Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 520 - 539)



  520. Do you accept the estimates that the NHS Confederation have put forward to us of 2.2 million bed days each year?
  (Mr Ransford) We certainly do not have evidence to refute this. I am quite prepared to accept that as a basis for discussion.

  521. One of the witnesses—I think it may have been in your evidence, but I may be wrong—suggested that there have been delayed discharges over many years. Why has it become fashionable to discuss delayed discharges in recent times?
  (Mr Ransford) There are various reasons for that. Certainly I can attest from my own practice over 30 years that this is not a new issue. Two matters dominate. One is that a whole series of other accommodation arrangements for people have simply disappeared, certainly for older people over the years: convalescence, different sorts of non-acute arrangements have disappeared, particularly from the health sector over the years. Second, there is no doubt whatsoever that partly as a result of policy, partly as a result of resources, services became more efficient. The acute phase has become more efficient, there has been more attention to performance, more attention to turnaround of scarce and expensive resources. That has understandably concentrated on people who are using resources which could be used for other purposes. There has been a penalisation of that process, which perhaps was not there in earlier years when the approach was more relaxed.

Sandra Gidley

  522. Mr Leadbetter, in your submission you are quite keen to suggest, understandably, that not all the blame should be laid at the door of social services and that there are many other factors over which social services have little control. Could it be that the fundamental reason or weakness is that the social care funding formulas do not cope with the system the way it is?
  (Mr Leadbetter) This also links to the point Mr Ransford was making. Funding for health has been significantly above the rate of inflation, also higher than the funding for social services, for a number of years. The recent budget went some way to remedying that. If you are getting increased activity in the acute sector, increased accident and emergency admissions. This increased acuity puts additional pressure on SSD. We know that 70 per cent of the people who are accident and emergency admissions are the ones who are in a situation of delayed discharge. The other factor we must take into account in looking at that—and I think it is a question of analysis rather than blame; we really have to move our terminology away from who is to blame to what the problem is and how we can solve it—is that prior to 1993—and it is a statement of the obvious, but it is sometimes a timely reminder—people who could not afford were funded by the social security system and that was demand led and it was increasing like this and the budgets were passed to social services and we directors described it as a poisoned chalice. It was a chalice mostly welcomed, but it made the system of assessment and rationing inherently wrong.

  523. My understanding is—and I am happy to be corrected if I am wrong—that currently it is a pot of money, no account is taken of an elderly population in some areas, social indicators, deprivation indicators, all of the other factors which could have an impact on how many people social services are having to fund. Would you like to see any change in the way that money is allocated to social services? I know that we would all like more money and you might get more money for some areas if it were done more fairly.
  (Mr Leadbetter) We clearly need a look at the system of allocation. Most people would recognise that the current system is something of busted flush. There is a problem with any system of allocation. Locally we have looked at various systems in the course of resource allocation, index, analysing the numbers over 75, analysing the incidence of sickness. However you look at it there is an argument from some quarter that somebody is disadvantaged. Any system has implicit weaknesses. I do think the current one needs a review as it does not give an accurate reflection. It is not as easy as the funding for education, for example, where you just look at pupil numbers. It is a lot more complex. I know I am stating the glaringly obvious, but there are no easy answers to how you allocate the money. It is hugely difficult.

  524. You must have some ideas. If you were given an audience with the Minister tomorrow, what would you suggest be looked at?
  (Mr Leadbetter) Over-75s, morbidity, softer issues like performance of GPs, level of referrals, incidence of consultant referrals. Let me take a step back and explain this with a story. In Essex one of the trusts came to see me asking for more money. They said they needed more money because they had a lot of people waiting. I told them that our figures showed they were receiving 26 per cent of the budget when on any demographics they should only be receiving 19 per cent. I asked them to look at consultant behaviour. They reluctantly agreed. They looked at consultant behaviour. They found that their consultants, as opposed to those in other trusts, were telling Mrs Smith when she went in that she should not worry, she could stay as long as she wanted and she could have a care package. This was a few years ago but measuring the softer issues like the behaviour of consultants, the behaviour of GPs, admission practices and the conduct and practice of social workers are all matters which need to be taken into account as well as having a mathematical formula, plus taking into account the role of voluntary organisations. In the richer parts of Essex the voluntary support is stronger than in some of the poorer parts. I am avoiding trying to give a simple answer and a simple formula to the Minister.

