Examination of Witnesses (Questions 260
WEDNESDAY 13 MARCH 2002
260. Why is that?
(Ms Herklots) They provide help to older and disabled
people in carrying out repairs and adaptations to their homes.
Handyperson schemes also provide the sort of smaller repairs or
adaptations that you might need, so it might be things like grab
rails or those sorts of things, or indeed things like home safety
checks actually to go into a person's house and see what sort
of risks there might be in terms of perhaps a likelihood of falling.
The issue for a lot of these schemes is actually trying to access
funding. That can be a particular problem. They quite often spend
quite a bit of time fund-raising, when probably they would rather
be actually carrying out the work. Health and social services
and housing variously fund these sorts of schemes, but in our
view there are not enough of them about. For older people it is
often quite small things which can make a big difference to their
being able to manage at home or not, or their being at risk of
needing long-term care or hospitalisation or not. So we would
certainly like to see further development of that work and also
further work to speed up the adaptation process. In our evidence
we refer to the disabled facilities grants system which is an
incredibly complex and difficult system for people to manage.
The Department of Health and DTLR are currently reviewing that.
We very much hope that that system is improved. The current situation
is that you get a decision on whether or not you will get a grant
within six months, so you wait six months before you even get
a decision on whether you are going to get the grant. If you are
the sort of person who needs to apply for that grant, you probably
need it quite quickly to get some adaptation done, so it is a
key area for improvement.
Chairman: Can I ask a question on that point.
From the constituency cases I have had I have come across a problem
that has appeared on a number of occasions where the means-testing
takes account of the full income of the entire family, and where
you have, say, young people living at home in their late teens
or early twenties, the amount of contribution under the current
scheme has led in a number of instances that I have dealt with
to families saying that whereas granny was actually going to remain
there with them, she was actually going to go into care instead,
because the family were not prepared to care in those circumstances.
Jim Dowd: The mean so-and-sos! Instead of rewiring
their house, stick her in care. That seems unreasonable to me.
Chairman: We are talking of Yorkshire people,
261. What is the difference between the social
services authorities and health authorities that have been welcoming
and taking on those schemes and those that have not? Is there
any pattern there?
(Ms Herklots) I do not think there is a pattern. From
what we have found, I think it is just in some areas that people
think more imaginatively about what can help them as workers,
as people who work in health and social services. So I think that
in some areas people make that connection with housing. We know,
for example, some local authorities bring together the different
strategies for older people, and are trying to plan in terms of
developing strategies for older people and trying to plan in terms
of a whole-systems approach where you are looking at the different
contributions that can be made. That sort of approach does help
to highlight the contribution that housing can make, and if you
fund some housing work you can actually save money on your health
budget or social services budget. I think that whole-systems approach
is certainly one which needs encouraging, because it does lend
itself to some more creative solutions around that area.
262. Where you are putting in bath rails and
things like that, do you still have to wait for an official OT
assessment for those kinds of things?
(Ms Herklots) Yes, there is a shortage of OTs, and
the problem is waiting for OT assessments.
263. Do you think it is appropriate always to
ask OTs for that assessment? Again, in constituency caseloads
you have the carers who say, "I can tell you need a bath
rail, why do I have to wait three months for somebody to come
along and tell you you need a bath rail?" There is a lot
of commonsense there, is there not?
(Ms Herklots) Yes. I think we need to weigh the balance
between where somebody actually does need that professional expertise,
because I think we all think we know where we can put the bath
rail, but put it in the wrong place and we can actually do more
damage. There are projects which are fast-track systems, which
have been very successful, so you get the OT involved within the
project and you do not get involved in a very long waiting process,
you fast-track that and people get some help.
264. So it is a fast-track system that might
help. Would Carers UK like to speak about that issue? I saw you
were nodding. Also what do you think can be done to develop domiciliary
services, particularly where carers could work and that might
help either to defer or avoid hospital admissions?
(Ms Whitworth) I have said this before already, the
whole area of domiciliary care is poorly funded. It is very often
actually quite simple measures that need to be taken in order
to make life easier or indeed to make care possible. It is not
rewiring a house; it is actually something like putting down a
few non-slip things under mats, putting up a few rails, putting
in a ramp, and life immediately becomes possible. So I would absolutely
echo what Helena said.
265. Would you echo that it may be dangerous
not to go through the OT route, because the rail might be put
in the wrong place?
