Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 380 - 399)



  380. Right; so you see that as a key element, from your point of view?
  (Professor Swift) I was going to go on to say that I think the way forward, for the present, might be to look at some of the models that we have discussed, intermediate care is a good example, and try to build into that a retrieval of best practice, in which, as I have suggested, you have a common organisation, with a common plan, which defines the need, which identifies the finance and delivers it together with shared accountability. Whether care trusts would help to achieve that I think remains to be seen, I think they might, actually, but one is aware of the sensitivities around care trusts. If that were the way to budget for a single intermediate care service, which is corporately owned across the divide, then I think that could be very effective and could deliver a lot into the system. My definition of the whole system, by the way, is not the whole NHS, or the whole of social services, or an acute trust, but is the total group of services, from the point of view of my field, which are focused specifically on the needs of older people, so that includes the hospital-based service, it includes GPs, particularly those with specialist skills training, it involves the social work staff and social services staff, for whom that is the complete remit, it involves obviously across the professions. That is the whole system; and it has this element of specialism about it, which sits alongside the generality of practice, which obviously is important to maintain. But not every GP wants to have an a priori accountable involvement and commitment specifically for services which have to do with the needs of older people, they may prefer, some of them, to develop skills in other specialities. And we would argue, from our field, that there is a specialism which has to drive the leadership of this group of services.

  381. I am exploring ideas, as we listen to evidence, and discussion has already touched on the fact that some of us were very interested in the case manager concept that we saw in North America, and I have been wrestling with the role of the nurse, in this possible process, or the role of the social worker, and I am very interested that you have seen the decline of the hospital social worker as a factor perhaps in some of the problems that we have now.
  (Professor Swift) I think, many of the things that you would identify currently as case management, particularly family counselling, those sorts of things, and negotiation, were undertaken by professional social workers.

  382. Absolutely. I was going to move on to Dr Dearden, for a GP perspective, a family care perspective, to ask you about your views on care trusts, as they may relate to the drawing together of the relationship between health and social care, and also taking account of the point that Professor Swift made about the role of the social worker, whether, in fact, you have, in your practice, an attached social worker, whether you see any merit in a social worker being attached to a GP, and that social worker possibly following the entire process through as a case manager, in the way we have seen it in North America? And I will come on to Mr Dolan in a moment or two.
  (Dr Dearden) I think, from our point of view, we would certainly agree with what was said previously, that a pure organisational change is unlikely to achieve what we actually want, and it is very much about how people work together; and where it has actually worked well now, even with the split that exists, is where the people have actually got together, established a need and worked together actually to meet that. Now the option of having single budgets and single commissioners and single arrangements is certainly something that is helpful and we feel would be good; not exactly certain that another organisational change will actually reach or change that what is sort of a learned behaviour. Locally, in Wales, we are actually trying a social experiment, which is our primary care organisations are co-terminus with local authorities; elected members will soon be on there, social workers, department heads, etc., are in our primary care organisations, and their input is very helpful at that kind of level. But, on the other side of the coin, we did actually try to institute social workers being attached to primary care, and, interestingly, they did not get any social workers applying, or not enough, because they did not feel it was a good use of their time. And so there certainly is a change in the way that all sides need to look at it; the primary care team is certainly developing, and I think the vast majority of people are now beginning to accept that social work input is actually vital to that kind of thing. And I think part of that, from a GP, is self-interest, because more and more people coming through the door do actually have social, housing, employment, benefit concerns, and they are coming into the general practice either because it has health side-effects or because we are the first person they think of when they come in. So the NHS is being accessed by lots of people, and if we could expand that team to bring in the counselling-type side, the social work-type side, I think most of us would be very much supportive of that kind of idea.

  383. I think one of the reasons why some of us are attracted to aspects of the Northern Ireland model is that certainly we have been to health centres over there where you go through one door and you could access all that sort of level of advice, you would have social workers, you would have nurses, you would have community midwives, CPNs, as well as GPs, under one roof, effectively; and it goes back a little bit to my experience of pre-`74, where we had something broadly similar in England?
  (Dr Dearden) One of the difficulties now in primary care is actually space, it is premises space, because what goes on in primary care has expanded so much; for example, I actually do not have a room in my surgery now, which is a three-storey, large, Victorian house—

  384. You see your patients in the car park then, do you, some days?
  (Dr Dearden) My patients see me in the car park, yes, but that is an entirely different story, that one. It is very much that I actually do not have a room now, a consulting room, that is not busy, or not being used, for less than an hour a day; every room is full. Only, literally, lunchtime, when my staff are off, doing other things, are my rooms not being used. So I would love to have the midwife based with me, and the social workers based with me, under one roof. I simply do not have a room that I could actually give them. So that is part of the problem. Now, in certain areas, I do not know what is going on in Northern Ireland, apart from when I talk to GPs, and I think I can report to you that they are very unhappy with what is happening, generally speaking, in the area, and I do not think they see it as they are in the best place to be.

