Examination of Witnesses (Questions 320
WEDNESDAY 20 MARCH 2002
320. If I remember, that actually was not what
we are talking about today alone, it was talking about people
being in the wrong institution, diagnosed wrongly, and who should
have been treated somewhere else; it was not just delayed discharges?
(Dr Dearden) I certainly appreciate that, but nevertheless
it is a reflection of the problem as a whole; but I accept your
point. If I may, can I speak personally, rather than as a representative
perhaps of the BMA, on this particular question?
(Dr Dearden) If you go back 10 or 15 years, I cannot
ever remember hearing about waiting lists, I cannot really remember
hearing about times, to the extent that it seems to be where we
are now. In Wales, for example, in my area, the waiting time for
a hip replacement is now six years, and that is the trust's own
published figures; our waiting lists are, on average, four to
five times English waiting lists, which some of the English press
do not actually give. In my area, a dermatology outpatient appointment
for a child is 14 months, for an adult it is two years; just an
issue that you might want to look at, at some point in time.
322. But what gave rise to the problem?
(Dr Dearden) Personally speaking, I feel, at some
point in time, someone decided that it was okay for a patient
to wait for a treatment; we then started to close the geriatric
hospitals, the long-stay hospitals. What we then did was, the
doctors, the resources, the physios, the occupationals, did not
come out into the community, where the patients went, they went
back into the secondary care sector.
323. Was the closure of those beds, and obviously
that gave the acute trusts somewhere to place people, was not
the problem that those beds were closed and yet there was no attempt
to develop intermediate care, any kind of replacement care for
those long-stay beds, which had their faults, do not get me wrong,
they had their faults, but you had acute services and the community
services, and that was it?
(Dr Dearden) Absolutely. The first things was, we
started to close those hospitals; the second was that we started
a reduction in acute beds anyway, so we went from an average of
85 per cent, 86 per cent occupancy, which is sort of the optimum,
up to 95, which is known to be difficult and will create knock-on
effects. Because we did not move those services into the community,
we left a very, very vulnerable group of people even more vulnerable,
because we did not have the facilities to take care of them.
324. We are talking early nineties now, are
we, is that right?
(Dr Dearden) We are talking sort of, I would say,
late eighties, early nineties, that process began; the problem
was, and the other side of the coin is, that it has not been reversed
325. But would you agree with the Audit Commission,
in the evidence they have given us, that things have improved,
that improvements have come on since 1997?
(Dr Dearden) I think it is fair to say that in some
areas there have been signs of improvement; but if you look in
general, basically, the waiting times, and I am speaking for my
area, have only got worse in the last 10 years.
326. How about delayed discharges?
(Dr Dearden) Delayed discharges, again, is a little
bit more difficult to measure, because it has only really been
looked at and measured to any great extent recently, so it is
very hard to go back ten years, because people did not identify
it as an issue eight or 10 years ago.
327. Professor Swift, do you think increased
demand might have something to do with it, as well, or the number
of hip operations 15 years ago?
(Dr Dearden) There is no doubt, increased demand;
if you just look at, for example, the number of people seeing
a GP, GP consultations have gone up 50 per cent in 10 years, GP
numbers have gone up fewer than ten. So, yes, you are right, the
sheer number of people accessing the service, whether it be NHS
Direct, through A&E, through ENT, or outpatient casualties,
and through primary care, in its various formats, the sheer number
of people coming through the door has increased. Some of that
is definitely medical, but some of it is also about social and
housing and benefits and reports, and so the demand on the NHS
is actually increasing, although not all of it, of course, is
(Professor Swift) Can I go back a bit more than 15
years actually; if you go back beyond that, there was, in fact,
a very big problem with bed-blockage, and also there were very
large numbers of long-stay beds, and, in fact, it was the development
of good partnerships between health and social care and good practice
that actually enabled some of those inappropriate long-stay beds
to be closed. So I do not think that just to talk about the closure
of long-stay beds is a correct interpretation of the causes underlying
that. I did a ward round at King's this morning, and I had a gentleman
who, two weeks ago, in hospital, in a full-team process, we agreed,
with his very explicit wish and that of his family, and his health
care need and the social care risk need, that ultimately he needed
to go into residential care; this morning we heard back from an
independent social services panel that they had rejected this
application, and we are in this situation where you have got a
negotiation taking place around the decisions of that person,
rather than shared clinical decision-making and ownership. One
of the problems has been the fragmentation of social work care
and Health Service care, consequent on the Community Care Act;
with all its good points, it has actually pulled professional
social work away from the nub of things in hospital, where we
used to work very, very closely with colleagues and their advice
was greatly sought, and their decisions, as part of a corporate
team, were also well taken and well respected, and they did the
negotiations within social services. It is a big story, it is
longer than that.