(Ms Whitworth) I think I would be cautious about allowing
that. I certainly would not want to advise somebody on where to
put a rail myself. These are no doubt the frustrations that people
face which should be dealt with.
266. On the handyperson scheme, does this apply
to minor repairs, fuses, tap washers, that kind of thing, which
are not part of the infrastructure but the kind of things people
do need to work to keep older people living on their own?
(Ms Herklots) It can do. They vary quite a lot in
what they cover. That would be part of the agreement on what the
services are there to do. Some schemes will provide that sort
of help that people need to fix things and make things work and
that kind of thing. They do vary. Most of them are more geared
to making sure that the person can maintain independence. It is
quite difficult to maintain independence if your water does not
work or you cannot turn your tap on. So those sorts of things
do get included.
(Ms Whitworth) This issue of simplicity of the solution
is really quite important. It is going back to the discussion
we were having earlier about personal care. People spend a lot
of time talking about personal care and the need to provide personal
care in the home, but the family and the person being looked after
generally would prefer to provide that personal care themselves.
It is other practical things that need to be donethe gardening,
washing the nets, the ironing, those thingsin order to
make it possible to provide the personal care. In thinking about
the costing of some of this, it is thinking about what it is that
people really want rather than what professionals think people
need which is important.
267. Can I ask witnesses about the issue of
advances in new technology and how they may assist with the problems
we have been talking about. We are talking about the issue of
people who have cut vision who may be discharged into a care setting.
I have certainly seen schemes where it is possible to maintain
them in their own homes where appropriate mechanisms are fitted
that monitor their care, the issue of tele-medicine which we are
looking at and on which we are taking evidence later in this inquiry.
Do you have any examples of schemes of tele-medicine in the community
care setting that may offer ways forward on the issues we are
talking about in this inquiry?
(Mrs Robinson) Not tele-medicine.
268. Perhaps that is the wrong term. I have
been to one particular company who are giving evidence to the
Committee where they are able from a central monitoring point
with terminals in the homes to maintain people in a very, very
intensive way through the carers who are coming tapping into the
terminals about care that has been given and they have contact
with medics through that. The Committee is very much aware of
the potential of these new developments. Somebody who talks about
these developments is Mr Austin. He sends me e-mails and I do
not get to them and so in the end he rings me up, which seems
much simpler in the first place! We are aware of the potential
to discharge people into a home setting with the means of monitoring
them in that home setting that were not available previously.
(Mrs Robinson) We do refer to this issue in our report
on care and support workers. We are rather cautious about those
developments because while on the one hand you are absolutely
right, the potential of the technology looks very excitingsafe
houses, smart houses, all sorts of things being done at a push
of a buttonthe thing that we at the King's Fund are most
concerned about is the surveillance features where as long as
the person moves across the ray once every whatever, everything
is okay. We felt rather worried about that and felt they had all
the potential for being very inhumane. They are keeping a radar
watch on some movements when the truth of the matter is for many,
many people living on their own who need care and support, it
is going to be labour-intensive. They need people with them, to
put it shortly. We are cautious about it. Certainly the "smart"
house developments are worth exploring but they are costly. On
a cautionary note we would counsel anybody doing any of this people
sitting at a bank of machines and saying, "If they are moving,
everything is okay."
Chairman: I think I gave the wrong impression.
Some of us recognise the potential for future schemes to enable
people to choose to be at home otherwise they would be in some
form of care setting, intermediate care, or in hospitals. I was
talking to somebody about the NHS and this whole area only yesterday,
somebody who works in a hospital in West Yorkshire who was saying
that there are four separate bar codes on patients in his hospital.
It seems we have got some way to go before we start addressing
269. In the summing up of the Committee's discussions
I want to spend some time on the future solutions. We have touched
on lots of solutions but there is one issue I would like to put
before all the witnesses before us and that is to what extent
do you think the changes in the structure of NHS that are about
to come inI am thinking particularly here of primary care
trustswill enable better systems of planning in this area?