  385. I am not suggesting it is a panacea, but it is a different approach?
  (Dr Dearden) Without doubt, it is a different approach, and I think we would agree that the split that has occurred has gone way, way, way too far; and, to be fair, over the last few years, it has been starting to coalesce again. Whether an organisational change will achieve that, or whether we need to be looking at incentives to help people work together; a simple example, if you actually had health services and social services coming together, with a single budget, to commission a certain service, and that was then pump-primed with additional money, that would help. One of the problems with having a single budget is, if both sides have an overdraft what you end up with is a single overdraft, and that is a very poor reason for getting together and working. So if that attracted other things then that would be an incentive to get them to work together, and people would start to see the benefit of it.

  386. So, if it is not structural, what kind of levers do we need, what incentives do we need?
  (Mr Dolan) I would return to the point about cultural behaviour and organisational practices, which sometimes, inadvertently, run counter to best practice and sometimes hinder the patients through the process. I do a reasonable amount of work in the north of Ireland, and one of the reasons why GPs are unhappy among it is that they have had a health services review and they are still not making any decisions about their health service configuration; it is an unsettling time there, and clearly that does not lead to good staff morale or working relationships. Speaking about relationships, both relationship and partnership keep getting used as terms, and I am struck that a relationship is when you know about the other people, you know about their problems, and in a relationship you share the successes, but a partnership is when you share the risks. And in Coventry, for example, where the social services had a many million pounds overspend, so did the trust, the trust gave the social service department £1 million, effectively to fund nursing and residential home beds over the winter period. Now, in broad health terms, if you could buy 200 beds with £1 million in social services, you might only get 50 beds in that time in the hospital, for that length of time, for that sort of money; they had a vested self-interest in working in partnership with the social services. I think care trusts are a very good thing, because one of the things is about you have got one budget, you have got one organisational structure, you empower individuals to make decisions; and, in relation to social workers, for example, in Hope Hospital A&E department, they have got Age Concern, who come in, working quite regularly in that department. And a lot of the patients' needs will be broadly called social work needs, when, in fact, what they are is how they find out about Citizen's Advice Bureaux, how do they get unemployment benefit, how do they get social service access; and that is about information. And I would not say, for a moment, that is what social workers do only, but a lot of that need is about information; and care trusts, if they are integrated, are ways of working more effectively as a service and more efficiently, as services. Ms Drown used to work at the RI, I used to work in the John Radcliffe, in Oxford, and was a very effective Finance Director,—

Mr Burns

  387. How much did you pay her?
  (Mr Dolan) Not enough. The bottom line is, she had an opposite in social services. Now would it not be much better, in terms of cost, which clearly Mr Burns quite rightly is worried about, if you only were paying one person for that sort of work, who could make decisions but also could delegate budgets; it makes sense to give money to ward sisters on the ward so they can determine what patients need. And I worked in mental health, patients could not go home because they did not have clothes. I work in A&E departments, they cannot get home because they have not got any clothes, we have had to cut them off, because they have had an injury, not because of masochism or sadism. And the fact is that you have not got the money to do it; so sometimes we have had whip-rounds for patients. Now would it not be nice to have a budget which percolated through a care trust to enable these relatively simple things to happen; which goes back to the heart of your issue, which is about delayed discharges. One final point I would make is, looking, if you like, beyond social services and health services, Surrey Ambulance Service have got an Intranet service with a real-time link to all of the nursing and residential homes and A&E departments in the whole county, so they can tell, in real time, what beds are available, what A&E departments are under pressure, what departments actually could go onto divert, so it will take some of the pressure off them. And using IT in a very effective way is a very good use of resources, but also what it is doing is empowering the Ambulance Service to direct patients appropriately to an area where they can get their care met expeditiously, as well as appropriately. So may I suggest the Committee looks beyond simply just the NHS and the social care, but looks at Ambulance Services and looks at a whole integrated package, because that seems, to me, a way that works, as long as it does not become a multi-headed, monstrous bureaucracy, which is sadly what pre-`74 led to.

  Chairman: I am conscious we have had you here before us for two hours, but we have a number of questions left, and having asked a long and rambling question myself I am going to appeal to my colleagues to be crisp and sharp in their subsequent questions.

Mr Burns

  388. Chairman, before we ask them, may I just correct something. I was not actually being rude enough to ask how much you got paid in a professional capacity, I meant how much were you paid to make those nice comments about Ms Drown?
  (Mr Dolan) Still not enough, Mr Burns.