328. I do not want to rescue the previous Government
on the Community Care legislation, but I would go back further
than you have indicated, to 1974, when we split health from local
government; but can we come back to this in a moment or two, because
I want to ask some specific questions. Mr Webster wanted to come
(Mr Webster) I only really wanted to make one simple
point, that has a number of consequences. Whatever the origin
of these things, it has got more complex, has it not; that is
one of the big changes that has happened in health care, that
it is much more difficult to come to the right outcome for each
individual. And I think what we have been identifying is that
there just are not the incentives for people to deal with that
complexity, so they use a simple, old solution that does not work.
And if you look at a very simple example of that, most of the
ways in which people's performance is measured in the existing
system, whether they are social workers or doctors or health care
managers, is not about how they share things with each other,
it is about how they do something within their own system. So
the incentive is always to look to your own.
329. Or do not do something within their own
system; ie do not encourage expenditure?
(Mr Webster) It is a measure of a particular thing
in their own system, rather than an outcome of a whole system;
and without those kinds of incentives then is it any wonder that
other people in the system then do not replicate the right behaviours,
because the complexity that is there, in front of everyone, is
not actually set down in anybody's targets.
330. Just to follow on, it is interesting, I
think I would tend to agree with that explanation. You talk of
systems failure, Professor Swift, in your submission to us, and
you also talk of removal of perverse financial incentives; could
you say exactly what you mean by that, what solution have you
got in mind there?
(Professor Swift) What I did initially was try to
illustrate, admittedly, historically, the impact of a successful
system on hospital bed occupancy, and the key to that was a whole
expert system, shared across professions and across health and
social services, specifically around the needs of older people,
putting that together with a common sense of accountability.
331. Do you think we have a system where the
acute sector sucks in resources too much and that those resources
actually could be better deployed elsewhere, but because of the
nature of the system
(Professor Swift) I do not believe that is the issue.
I think you need to have strong resources in the acute sector,
because that is where, particularly with the ageing of the population,
there is a very major reservoir of immediate acute social and
health care need, and that is what we are talking about. So I
do not think it is a case of either/or, and I think the substitutionary
view, of community versus acute care, is damaging to the needs
of older people. I think they have got to work together.
332. But when you have a situation where the
acute budget is growing quite quickly and the social services
budget is not growing as quickly, is that a problem?
(Professor Swift) I think, clearly, that is a problem;
but, equally, I think that, because of the fragmentations I have
described, there is probably less efficient use of scarce resources
on both sides of that divide than there could be, and I think
if you could bring the two together you would have mutual support
to make hard decisions sometimes, to stick to them,
333. One budget, you are talking about?
(Professor Swift) Possibly, for a defined co-ordinated
service. I think we should look very hard at that and the opportunities
that that could bring.
334. Just back to Andrew Webster's point; you
say it is more complex, and I can understand that certainly, if
you go back to local authorities not having to pick up the tab
for some of the costs in the way that they do now, that creates
one issue of complexity, but why is it more complex, apart from
that, than it used to be? And you talked about incentives for
joint working; have you come up with any possible incentives that
we as a Committee might want to recommend?
(Mr Webster) When I was referring to complexity, I
think I had quite a number of aspects in mind. There is a very
interesting piece of evidence before you from the King's Fund
about respiratory disease and the impact that that has on admissions
to hospitals; that is the kind of learning that could inform much
more efficient use of lots of resources, but actually it is not
normal practice within health economies to do that kind of mapping,
and it takes resources and people with those skills and a will
to do that for that to happen. If you think about case management
we were talking about earlier, that requires people to be able
to look at, it is more complicated than being an occupational
therapist, it is probably much more interesting, actually, but
it is more complicated.