To what extent do you think it will enable the NHS to get a grip
on the issue of delayed discharges and provision of care in the
hospital setting? Our inquiry is about the problems which affect
the NHS and yet the NHS has very few levers it can pull. These
are external factors beyond its control. Do you feel that there
is an opportunity with ECTs to come at this problem in a different
(Mrs Robinson) Yes and no is my answer. Yes, the potential
is there for primary care trusts to have most of the budget to
use it in a different way, but there are huge provisos attached
to that. In the short-term I fear that things will get much worse
because the truth of the matter is that they are new organisations
only just setting up. Most of them do not know where the current
resources go. They do not have that information about where the
resources are going in the Health Service. Unless they have that
information they cannot make any decision about how to move it
270. Do you think they offer an opportunity
for more flexible thinking that is not constrained by the old
NHS orthodoxies, that we can come at this problem from this way
rather than that way?
(Mrs Robinson) Potentially it does, particularly where
you are getting much greater community involvement than you get
with health authorities and acute trusts, but I think they are
really stymied in terms of how much real flexibility they have
got to use money in different ways when so much of it in the NHS
is spoken for by increased prescribing charges, increased money
for salaries, and so forth. Their room for flexibility is pretty
271. In giving them more flexibility, are they
the people to develop the financial incentives that you mentioned?
I would think they would have to come from that bottom-up rather
than by way of a top-down system? Do you think that is a possibility?
(Mrs Robinson) I would be interested in your thinking
on that. When I said that, I assumed it would be something government
would put in place either by legislation or through instruction
from the Department.
272. When the Committee was in the United States
recently we heard of a system which had been set up where hospitals
had penalty payments for days patients spent in beds beyond the
pre-ordained length of stay for a procedure of the kind for which
they were in hospital. Just thinking laterally here, do you think
that idea has any merit? Could we take something from that?
(Mrs Robinson) I do not think I know enough about
it. What I do know is that those health maintenance organisations
in the States have the power, because they own the budget, to
impose those penalties on the hospital system and we do not have
that kind of system of managed care in this country. I think we
would have to do it rather differently to achieve that bottom-up.
273. What was interesting in the States is acute
trusts had started to invest in their community services so that
they could get people out of beds to meet these objectives. The
interesting thing is you were saying before if you merged the
budget the acute trust would raid it, but in fact it can work
the other way and the acute trust starts to think "we need
to invest more in the community". Do you see what I mean?
(Mrs Robinson) That would fit very much with what
I was saying about introducing the incentives so there is a penalty
on either or both the local authority or the NHS if they do not
do X, Y, Z and therefore it would be in their interests to do
precisely what you are saying to avoid having to pay the higher
charges which will then be levied because they have got someone
sitting in a bed when they should not be.
274. It is part of the problem that there is
no incentive for social services to take somebody out of hospital,
is it? Is that a real problem?
(Mrs Robinson) I think that is right. As long as you
can say, "If you"the local authority"keep
that person in this bed, when everyone's agreed it's now your
responsibility, and you don't suffer any financial penalty whatsoever,"
they do not have an incentive to have to do it. If they actually
had to pay for the cost of, say, the hospital bed, and that was
more than a residential care placement, I think you would find
them moving and providing money from somewhere.
275. Can I put these same issues perhaps to
(Ms Whitworth) I am slightly worried about penalties
being imposed on organisations that are already strapped for cash.
I am much more inclined to think in terms of incentives. Certainly
you can see that a penalty on the PCT would probably concentrate
their minds on discharging people more quickly, but I think they
are already fairly concentrated on that. My concern would be about
who would pick up the pieces; that actually you would have to
put in place proper systems to pick them up. I am not sure that
PCTs of themselves can provide the solution. They may provide
a good structure within which a solution can be delivered, if
resources are made available, but I think the answer is a resource
problem and not so much an organisational problem. I think the
idea of PCTs, particularly the new developments about patient
involvement locally, does actually mean that PCTs will become
much more responsive to local needs.
276. You are not necessarily advocating a penalty
(Ms Whitworth) No, no, I do not. I am engaging in
277. I think that in the NHS there is an opportunity
to get into this question of incentives, is there not?
(Ms Whitworth) Yes.
278. Perhaps Ms Harding would like to comment?
(Ms Harding) I would agree that PCTs do offer the
potential for improved investment in the sort of first-stage servicesin
social care, in primary care, in community health serviceswhich
are very important and very critical for older people. The potential
is certainly there. What I think would need to be retained is
a sort of breadth of vision that they did not become narrowly
focussed either on national targets or on specifically medical
definitions of needs and care.
279. But do you think we might see more health
money, so to speak, being spent in a community or social setting?
(Ms Harding) Yes, we might.