Dr Taylor

  389. A very quick one, to Professor Swift, on integration. Is not the geriatrician in the ideal position to push forward the integration; geriatrics, since its invention, has been largely a hospital-based service, and is not now the time geriatricians should be moving out into the community, really to weld together primary care and the hospital service? I know of one community geriatrician, in the middle of Wales, who is that because she does not have a hospital at all.
  (Professor Swift) Geriatric medicine, as a specialty, started way out there in glorious isolation in the back of beyond, where it was not accessible to anybody.

  390. I think I was around before it started.
  (Professor Swift) Then it moved into various precursors of intermediate care, in order to get in on the act a bit earlier, and began in that process to become a community-orientated service, which, nevertheless, had to be an advocate for patients in the hospital system. And, as a result of, apart from anything else, the resource efficiency of that approach, but also the element of unmet need, this specialty moved very much into mainstream hospital practice, where it now sits; and, in fact, if you want to look for a general physician, nationally, you are more likely to find one who is practising in our specialty than any other. But that does not mean that the remit of the field no longer continues to cover all aspects of need, across the community divide, up to and including continuing care, and forward actually into preventative medicine, a lot of us are doing joint work with our colleagues in primary care on the best ways to screen and prevent disability in later life. So the answer is that, if we are doing our job properly, we have never been out of the community anyway, but we have been in the hospital, to have an important clinical role but also an important empowerment and advocacy role on behalf of a group of patients; and I think both of those things need to continue and be kept in balance. There are a number of new posts of community geriatrician, and some of them are coming along. There are no where near enough consultant posts generally but some new posts with a community emphasis have been established on the back of things like intermediate care, as an initiative. Those individuals reflect that spectrum of commitment. And there is a balance; some of them will have the majority of their time based in the community but will still have access into the acute hospital sector; and we believe, in the BGS, that that is crucial, that that `across the divide' principle is maintained. But we do think we have lost our community remit; to some extent, we have lost it through the sorts of mechanisms that have affected professional practice, across the community hospital divide, as a result of structural change, and geriatricians, to some extent, feel disenfranchised by that. So we are looking to retrieve it, but not at the expense of the vital role that we believe we have to play in the hospital, where so much of it has to be driven, because that is where there is a big focus of need; and it worries me, when we talk about getting it right in the community, but not actually getting it right in the acute hospital.

Dr Naysmith

  391. I am at the stage of picking up one or two things again that were in your evidence, Mr Webster; in fact, there are one or two things I think we already touched, just before I went out, I had to go out for a few minutes, so I hope you have not been asked one of them already. Basically, in your evidence, you talked about resolving the problem of delayed discharges requires a new approach, which puts the older person at the centre; now could you tease that out just a little bit and just say exactly what you think that would demand of the partnership between ages, changes in attitude, that sort of thing? How is it likely to be brought about, how can this transformation happen?
  (Mr Webster) If I can pick up on the points that were just made, I think the average older person listening to this conversation would be staggered at the suggestion that, in order to buy them some clothes, we had to restructure the NHS. But I think that is symptomatic of a general issue, that we translate people's simple needs and simple requests into things that are immensely complicated for us to discuss, and then forget to deliver what the person wanted, in many instances. So I think we are talking about quite a profound change in professional attitudes, where the primary responsibility of all the people is the delivery of the person's specific individual requirements; and I think that maps to a much wider change in culture, about being responsive to the individuals who use the service, rather than the people who run it. And I think there are really positive examples of that happening, right across health and social care, where people are much more empowered to speak up and to get things differently and to choose. And I think one of the things this Committee could do would be to refer continually to the evidence that you have had from people who use the service, as a benchmark.

  392. Let me just put it to you, you yourself said things are a lot more complicated than they used to be; the people who are dealing with older people, with all respect to Professor Swift, who specialises particularly in geriatrics, I understand, a lot of the professionals that are coming across have other responsibilities as well, they are dealing with not just older people, social workers, although they tend to specialise a bit, they are not supposed to specialise as much as they used to, and that kind of thing. How do you get all these people to collaborate, when it is not necessarily the only thing that professionally they are supposed to do, is to look after older people?
  (Mr Webster) I think it relates quite closely to the preventive discussion we were having before. The first question that any of them need to ask is do they actually need to collaborate, or could they resolve this themselves; because in many cases, the reason for collaboration is to share a risk, rather than to effect an outcome.

  393. When we had that discussion earlier on, the Chairman was muttering, "The one thing they don't want to share is their budgets," and I think, in a sense, that is true; so how do you get—
  (Mr Webster) Most of the front-line professional staff do not have a budget to share, or not share, in this system; most of them operate within a system that requires their line management to share budgets. So I think one of the things that clearly could change would be that, I think the example from Coventry is a positive one, an example where you know, as a front-line worker, that flexibility will be displayed by your organisation, in its dealings with others, in the way that the budgets are managed. But that requires the sorts of incentives that I was describing earlier, where, as a manager in one of those organisations, you are encouraged and rewarded for taking that risk with your budget, rather than that being presented as something which is unacceptable and likely to lead the organisation into some problem that it might otherwise have avoided. So I think there are some messages that need to come from the top; but I think we are also pointing to some real changes in professional attitude and professional boundary management.