  525. There is no simple answer.
  (Mr Leadbetter) No.

Julia Drown

  526. You say it would be helpful to move away from the blame culture. Do you think there is an issue at all in social service departments of playing the victim and not being as proactive as possible? Could that be a reason why some areas do very much better than others in terms of performance, for example, the issue over the loss of capacity, which is a very real issue, nursing care, residential care? Undoubtedly social services have a responsibility in trying to manage all those but it seems to be, from your evidence and what we hear from Directors of Social Services, there is sometimes an issue of trying to throw the problem elsewhere. Do you want to comment on that?
  (Mr Leadbetter) I do not think by and large social service departments act the victim. Sometimes we are placed there and have to defend it robustly. We do it very well. I have a stream of figures I can go into if it is appropriate where I did a ring round of the departments and all of them achieved their targets for capacity. When the £100 and £200 million came, all of them achieved their targets for reducing capacity. All gave me a list of very creative initiatives, some different, some extremely creative, some averagely creative. I was hugely impressed by what had been achieved: funding of outreach teams; funding of practice nurses; funding of co-ordinators; transferring money to health; so many initiatives we could submit in detail indicating a very proactive response from social service departments; a very high level of generality, but approximately 50 per cent of the money spent on increasing fees, 50 per cent on creative schemes. That does not read to me like social services departments playing victim. It does read that given the cash there is a lot of creativity and willingness and very, very strong partnerships emerging from the care groups.
  (Dr Morgan) There is a general issue which is the nature of the incentive system. This is not about social services, it is about health and social care. One of the frustrations for managers in organisations who tackle these agendas in partnership and very robustly is that at a point we get later in the year where there are potential problems, the problems and resources tend to go to the people with the biggest problems. The better you manage it, the less additional resource you get to lever even further change. That can be very dispiriting, perhaps not to senior managers, who tend to work in those organisations in very strong partnership between health and social care, but often people on the ground. They see adjacent communities having additional resources in and they are left to manage with the resources they had at the beginning of the year.

  527. You can understand why the Government does that. It wants to focus resources where they are needed most.
  (Dr Morgan) Absolutely.

  528. So what is your alternative solution?
  (Dr Morgan) It is trying to find the balance between the two. To give a little bit of extra money to the communities who are doing well as a reward would actually drive the innovation and the leading edge, because then you could really try out some of the things where you need to have parallel funding in place to lever out the change. One of the problems for health and social care is that you are trying to deal with it in the here and now, put in alternative solutions, nobody trusts the alternative solutions until they have been up and running, at which point you can withdraw the old. It is how you loop the thing round and use the communities who are really demonstrating they can manage it effectively to be the pilots and the leaders so they have some incentive rather than seeing all the resources and what they regard as an easier option potentially in the adjacent communities. It is how we get that extra bit in; not replace the first but add in something which rewards good performance.
  (Mr Leadbetter) There is a question of sustainable long-term funding. We welcome the £100 million and the £200 million but that creates a tail, depending on what we euphemistically call turnover but usually means deaths. The LGA and we estimate that could be around £160 million; it is a significant amount of money. Each of the short-term initiatives, whilst welcome in a limited way, add to the longer-term problems and reduce the possibility for creativity because you know you have a financial headache waiting in the wings.

  529. When you go back to Department officials on that and ask whether it is going to be a one-off or whether you can be assured that it will at least be taken up in the next year's spending round, what is the response you get?
  (Mr Leadbetter) Guardedly optimistic and wait for the comprehensive spending review.

  530. Does a responsible authority not take that as meaning that they can plan on this?
  (Mr Leadbetter) A responsible authority takes a risk because people are waiting in hospital and we all agree that is not advisable. So we take a risk and we depend on the £200+ million which local authorities spend extra on services for older people above their allocation. That is what happens.

  531. Are you saying it is not advisable?
  (Mr Leadbetter) No, my advice as director is usually to risk it

Dr Naysmith

  532. I want to explore something Mr Leadbetter said about what happened a few years ago when the system was better because it was demand led and less of a problem. Could you say a little bit more about that and the transition to the situation we are in now, how that came about and how it was managed?
  (Mr Leadbetter) I am sorry I did not mean to infer that it was better. It was demand led. I happen to think it was worse, but it did mean that there was a ready supply of money in the social security budget. If people were waiting and could not afford it, they could go into a home. There was a famous study from York university which indicated there could be up to 40 per cent of people wrongly placed in residential and nursing care who could be placed in the home. It was not a better system, but the advantage was that it was demand led.

  533. I just wanted to clarify that. You do not think that was necessarily a better system.
  (Mr Leadbetter) No. That was partly in answer to the Chairman's question about why this is suddenly an issue. It has been growing as an issue since 1993 because the capping of the funding makes it so, because we ration.

John Austin

  534. The logical conclusion is that the way of easing the situation is not by replacing however many thousand care home places have disappeared, but looking much beyond that.
  (Mr Leadbetter) It needs to be addressed in a much wider context. There is what my health colleagues call demand management which is really looking at how we can better support people in the home and minimise admissions. One of your previous presentations talked about the possibility of tele-medicine with the possibility of quicker diagnosis. We know sometimes that people are admitted because of undiagnosed stomach conditions for example. Quicker diagnosis, more access to diagnosis, community outreach teams can all prevent people going in to that "front door" which means they can then become in patients. We also know the figures. It is that close to 40 per cent of infections can occur as a result of a hospital stay, so we are all agreed that keeping people out of hospital is better. The figures for residential care are constant, which suggests that there has been some success in keeping people in their homes as well.

