Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 540 - 559)



  540. Getting behind why we are where we are, in terms of a pecking order of problems, you talk about local authority finance. Would you say that is the single biggest cause?
  (Dr Morgan) No, they are all inter-linked. The biggest issue is about the alternatives to admission. It is about the point at which somebody makes a decision to put somebody in a hospital and it is how we manage that better. Some of that is within the control of the NHS, it is within the control of GPs, or hospitals' A&E or ambulances. There is an issue about how we manage those more effectively, not to put places where the tendency would be to admit.

  541. Do you mean that people are being admitted to the system who really should not be?
  (Dr Morgan) Absolutely. Every audit we carry out suggest there are people who, if the alternatives were available, could be managed without the type of care that goes on in an acute hospital. It is developing the alternatives which would allow you to have a range of decisions.

  542. How many people do you believe are coming into the system who never should? What kind of numbers? Is it possible to put a figure on that?
  (Dr Morgan) General practice would probably have some figures. I have seen some audits.
  (Dr James) There was a paper in the BMJ in about 1998 which looked at a few across the country. They were suggesting that of emergency admissions about 20 per cent were avoidable.

  543. Is that a consultant referring into A&E?
  (Dr James) No, it is referrals into hospital, admissions into hospital. It is very difficult to draw any big conclusions from this but the same study showed that about 50 per cent of bed stays were potentially avoidable.

  544. This is suggesting that the problem of delayed discharges is not principally one of resources or of organisation, it is one of poor decisions on the ground. Is that what you are saying?
  (Dr James) It is probably a symptom of lack of ability to care for a patient in an holistic way. We have a referral process and only a few destinations for referrals such that if someone has a problem, typically an elderly person, that is then medicalised, even if it is a social problem, which means it is a medical admission and they go on from there and get disadvantaged from that point.

  545. Has there been any success in bearing down on that figure? If you are saying this is the single biggest problem—it is the first I have really heard of it—surely you would expect that a lot of attention would have gone into bringing down those inappropriate referrals. Has there been any success?
  (Dr James) I know of very little success. There are some successes in admission avoidance, there are some good rapid response teams down in the community particularly with the elderly, but there are still many services and many health economies which do not have the range of alternatives such that people are admitted inappropriately.


  546. You have used the term "medicalised" for problems, which is a very interesting term. How much do you feel that has occurred as a consequence of the difference in investment in the Health Service as compared with local authorities' social services provision?
  (Dr James) I am not sure. It is a matter of the difference in investments. It is still a matter of the way we work independently of each other. I am talking about health service and social services. If a health worker, say a GP, at one o'clock in the morning is called to a patient who has fallen, then their training and response is a medical one. We do not yet have sufficient joining up of our services to say that it is actually a social problem and we can refer it straight to the social services who can arrange district nurses to care or look after or put this person back to bed. In the end it turns out that they get admitted.

  547. Do you think that the concept of care trusts might take us some way in that direction? As some of you know, I have long argued for full integration between NHS and social services. That position may not be supported all round this table but do you think care trusts are an option? What are your views on whether that might address the "medicalisation" concept that you have floated?
  (Dr James) Theoretically care trusts give you the potential to address and sort this problem out. If there is sufficient incentive to do this and look at that particularly, then there is a good chance. Hearing evidence from Northern Ireland, where they have a single stream of funding for social services and health, this issue still is not particularly well addressed.

  548. As I understand it, they have a single organisation but separate streams of funding. I am advised they still have separate budgets.
  (Mr Ransford) You and I have discussed this before. There are two distinct concepts here. One is care trusts and the other is integration between health and social care. The second is absolutely essential and the first is one means of delivering the second. It is absolutely essential that we integrate our effort to create what has been called here a whole systems approach and we work towards creating a healthy society and that is much wider than health and social care. It brings in housing, it brings in education, it brings in transport, it brings in a healthier environment, a whole series of different things, which we must align and integrate to ensure that the citizen in our language gets the right deal. There is a whole series of ways of doing that. It seems to me that the flexibilities allowed for bringing local government and health budgets together used imaginatively can achieve exactly what we are looking for. If in a local arrangement, a care trust is seen as the best way of delivering that, that seems to me fine, but there are other alternatives because the creation of the care trust, which is part of the NHS, takes it into one organisation and not the other and loses perhaps some of the benefits of partnership. There are all the alignment issues which have to be taken into account as you reorganise. You can achieve that integration in many ways and we are seeing them coming through now.
  (Mr Leadbetter) To give an idea of what is available, Essex encompasses within its boundaries 11 primary care organisations. We have chosen in partnership with four of those primary care organisations to have a single manager, matrix, accountability to manage health and social care for all elderly people's services in those four primary care organisations. We have also chosen, though it is only one eleventh of the solution, to go for a care trust for older people, also including the district council so we can encompass sheltered housing, but that is just one solution of very many and in a proportionate sense it is just one eleventh. We can explore these options because Essex is a big county. The thrust is towards integration, partnership, shared workforce planning, shared budgets, partnership trusts—we have two in mental health—but not a one-size-fits-all solution.

  549. You do not feel that the care trust concept clouds the debate and restricts you on developing various options? You still feel that there are options available to explore locally and you have the freedom to do that presumably.
  (Mr Leadbetter) Absolutely.