  394. I think one of the other things in your submission was, you talk about the active management of long-term conditions; now what does that mean?
  (Mr Webster) There is a lot of literature now about disease management, and the proper pathways that people should follow through the healthcare system that is familiar to lots of people who work in healthcare. Good examples of that would be people with respiratory illnesses being checked much more frequently in the winter, when they are quite likely to end up in hospital; so, rather than waiting for them to arrive in A&E, someone is actually doing the checking before they arrive. There are many diseases now, the chronic diseases like diabetes, which we have studied in depth, for example, or risks, like the risk that people will fall over and fracture their hips, many of those things can be actively monitored before the symptoms arrive in the system, and most of our work would point to real benefits for those people, in not suffering, and real savings in the system by not having to treat them, from much more active attempts to make sure that people are safe.

  395. What do you think of that, Professor Swift?
  (Professor Swift) We did a piece of research at King's, which was published in The Lancet at the beginning of 1999, showing that, if you looked consecutively at older people who came to A&E who fell and you randomised them into two groups, one was given what Brian will remember as the standard practice of referral back to GP and fracture clinic, "Your patient attended; sustained the following injury," etc. The intervention group was seen afterwards, on an index occasion, by a physician who did what I would call a decent medical check, or the nearest thing to a comprehensive assessment, of the individual's intrinsic risks, and they were seen by an OT, who, as a model of interdisciplinary practice, looked at the home, did a safety check. And the results of the trial showed that in the intervention group you reduced the total number of falls in excess of 60 per cent, and the total number of people who fell by about 50 per cent; that has massive implications for bed occupancy, for fractured femur, and is one of the reasons why the NSF, I think, quite rightly, has a section on falls as part of it. And falls is actually a wonderful model of the totality of care that Andrew talks about, because it follows an individual through from primary prevention, through the risk criteria and right through, where necessary, to rehabilitation after fracture, and indeed through to continuing care.


  396. Can I just butt in on that, because it struck me, I am trying to remember, somewhere, whether it was on a visit we did to the States, we came across a scheme where they had actually taken proactive sort of attempts to prevent falls.
  (Professor Swift) This is Mary Tinetti's work.

  397. Is it; nailing carpets down, dealing with floors, it was very interesting?
  (Professor Swift) It was very similar; it was multi-dimensional, it involved health checks for the individual's intrinsic risk factors, and also a look at the house. It was actually fairly expensive. And the beauty of our sample was that there was an opportunistic look at a group of people, actually, largely, very healthy, they were mostly fit, independent people, at an early stage, who happen to have fallen, and it was a way of picking up people at early risk and preventing further problems.

Dr Naysmith

  398. I know, in a sense, we have been round this already this afternoon, in a couple of different ways, but how do we get it to happen, does it need more resources, or what does it need, what does it need to get this sort of thing to happen much more, because I am sure we would all agree, would we not, Dr Dearden, that that is the way we should go?
  (Dr Dearden) Picking up the point, there is evidence that you can say the same thing about falls, but also heart failure, those issues, and COPD, the sort of respiratory illnesses; and there is evidence that, where you actually set those schemes, if you like, it is a halfway step between the primary care type and the acute hospital type, in the middle there is a special list, or special input, into the kind of routine management, monitoring and treatment, which is more than crisis to crisis to crisis.

  399. We are all agreed that it is a good thing, but how do we get it to happen?
  (Dr Dearden) In Cardiff, they have actually made an application for this, and the application involves some equipment, like (Echos, ECOs?) and things like this, which will be community-based, also community facilities to see those people, because the hospitals do not have the room; also there will be one or two specialist nurses who will be trained up, as we have asthma nurses and diabetic, parkinson nurses, who will have the role of the monitoring, they actually do that, but with consultant and senior registrar input. So, to some degree, it is about a place to do it, it is also with the equipment you need, because, of course, it is a little different from primary care, where you might have a stethoscope and a lung function, it is actually much more about the sort of equipment you need, but also then you need someone with enough specialist knowledge to actually be able to do that on a non-crisis, routinely monitoring kind of thing. So this does come back to some resources, some new resources and some new personnel; but some of it can be diverted from the hospital. If not so many people are going into hospital then obviously you will free up, you have got to get it there in the first place to reduce the admissions to free up the people; so, again, it is a bit of pump-priming and getting it there in the first place.

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