National Audit Office found that NHS trusts
cited transport as a prime cause of delay in hospital discharge
in about a quarter of the cases. Something as apparently simple
and fundamental as getting the transport there on the day of discharge
is actually causing some problems.
204. Picking up the points that Age Concern
were making there. In your evidence you talked about welcoming
the preventative services but you were a bit concerned they were
focused on trying to avoid hospital admissions. You talked then
about some issues on housing and other issues that need to be
addressed. If you were in charge of policy how would you have
gone about delivering intermediate care?
(Ms Herklots) Certainly we welcome intermediate care
and the principle of it. What it misses, though, is really going
back a stage not just looking at the sort of package of care you
need, whether that is around coming out of hospital or perhaps
being at risk of going in, but about maintaining older people's
independence in their own homes and preventing unnecessary admissions.
That can be services as fundamental as information and advice
to older people.
205. Would you say that the Government should
be doing those things "instead of" or "as well
as"? Is the top priority something different for you?
(Ms Herklots) Intermediate care and preventing delayed
hospital discharge will not succeed in its objective unless you
also invest in preventative services which are around practical
help at home, housing adaptations and repair, and combatting older
people's isolation as well. Quite a lot of helping people stay
independent is about making sure that they have got the confidence
to do things. If you are isolated and living on your own and not
getting some support that can put you at risk of deterioration.
Intermediate care is a positive step forward but it does need
to be matched with a broader range of community services as well.
206. Was not the idea when intermediate care
was looked at that it would be something more than beds and it
would be some of these other services as well?
(Ms Herklots) I am not sure what the idea was, but
it certainly has not come through. What has come through is a
time limited model, which itself causes some problems because
after the period of intermediate care ends there is then a new
207. I think we are going to pick that up later.
Can I pick up one point that Carers made where you said that one
of the problem carers come to you with is there are not the nursing
beds when they need them and that is why somebody ends up going
into hospital. In dealing with those calls could many of these
be dealt with if there were domiciliary nursing services to support
those people at home? In those cases is it really break down where
those people cannot be cared for at home?
(Ms Whitworth) In many cases you are talking about
a carer needing a residential home placement because they feel
unable to carry on caring at home. It might be that proper domiciliary
care arrangements would enable them to carry on caring. Very often
you are talking about somebody very elderly caring for somebody
very elderly and at some point that capacity for caring is no
longer there. We do believe people should have a choice about
whether they carry on caring or not and residential care is sometimes
the only option.
208. Is it the only option or you were saying
earlier it might be possible and people might want to do the care
(Ms Whitworth) Yes, but I cannot tell you how that
would break down.
209. We have already talked quite a bit about
the alternatives to hospital admissions but there were a couple
of points in the King's Fund evidence I would like to pick up
related to that. You suggested in the evidence that there is a
lot to be done in the area of preventing people reaching what
you call "crisis point". What do you mean by "crisis
point"? Is it signalled up so you know it is going to happen
and why are the signals not picked up?
(Mrs Robinson) In our submission I referred to a study
we had undertaken looking at winter pressures and what has been
going on in London in particular, and what we found thereand
clearly this refers to your question about emergency admissionsis
lots of old people being admitted in an entirely predictable way.
We looked at what had been happening over a period of years and
found that crisespneumonia setting in, bad episodes of
bronchitis, really acute illnesswas happening time and
time again in a particular month in the winter. You could predict
when it was going to happen and most of those people turned out
to have chronic respiratory disease. It is not surprising when
you hear it now but I do not think people did know it until they
looked at the statistics. It is entirely possible if we worked
in a very different way, which we have not done in this country,
and target those people who are known to the services, they are
known to their GPs, they are known quite often to social services
and community health as people who have chronic respiratory disease,
who are likely to be at huge risk of developing severe illness
in the winter months and there is a whole range of things you
can do over and above making sure they have their flu injections.
The kind of things Age Concern are sayingputting in intensive
care packages of care and support, including improving housing,
so that they do not get cold and damp.
210. What would you do to get this onto the
political agenda to try and make sure this kind of thing happens
(Mrs Robinson) There are two things. One is looking,
where the Chairman began, at what is the cost of these delayed
discharges at the moment. That it is better to invest money elsewhere
is clearly an argument to be made. The second thing is to find
some way of supporting primary care, essentially in deprived areas,
for the kinds of peaks and troughs we are talking about in this
King's Fund study, and supporting primary care to do the outreach
work and work with those individuals. At the moment many of those
general practices are not well set up to do that. I think there
needs to be some real investment in general practice and primary
care more generally, and in the inner cities particularly.
Dr Naysmith: I do not suppose any of the others
would disagree that we need more of that kind of preventative
211. Has any of this been piloted anywhere?
Have any of the health action zones thought about this kind of
(Mrs Robinson) I do not know about the health action
zones but the London Regional NHS Office with its social care
counterpart has mounted quite a large-scale development programme
for older people's services in the capital and they are trying
to, in different ways, what they call "case find"find
these people who are known to be at risk and known to be vulnerable
and work intensively with them. It is early days to find any answers
to what they are doing but they are trying that in a very imaginative
212. Does the London National Health Service
Social Care Office that you are sponsoring impinge on this area
or is it something quite different?
(Mrs Robinson) I am sorry?