335. But patients have always been presented
with those issues over the years?
(Mr Webster) But they have not been presented with
the same range of potential solutions, in the past, because there
was a much more standard mode of people coming in and out of hospitals,
for example, and longer stays, so there could be more time. In
terms of what incentives could be built in, many of those would
have to be around the performance of senior staff, because those
would then be mirrored by more junior staff. So I think incentives
will be quite simple things, like the targets that the people
who are chief executives of hospitals, or social services authorities,
are actually given.
336. We will maybe mention this later, but it
gets into saying you will co-operate, and what are you talking
about, performance rate of pay, what are you talking about?
(Mr Webster) It could be many of those things; but,
at the moment, I think, I do not have a piece of evidence to bring
to the Committee, but I think it will be commonly accepted in
the system that your primary targets are not the ones around sharing
activity with other organisations, and those for very good reasons,
because the core funding and the core issues and the core priorities
are located elsewhere, for most of those managers.
Chairman: I think we will come on to this in
a moment or two, perhaps with some questions from myself, actually,
to expand on it in more detail, I suspect.
337. Can I go back to discharge planning in
a bit more detail, because we have covered it a little bit. Obviously,
you are all in favour of the whole systems approach, which is
absolutely key, and I think it is in the Audit Commission evidence
you talk about single assessment, Professor Swift has talked about
single point of access, single assessment process; could you go
into a bit more detail and describe exactly what you mean by that,
really Mr Webster, and then Professor Swift?
(Mr Webster) It is actually already a requirement
to create a single assessment process for elderly people, it is
in the National Service Framework, it is a target for health authorities
338. Can you take us through it, who does it
and what is it?
(Mr Webster) No, I cannot, because that is the issue
that people are grappling with at the moment; the requirement
has been placed on organisations to design a system that meets
those criteria, but the delivery of that still rests with those
people, they have to come forward with the sort of thing I described
earlier, a map of the process and the key accountabilities and
decisions that are to be made for each individual person. I would
not underestimate how difficult that is to do. I think that people
are finding that very, very difficult to do. I do not know whether
Professor Swift can give you any kind of personal insight into
that, but it is certainly the case that many local health and
social care organisations are finding it an extremely difficult
thing to grapple with, right as we speak.
(Professor Swift) Let us talk about hospitals, first
of all. I think that what happens in hospitals is that it is essentially
a specialist function, and it has to do with a proper, accountable,
interdisciplinary team doing just that, and creating reliable
data about an individual with complex problems. So that is what
happens in hospital, and it is the basis of decision-making, and
if it is done well and you are enabled to implement the decisions
then that is how you get it right; if you do not do that, you
get it wrong. I think the difficulties at the moment arise about
the concept of the single assessment process applied across the
board, in social services and primary care, in the hospital sector,
and, of course, there are logistic problems for GPs already overburdened
with targets. I think that there is a debate going on between
general practice and the National Directorate on how that should
be done. Anything, however, which itemises what inevitably will
be the recurring, relapsing, cumulating, complex problems that
constitute the career of an older person through the system and
improves the flow of information, in that respect, if we can get
that right, I believe there is massive gain to be had. For example,
some delayed discharges could be traced back to unnecessarily
duplicated investigations, because we have not got that information
ready to hand, people sitting waiting for procedures in hospital,
there is undoubtedly an element of that. So if we are able to
benefit from that, and mainly it is in the area of information
flow, then I think we should not minimise its potential impact.
In hospital, it has to do with the enabling of specialist teams
to do their jobs, and we have expressed in our written submission
the anxiety about the spreading of patients across hospitals,
in doing that well, it is a factor of overoccupancy of hospital
339. But the whole accountability approach has
got to take on board primary care with it?
(Professor Swift) Of course; absolutely, and there
is tremendous advantage in that. You build the bridge at an early
stage between primary and secondary care, so that you have got
joint ownership of a complicated patient; that has got to be good