Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 440 - 459)



  440. It struck me, when I was looking at the system in Bristol, that there were two things that were very important; one was flexibility, not necessarily filling in lots of forms, and obeying certain rules, and things, and to get jobs done quickly, you know, there are these operators who could be `phoned up and 24 hours later, or maybe even sooner sometimes, they would be round at somebody's house just installing a handrail, or something like that. So what are the lessons we can learn from that?
  (Ms Adams) The lesson that I have picked up from looking at these small handfuls of projects is, where there is a will there is a way. Now, Bristol, you have got social services and housing and health pooling money, and a willingness to just fast-track systems, and for occupational therapists to accept that they do not have to assess everybody, and to trust the people that are going out and doing the grab-rails and handrails, that they will come back to them if there is a bigger problem. In terms of the Leeds scheme, the lesson there, again, is finding a completely fresh way to pool budgets, and to give a lump sum, and capacity planning law is being used here. Last year, the Leeds project did 1,900 small adaptation and repair jobs, and it is very simple, the OT at the hospital literally writes down what they think they want and what the person says they want, it is faxed through, it is done within 24 hours, with their directly-employed operatives. And so what you have wiped away is estimating by two or three builders, you have wiped away lots of home visits and you are churning through masses, at very, very low cost; that scheme is saving the local hospital about half a million a year, even on a very conservative estimate, by getting people out of hospital 24 hours faster than otherwise would be the case.

  441. Is that what contributes to the eight months delay you were talking about in people getting what they asked for in the first place?
  (Ms Adams) Those are the small-scale ones.

  442. Is this a system of rationing, you know, the expenditure?
  (Ms Adams) No, I think it is using the money a bit more effectively, really.

  443. No, I mean do people do this, allow this sort of thing to happen, because a lot of people must know it is happening, just as a way of not expending the money as quickly as it would otherwise be expended?
  (Ms Adams) I think it is a problem, arguing over who is responsible, as well, like health saying, "That's not us, it's housing," or social services saying, "That's not us, it's housing." Giving you some good news stories. A bad news story, and this is how things are not joined up, one of the models in the book was the Hackney discharge scheme, and really working at the sharp edge, very extreme problems in Hackney, and I have got a good model, works very well, there had been money for small repairs and adaptations, literally in the last few weeks, Hackney Council said, "No more money in the pot." And I rang last night, just to get a really up-to-date picture, you have got somebody being discharged from hospital to a house with no heating or hot water, and so you have got housing just sort of completely pulling the plug there, and that is in a unitary authority.

Andy Burnham

  444. Like Doug, I am a big supporter of what you do. Can I just ask quickly, what percentage of the population, of the people at risk, we might say, are you currently reaching, and other organisations like Age Concern; are you scratching the surface?
  (Ms Adams) Yes.

  445. I would anticipate there are many more elderly people who never get close to the scheme, who could benefit, is that correct?
  (Ms Adams) It is scratching the surface. There are 230 home improvement agencies in the country, so there is not even one scheme in every local authority area, and I have found only seven specifically doing hospital discharge work; and, of those 230, the average is they have got four staff, even in quite a large area. Bristol is completely different, they have got 40, and that is an example where the local authority has really taken it on board and is seeing its potential; they did 30,000 jobs last year and it is worth £60 million.

  446. Can I just ask, in my experience, locally, it is not just practical improvements, handrails, making the place safe, there is also an issue about coping psychologically; if the lawn is cut, if the front is painted, and it looks smart, people feel that they are coping. Is that true as well?
  (Ms Adams) It is knowing you have got somebody to turn to. That came up in interviewing people for the book, over and again, it is actually saying, "Well, you've done this for me, but I also now feel better because I know I've got you to turn to if something else goes wrong," which it does, if you live in a house. And it is not just about repair and adaptation, it is also about leaving people better able to cope with things in their house, by doing perhaps income checks; and some are going further than others on straddling the care. The Warwick is a very interesting one and it is unique so far, in that they are now running a seven-day a week, 24-hour home care service, attached to the repair; so it is very holistic. Because they will get `phoned up by the hospital, and they will say, "Mrs X needs to go home, can you go round, can you provide carers going in twice a day, can you go round and do the adaptations with your worker," and they will turn those around within 24 hours. And then the case worker goes in and tries to rehabilitate the person as well, so to get them back on their own feet. Because I think one of the things David said that was interesting was that continual assessment, if somebody goes into residential care, and the issue is do they ever come out again. And I think that is quite different with children and older people, because of institutionalisation, and you see people go downhill really quite quickly.