213. The NHS Social Care Office which is mentioned
in your evidence; is that related to this area or is it something
(Mrs Robinson) Yes it is. The NHS London Regional
Office and The London Social Care Region have mounted this services'
development initiative and we are supporting them with various
briefings and facilitating meetings and bringing managers who
are working together into the King's Fund for some leadership
development courses to help them work together better.
214. Is it going well?
(Mrs Robinson) It is early days but, yes, so far.
215. Picking up on a point Tessa raised earlier
on discharge planning, when we visited Vancouver and the States,
there were quite good examples of how discharge planning works
and particularly aggressive management, I have to say, in the
States which was driven by the insurance companies wanting to
make a profit, to the extent where the discharge was being planned
almost before somebody went into hospital. How widespread is that
in the UK? How aggressive is it and how prevalent is it? It is
something that is on the up?
(Ms Harding) I do not particularly know the answer
to that but I am not sure that anybody does. I think it is one
of the reasons for the existence of the Commission for Health
Improvementto identify and help spread good practice within
the NHS. We do not have good systems for doing that at the moment.
I could not tell you what the proportion is.
216. Are you aware of any good practice that
might be interesting for us?
(Ms Whitworth) Can I make a comment. As you know,
we are looking at it from a slightly different point of view and
after we published our report on carers' own experiences of hospital
discharge which were very dismal and showed that things had generally
got worse since 1998 rather than better, our office in the north
of England carried out a survey of 23 trusts up there looking
at their hospital discharge policies particularly to see how they
address carer's needs. We found that whilst there was mention
of carers' needs in the majority, what happened in practice was
not very good. There was some good practice in that. Because when
we published the report we agreed not to identify the trusts,
that information is not available to me now, but certainly I can
make available to the Committee some further information about
what we found when we looked at those trusts. Generally speaking,
the experience is that whilst a policy might look good on a shelf
it is in the implementation of them that many of the problems
occur. You see decreasing consultation of families and carers
around the discharge and of course that is absolutely crucial
if you are going to discharge somebody who needs support in the
community, it is very important that should be in place. We also
found that people were also reporting that they felt less involved
and less informed and they were less likely to get a copy of the
Chairman: It would be very helpful to receive
that as soon as possible.
217. Several of you have mentioned in your submissions
the need for statutory guidance linked with good practice guidance.
Should that be one of our strongest recommendations?
(Ms Herklots) I think it should. The problem is that
the Government has introduced new guidelines for continuing care
which has replaced the previous hospital guidance and that has
left rather a confused situation. Since the original guidance
was drawn up much has changed both in health and social care.
There is a real need to clarify what the responsibilities should
be so that older people and patients are clear, but also to work
on the hospital discharge workbook which was very good in terms
of setting out what should happen. That is the sort of place where
you could record some good practice and some expectations there
about what should happen. Just on that point, we think it would
be important that it would cover NHS patients in private hospitals
as well. An issue that is raised with us from time to time is
that sometimes private hospitals may be less familiar with the
need to plan discharges than NHS hospitals and if, as appears
to be happening, there is an increase in people going into private
hospitals for NHS care then that is an area that should be covered
by the guidance as well.
Dr Taylor: That is certainly a recommendation
that we can forward.
218. Does anybody else have any comments on
discharge planning before I move on to my next question. This
is to Helena. What evidence has emerged from your community care
studies about the criteria for discharge? Is there any evidence
that there is pressure because of pressure on acute beds and what
do you think the Department of Health could do to promote more
effective discharge planning?
(Ms Herklots) The evidence we get is from older people
and their relatives who contact us and, indeed, from social services
and health professionals who are trying to battle with the system
and make things happen. The main thing to say is that there is
quite a variety of practice. There are some pockets of good practice
where people work very hard together to try and plan good discharge,
and some examples of that that local Age Concerns are involved
with, for example, is where someone visits the ward regularly
and works with the health staff there and then "goes home"
with that patient and provides support actually upon discharge.
This project is particularly focused on people who live alone.
Those sorts of things are happening, which are very good. The
problem is that what happens in the hospital would be to a large
part determined by what is available in the local area in terms
of care, and that is what affects decisions. So if, for example,
there is the availability of care home places at the fees that
the local authority will pay then obviously that is an option
and people may get discharged to a home of their choice at that
level. Too often, though, there are waiting times for funding
or there are problems where there are not any care home places
available at the local authority rate. What we find there is that
relatives are put under pressure to top up so that their relative
can be discharged. It puts relatives in a difficult position because
they are obviously worried about their loved one in hospital who
wants to be discharged, but if there are not care home places
at the local authority rate then it puts them in a very difficult
219. Have you or any of the other witnesses
any evidence of the way in which people who have resources and
capital are perhaps being discharged from hospital earlier on
the basis that local authorities do not fund them and therefore
it is cheaper from their point of view? I can recall one case
where there was fairly clear evidence that this happened and the
family were aggrieved when they were allegedly told by a ward
sister that had their mother not had the resources then she would
have remained in hospital.
(Ms Herklots) We have not carried out a thorough investigation
of this but there is anecdotal evidence where if somebody is able
to top up or pay their own fees they are able to get out of hospital
earlier. We have certainly had anecdotal evidence of that.
(Ms Harding) From similar sources there is anecdotal
evidence through helplines and so on.