Dr Taylor

  535. Can we pick up the question of choice that you brought up? We had conflicting comments on the importance of this. The Department of Health said it contributed about 8.1 per cent to overall delays. The Independent Health Care Association really did not rate it as a problem. In the paper from the Association of Directors of Social Services in the table in paragraph 3.4 it was something like 14 per cent of councils thought this was a pretty significant thing. What is your view of the choice directive? How are you implementing it? Is there any way of getting round it quickly by having interim arrangements so it does not hold things up?
  (Mr Leadbetter) Locally what we have agreed with most of the trusts is a letter to patients when they go in giving them the evidence that it is as well for them as soon as they are medically fully fit to be out of hospital. If their first choice of home is not available we will place them in a second home and then get them in the first home quickly. We find that giving that information to people helps them make a fairly informed choice that perhaps it is not as good for them to wait in hospital. We think our figures at round about 14 per cent are sufficiently robust because there is the situation of the old person in hospital who had expected to go home being told unequivocally that it would not be safe and being in trauma; maybe medically fit but does not want to face the consequences of not going home to a home she has lived in. Those situations will always be present and we need flexible and sensitive responses to people in those situations, not a simple question of counting numbers and counting bed days lost.

  536. Will most of your families and their relatives accept going to their second choice in the short term? Do many of them stick out for their choice?
  (Mr Leadbetter) One or two but very few if it is approached properly. There is a question of context. If you are a small urban authority, there may be ones, but if you are a big county people who live in a small village know they will have to travel a long way to find a home. There is a question of where you live, where you sit and what your expectations are.
  (Dr Morgan) The service would see is as patchy. There are places where choice is being effectively managed between health and social care. I must stress that this has to be seen as a joint issue. In other places it is still something which often nurses, often social workers, find very difficult to encourage people to accept a short-term placement. There are some very good reasons why clinical professions are not in favour of that. We know that for elderly people, multiple moves are not a positive health outcome for them and it leads to harm in itself. You often have people who have some very good reasons for not encouraging people to think about a short-term option. It is patchy, because there are some very good protocols across the country, and Essex would be one, where people are managing this in a fairly dynamic way and managing to satisfy both patients and their families. Families have a terribly important part to play in here because choice is often not about the individual. They are often more flexible than the families and we find that very often. The family want to do the best for their parents, their mother, their father, are often far more concerned about things being just right than the individual themselves. It is a very complex thing but you need both high level agreements about how to manage it, and you also need something to help clinicians make effective decisions, clinicians and social workers.

  537. Are you as a Confederation pushing that these sorts of protocols should be adopted all over the country?
  (Dr Morgan) We would not be pushing in that sort of way. What we would be pushing very hard for, the important bit, is to have proper local agreements of what is going to work in local areas. Rather than push a one-size-fits-all, it is much more about having the right type of relationships and a whole systems approach. The answer here is not just focusing on choice at the end, it is focusing on prevention, stopping people getting in, focusing on admission, how you put alternatives into admission. It is then focusing on appropriate planning once people are in hospital and only then do you get to the point of discharge. There is a whole lot of things which need to be done in a coherent joint way and the balance in any community is going to depend on a whole set of local factors. It is putting those local plans together which are relevant rather than saying there is a mantra which will solve something which is a complex problem.
  (Mr Ransford) It is very significant and it is bound to be patchy be definition. It will depend on relative capacity, depend on a whole series of things. The two points which it is absolutely crucial to emphasis are: you raised the question of getting round, dealing with it imaginatively yes, but usually in these sorts of circumstances people come up with ideas like holding centres as a way of moving people away from acute facilities, waiting for the place of their choice. As has already been explained, multiple moves and treating people with less dignity and respect than they deserve usually increases the problem. The real answer here is to ensure that there is capacity and build a system that can deal with multiple needs. I am a strong advocate of these matters being part of local government. That is not solely based on the organisation for which I work. Local government's wider community leadership role should ensure that there is capacity built in communities to deal with a whole range of needs to create a healthy society and to make sure that there is sufficient resource in the area from which to commission, so hopefully we can have our cake and eat it with the individuals and their families having sufficient choice and we having sufficient alternatives to make that choice meaningful. It really relates to an earlier question about whether we are victims. Whether we are or not does not matter, because we have to be proactive. It seems to be a mixture between creating capacity and certainly using the flexibility of resources, which is now possible under the 1999 Act. We see more of that coming forward. Where everyone works together to create the right solutions means the choices are in a better context.

  538. It has just been pointed out to me that we have not received any specific examples of choice management. Would it be possible, not necessarily now, for the LGA and NHS Confederation to supply some specific examples?
  (Mr Ransford) Yes, we can do that.

Andy Burnham

  539. Reading the Confederation's submission, you talk a lot about factors beyond the NHS's control and beyond the control of the Health Service. Is it fair for me to conclude therefore that you see the whole issue of delayed discharges principally as not one of the NHS's making?
  (Dr Morgan) No, that would be unfair. It is a whole system thing. There are issues around the NHS becoming more effective at working with local government, putting in effective preventive schemes, thereby avoiding old people being in a position of having an acute crisis. That cannot be done either by local government or health working independently. We have a lot of the information about who old people are.

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