  447. And that can happen in hospital, can it not?
  (Ms Adams) And that can happen in hospital too, if they keep them in too long, and I think that is where you have to look at the bricks and mortar and develop initiatives with a continuum, as opposed to thinking you can put them in institutional care for a certain amount of time. The exception to that, I suppose, is, Doug has had to go now, but we have talked very much about the small-scale things, there is a need for larger adaptations as well, and perhaps large repairs, and that does take a bit longer. And I have come across an initiative in Coventry, where the person is moving out of hospital, the health authority is paying the weekly rent on a residential care unit in a housing association property, it is level access, it has got an accessible bathroom, people go there for a few weeks while the major adaptation and repair is being done; and so, instead of paying £300 a day in hospital, they are paying something like £60 a week. And it is looking at innovative uses of the stock that we have got and sheltered housing and thinking about two stages to get people out of hospital on their way back to their own home.


  448. Dr Naysmith will return, we assume, he is having his photo taken with the Prime Minister; for what reason I am not sure. Mr Hassell?
  (Mr Hassell) If I may come back, there has been a suggestion about the debate being hijacked by residential care providers. What I think it is important to point out is that many of my members and many providers in the independent sector provide not only residential care but they are, of course, providers of home care, healthcare at home and other specialised services, services like acquired brain injury, etc. So we have absolutely no problem in having discussions about innovation and developing new services at all; the problem is, I think, actually getting people round the table to talk about the requirements and to talk strategically about the need for investment in diverse services. So I think you should take on board that the sector is more than willing to talk about the development of new services, but we have to have the right environment to undertake those particular discussions, and, I am afraid, in the case of many authorities, it is very difficult to get them round the table to talk about future needs. If I may, just finally and quickly, as a second point, I know Bill mentioned National Insurance a moment ago, we are very supportive of and very committed to working in partnership with the Government, particularly in helping the Government to achieve their plans under Delivering the NHS Plan, last week. We do have problem, of course, though with the tax on care, the 1 per cent on employers' National Insurance, because that will add about £75 million to the cost of a sector which, we have already discussed at length, is having huge financial problems, so I think that is an unfortunate additional cost.
  (Mr Rice) In order to help to explain the complex nature of the debate, could I position technology against the care and repair points, all of which I absolutely support. We have talked about falls and what a load on the overall health delivery system falls and broken hips impose. Most people do not break their hip on their first fall. One of the frustrations that I have is that the technology that is available within the industry is deployed too little and too late; typically, our average user has the technology for perhaps 30 months before they move into intensive care, and, typically, it is after they have fallen once, twice, or even broken their hip. Now the initial fall does not typically break the hip. The technology is quite capable of interpreting the increasingly restrictive mobility of the elderly, the frail, and actually triggering the deployment of the kinds of services that Care & Repair offer, in order to prevent a fall and prevent a broken hip. So when I say that 1,000 to 2,000 beds are occupied by hip fracture, I think we could actually reduce that number if we deployed technology which then triggered the right response, in order to kit the house to make it as near as possible fall proof; you will not stop people falling but could reduce the incidence of falls many times though the precise measurement of mobility. One of the things about technology is it has moved on a lot in the last five to ten years, on the back of mobile telephony and wireless technology, and we have very sophisticated technology available now in this country that can help; typically, it is not used in that way, but it is part of the solution.

