Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 320 - 339)



Dr Naysmith

  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?

Mr Burnham

  321. Yes.
  (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 quickly enough.

  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 medical.
  (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 in?
  (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.

Andy Burnham

  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.

Julia Drown

  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.

Dr Taylor

  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 and councils.

  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 beds.

  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 news.

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