Andy Burnham

  550. On inappropriately referred patients, is it a logical step to say that the majority of people who are delayed discharges are the same people who are inappropriately referred? Am I right to make that link, that the system does not know how to cope with people who have fallen between the cracks and there is no place for them? Is that right?
  (Dr Morgan) There will be an overlap because for the patient who falls over late at night and has no-one to lift them up, the rational decision, if you are the clinician who cannot get out of hours cover because of the way the resources are currently focused, is to admit. Those are going to be the same people who do not have support networks in the community at the point you reach the end of the process. These are linked. They are not identical groups but there is a very strong overlap. The way this links back into the issue about a whole systems approach and the use of resources is that the more we use the resources at the other end, about delayed discharges, getting people out of hospital, the less we are able to use the resources to put in schemes which prevent people getting into hospital at the beginning. The problem with things like delayed discharge on a clinical basis is that we know the longer we keep somebody in hospital, the less socially able they are to function at discharge, they are institutionalised.

  551. You talk of the lack of capacity in the community, lack of capacity in the independent sector. Is the NHS in partnership with local government increasingly looking at developing its own step-down, intermediate care or even residential care capacity so that you are more masters of your own destiny, so that you can move people through the system? Is that something which is coming?
  (Dr Morgan) Yes, there is a lot of debate about intermediate care and what that really means. People are experimenting with a range of different models, some of which are at the front end, stopping people getting into hospital and some of which are about getting people out at an earlier stage in recovery to allow them to recover in places without the high-tech sorts of things you get in an acute hospital which is not the place if you are recovering. It is fine when you are ill: it is not when you are not ill. All of those have to be done jointly. Some of the most innovative schemes are not actually about health and social care, they are about being able to put aids to daily living into a house very rapidly, they are about the range of housing options which are available to people, they are about a range of support systems which might come from the voluntary sector, about how you help people maintain their independence. They are quite complex because you need a mixture of all those things together.

  552. You would be relaxed about health resources being spent on things like that.
  (Dr Morgan) It is perfectly appropriate and that is what primary care organisations are already looking at because we know that the big place we spend money is the acute sector and if we want to develop things which actually prevent and manage things, then getting money out of being spent in the acute sector is the best place for patients and for the service. You will not find the NHS has a problem with that. All we have a problem with is how you link all these complex things together at a local level when you never have the money to double run. At the heart of this is the issue about how you get professional confidence. At the end of the day, once you have got the facilities you have to have professionals who make decisions and feel safe in making a decision about an alternative in a world which is increasingly litigious and things like that. You have to have the services there, demonstrate they work, teach, learn, gain professional confidence before you get the big wins. None of the systems has enough of the spare capacity to allow us to do that in a systematic way. What you have is 1,000 flowers blooming out there and virtually every community can take you to half a dozen innovative schemes, but they are not properly evaluated, they are not linked in yet to a whole-system approach because of the difficulties in pulling all the different bits of resources together in a systematic way. It is a complex problem.

Julia Drown

  553. It was depressing to read in the submission from the NHS Alliance about the ongoing problems of definition of delayed discharge. We are all aware that the Department of Health tried to get over this by laying down a definition which was supposed to be applicable from April. From your evidence that is clearly not being used, so you could tell us a bit more about that perhaps and what you see as an alternative definition. I have to say I have a concern about trying to pursue other definitions because you just keep on talking about problems and definitions rather than getting on and delivering for people. In particular you say one of the issues was people defining what a multi-disciplinary team really is. Is that not just people arguing about it for the sake of it and not getting on delivering the services that everybody would agree people need?
  (Dr James) It is something which can be argued about and therefore can cause delay if people wish to argue about it.

  554. So what is the solution? Surely it is not about creating an alternative definition, it is about just getting on and delivering.
  (Dr James) My issue with definitions is on two levels. One is the technical definition itself in that the definition is well set out in the guidance about situation reports, but there are local interpretations of that and local differences from that. The example I gave was of a health authority, which, even though it reports on a seven-calendar-day wait for social services assessment, actually allows seven working days to be more reasonable. That is then compared with another neighbouring local authority which does not do that. There is disagreement about the readiness to discharge, disagreement about the health and social needs on discharge and there is disagreement about what constitutes the multi-disciplinary team which has to say the patient no longer requires the acute bed.

  The Committee suspended from 4.56 pm to 5.08 pm for a division in the House

  555. In responding on these issues on definitions is the definition you are referring to the same as the Department of Health one, which I know does not seem to refer to seven days and you are referring to seven days in your definition?
  (Dr James) The definition I have been mentioning is the one where targets are set, where numbers are counted and reports are made to health authorities and they are collated nationally as far as I know.

  556. Surely it has to be on the Department of Health definition?
  (Dr James) Yes, I should like to think it is.

  557. That does not mention seven days.
  (Dr James) Ho-hum.

  558. We are not going to resolve this today, are we, unless anybody else can help us?
  (Dr Morgan) I am not aware of the seven day figure. I would have to go back and check.

  559. But Dr James uses it in his definition.
  (Dr James) The other difficulty is how these figures are collated. My understanding is that these situation reports which have to be given to health authorities are collated at health authority level in terms of the acute trusts. So health authorities count which hospitals have delayed discharges and they do not count as a delayed discharge until they have been awaiting social services assessment for more than seven days. The national collation is at commissioner level. Nationally you see by primary care trust, by commissioner, the number of delayed discharges. It is all very confusing and cloudy.

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