Julia Drown

  449. Can I start by going back to Independent Healthcare Association, and the issue on capacity. You said in your evidence that the financial cost to the NHS, and that is the taxpayer, of what is essentially a chaotic and fragmented system, is profound, and you were just speaking there about the wish to get people around the table to discuss ways forward. In your evidence, the focus was very much on the need to raise the level that is funded for residential care places. Do you actually think there is a structural problem bigger than that, and is there a particular structural change that you would recommend, for example, national planning, rather than local planning, national planning of fees, or other issues?
  (Mr Hassell) I think it is difficult. I think you probably need both. I think you need the national steer, clearly, which is what the Government is doing with the NHS Plan and Delivering the NHS Plan, and I think that is to be welcomed. But, I think, likewise, of course, you must have that local planning, because you do not need me to tell you that the circumstances from the North East to the South West are totally different; so I think both are needed. I think the Government clearly put in place the national framework. I have certainly noticed over the recent years, and covering the entire spectrum of our members' services, from acute hospitals through to home care services, that there is a lot more openness and involvement with the Government, we find it much easier to talk to the Government than we ever have done with any previous Government. So I think it is to be welcomed; but I think we need that national planning, but, of course, the implementation has to be locally-based. And, certainly, I think that we welcome the new role for PCTs, because I think that again will help to focus the delivery of local services. And, from the point of view of the main thrust of your inquiry on delayed discharges, although, as we have suggested in our evidence, there may be what I am now calling best value savings, by using the independent sector, as opposed to beds being blocked, I say that because, of course, of the churning nature and use of facilities. Where I think there are some real economies to be made are actually, and it is a little like Tony's comments a moment ago, that in the prevention of admissions to hospital, in the first place, and whether that be through technology, Care & Repair, or indeed placements in homes, I think, if we can get in place, which I am hopeful the PCTs are more likely to do, the rapid use of alternative methods of providing for people's needs, it will help to reduce admissions, and therefore help in terms of the bed-blocking, the delayed discharges.

  450. There are some delays to discharge that occur because of the choice directive, because a particular individual wants to go to a particular home where there is not a place available, and it seems that a number of independent homes are not keen to take people temporarily, while they are waiting for a home of their own choice. Can you tell us a bit about why there is not the enthusiasm from independent homes to take residents on that temporary basis?
  (Mr Hassell) I would suggest that some homes actually do take people on a temporary basis. But I think, philosophically, some people feel that it is perhaps wrong for the person who is leaving the NHS, in that they are actually being moved, at a very difficult time in their lives, from one environment to a temporary environment, to their final home, that that is destructive on their lives. Equally, of course, for people who are resident and have made it their home, it is not a good idea having people constantly go through. But, certainly, I think the reasons are philosophical rather than anything else, because certainly I am not aware of there being any; in fact, quite the reverse. I would suggest that probably, financially, it is more beneficial; but if you are going to go down this route then I think one needs to develop proper transitional models. It could be argued that intermediate care is one of those transitional models, it is rehabilitation-specific, it is time-limited for six weeks, it is one way of viewing it, but it is a transitional model, until the person's assessed needs are provided elsewhere.

  451. It certainly is a frustration of some hospitals that they feel it would be in a person's best interests to move into a nursing home or residential home; is your group doing any work on this, to try to come up with the protocols that you are talking about?
  (Mr Hassell) I am not aware of it. We will certainly give it some thought, and I will certainly talk to my members about it. You may be interested to know that I think there is about just under 9 per cent of the people who are in beds in the NHS awaiting discharge, just under 9 per cent of them are there because of their own choice requirements; about 24 per cent of the beds that are blocked are, in fact, people who are awaiting nursing or residential care home places. So the choice issue is a relatively small one.

John Austin

  452. You said the 9 per cent are there because of their own choice?
  (Mr Hassell) Sorry; because they are using their rights under the choice directive to choose their own home.

Mr Burns

  453. This problem that you have raised are people who are having their discharge delayed because of choice, because there may not be availability. How do you think, or maybe you do not think, that penalising either the NHS or social services is going to help the situation; is this introduction of penalties going to improve the situation with regard to delayed discharge, or is the right of choice and the problem of capacity in certain areas just going to be an unfair penalty on particularly the NHS?
  (Mr Hassell) I do not know whether it is going to be an unfair penalty on the NHS, quite the reverse; it strikes me that it is more likely to be a penalty on—

  454. Sorry, I mean social services?
  (Mr Hassell) Yes, on the social services. I think, certainly from the point of view of our members, and I think it is true from the point of view of the Department of Health and Ministers, that substantial sums of money have been put into social services, but, of course, Ministers are not able to direct social services on how to spend that money. There has been a reluctance to ring-fence money, and I think the issue of cross-charging that was announced last week, where a local authority does not place somebody in a care home, is actually, I think, quite an imaginative way of trying to encourage, some people take the view it is negative, but, I have to say, nothing else seems to have worked.

  455. But if someone in hospital is exercising their right of choice, you cannot blame social services if they are not being placed if there is not a bed that fits their choice available; so it just seems rather, and to my mind, an unfair and also unworkable penalisation of social services?
  (Mr Hassell) We have to wait and see what the details are, of course; it may be that if somebody is remaining in hospital of their own choice, because they are exerting their rights under the choice directive, that may be excluded from the rules. I have no idea at this stage, I am not sure the rules have been written.
  (Mr McClimont) I think we do need to wait for some detail here. But, looking at the new announcement, it struck me that it was unbalanced, inasmuch as on the NHS side they are supposedly going to be given incentives for additional activity and money to follow volume, balanced by a stick, and if that is the carrot, balanced by the stick of penalties for emergency re-admissions, and that seems to me like a balanced approach. From the social services side, there is the penalty stick for blocking beds and there is no balancing carrot of any relationship between the money that is given over to social services and any form of volume counting at all; there is no actual measurement of the volume of care or client outcomes from the money that is used, in any of the systems. So it is very difficult to have that balancing carrot, but it would be positive if there were one.


  456. Mr Lewis, you presided over the ADSS at one point, so you are a man of great vision; what are your views on this?
  (Mr Lewis) Whilst supporting the choice question, and I think it is an important principle that we stick with, nevertheless, I think it can divert us from potential other pitfalls. I think that, if a local authority, and they have finite budgets, if, in fact, the places are there but not available to that individual because of the pricing policy of the local authority, the contracting price that they will pay, then I think that the stick probably is a useful instrument, because, in fact, they are denying people the opportunity to move to more appropriate accommodation because of their contracting strategy. On the other hand, if they have got a finite budget, then if you have got two people requiring nursing home care, one is in hospital, one is in the community, it may well be that the person in the community's needs are far greater, but the local authority is going to offer the place to the person in the hospital first because otherwise they enter into a penalty. And I fear, therefore, for those people who are not coping at home and who could more appropriately be cared for in a residential setting being denied that.

Andy Burnham

  457. Can I just quickly return a question to Mr Hassell, on this issue of delayed discharges and the role of independent homes generally, in managing those. Is it really clear that some homes which have places available will not take local authority-funded residents, because of the fees they get; does that happen?
  (Mr Hassell) Yes.

  458. Could I then take you on. I understand the issue of fees, but we did have the example, a few months ago, of independent homes withholding the fees for nursing care that were given to them by the Government, the element of free nursing care, from self-payers, I might add, as a way of getting back at the issue of fees for local authority-funded residents. Do you support that action by those homes, and would you uphold their right to do that, and do you not think that that may have damaged confidence amongst the wider community, in the actions of those homes that did that?
  (Mr Hassell) It is a complex issue. I think, firstly, it was unfortunate that the suggestions, incorrect suggestions, that homes had been withholding money from residents, because—


  459. Incorrect?
  (Mr Hassell) Incorrect.

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