Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 620 - 635)



  620. "Kind" does not mean "soft" does it in the way you have used it there?
  (Mr Leadbetter) No.

  621. Dr Morgan, you mentioned the role of community hospitals and that because of the pressure on them part of their effort is being negated because of having to admit people who actually require a placement in care homes. Can you tell us more about the evidence to support the fact that the role is being compromised at the moment and what is known about rehabilitation in community hospitals in practice?
  (Dr Morgan) I do not have any national research evidence, but I do have research evidence from the patch I worked in before. We are looking at exactly this. As you go round the country the number of admissions overall to community hospitals is falling. One of the reasons it is falling is that the range of skills available in community hospitals to be an admission deterrent before you go into the acute hospitals is no longer there. People are admitting patients they previously managed into the acute hospital so that leaves more of the community hospital beds there to deal with delayed discharges. What you are actually doing is moving people around the system, moving them to a level of care which may be higher than they actually need rather than using them appropriately. We currently do not collect statistics—for us this is the biggest gap in the statistical analysis—of the number of blocked beds within community hospitals. In communities which have large numbers of community hospitals, they may be more important in terms of how the system is working than the number of blocked beds in the acute sector. That is not true everywhere, because not every community has community hospitals. When we begin to look at what goes on in community hospitals, it is clear that not all the work which goes into community hospital is dealing with the issue of avoiding discharge or early discharge, some of it is about care which could be provided in other places or in people's homes. Once you put a bed somewhere, there is a tendency in the system for clinicians quite appropriately to put people into the bed because you have nursing care, you have a nursing home. In our research 40 per cent of the work that went on was with people who, if they were in a community without a community hospital, would be cared for in their home. If you put them in a community hospital, that is where your money is. The money in the health service in those communities is not going into community support, therefore social services cannot provide the intensive home packages because the money is tied up in the beds. How you then move and get communities to think differently about the use of their community hospitals is a very difficult issue. The other issue is about how you provide the type of work which ought to be going on there, which is either pre-admission, avoiding admission to an acute hospital, or enabling earlier discharge with intensive rehabilitation. The problem there is finding and getting the links in to the staff to make sure the staff there can provide the degree of rehabilitation which is needed. The evidence we have around that is very patchy, but certainly the stroke audit which goes on across the country demonstrates that the majority of community hospitals are not as effective at rehabilitating people with strokes as acute hospitals because they are not intensively geared to rehabilitation. All of this is circuitous because you need to break the loop somewhere to take the money out of beds, to put it into the people, to look after people in their own homes, to avoid the admissions and then to allow you to get staff in the hospitals and the beds we have more geared up to provide more intensive packages so that people can genuinely be rehabilitated into their homes. The problem is that once you have a bed it will be used, anywhere in the health system it will be full, because that is the way the system is geared to respond.

  622. It is not just a question of breaking the loop, is it? What you are saying is that there comes a point where you have to do both at the same time.
  (Dr Morgan) You have to double run.

  623. You cannot stop one and then start the other because people just will not wear it. The impact on public spending of doing that, both locally and nationally, is quite enormous.
  (Dr Morgan) It is, but often what we need to break the loop and the cycle is not that complicated and does not need that much money. However, because the money is tied up in expensive things, it is hard to re-allocate it to the cheap things and this is where the primary care organisations can see a range of very cheap alternatives they could put in, often around things you can put in to enable people to stay in their homes. The money is so tightly tied up in the acute sector, because we are running on the treadmill there with 95 per cent capacity, that they do not have the opportunity to do these creative level things which would begin to break the cycle. The issue for primary care organisations at the moment is how they build the space into their planning to allow them to do some of this up front, which in the long run, over two or three years, is going to produce real benefits for them but in the short run, in delivering their short-term targets, it is not going to help them at all. They are always trying to work both in the short term, what do I have to do this year to deliver the things I have to, and how do I lever some change for the future and where do I find the resources to do that? When you are up against that on a year-on-year basis, the rational response is to deal with the short-term here and now, rather than lever the change for the future, which is actually the more important thing to be doing.

  624. I accept your point entirely. A large part of the budget in this particular area of activity actually spends itself. The scope for discretion is very small because of traditional spending patterns. Dr James, your view of the provision and level of rehabilitative services?
  (Dr James) The level of rehabilitative services is in its infancy at the moment. There are some very good examples around the country of hospital-at-home types of work where people can be discharged very early and reduce the length of stay at the hospital so it frees up the acute bed. People are also having admission avoidance. You have heard the whole list of the expected intermediate care portfolio which we hope to see. It is in its infancy and the frustration is that we are finding it hard to find the money which we hope to use to modernise our services and redevelop these new services in balancing the capacity with the demand all across the health services because of our short-term targets which we have to hit.

Siobhain McDonagh

  625. You argue that the contribution of the whole authority to promoting the independence of older people needs to be better considered and that this should be addressed through the local capacity planning groups. Is this whole system type of approach one which is widespread? If not, how do you believe it can be encouraged?
  (Mr Ransford) It is certainly increasing. There is a general view now that these problems can only be tackled holistically. If you try to concentrate on one part of the issue you might solve that particular indicator, which creates problems elsewhere. With the development of the national service framework, with an understanding that this is a shared issue between health, local authority and a whole range of providers, it needs to be cracked differently. There are two ways of doing it, both of which are quite simple. One is demonstrating what works, demonstrating successes, because there are successes, which might not be immediately exportable from one area of the country to another, but the principles certainly are, that you can use other people's ideas. Traditionally in local government, partly because it is local government, we have been slow to learn lessons developed in other parts of the country for a whole series of reasons. Using every means, using practice example, using publicity, using the internet, using whatever you can to share solutions because everyone is looking to solutions. The second thing we can do is use mechanisms which are being developed mostly for other purposes but it seems to me directly for these purposes: the growth of local strategic partnerships which grew out of neighbourhood renewal, the new responsibility which local authorities have, developing the social, economic and environmental well-being of an area generally so that the local authority, as well as its service role, through social care, through housing, through its different services, has a responsibility to show that this is the need and responsibility of the whole community. We are seeing evidence coming forward, where this is taken seriously at the LSP level and where the local capacity work is done within that context, that there are gains to be had.


  626. One of the issues we have not touched on is the question of cross charging social services and the proposals which have been brought forward recently which may end up with social services effectively being fined for not offering appropriate alternative care to the acute provision. Your views on that Mr Leadbetter.
  (Mr Leadbetter) With the current numbers of people in Essex, it would cost the county council £800,000 per year and we did not hit our target. Two views emerging from the membership. One is that it is a perverse incentive; why do we not incentivise the national service framework if we are looking at incentives? Another one, those councils who are perhaps not prioritising social services would not want to be fined so they may then prioritise social services, so there would be an advantage for S.S.D. in those councils. It is a difficult one to call because we have not seen any detail of what the scheme might look like. We have contacted Sweden. We were told ten years ago when it was introduced that there was some evidence that it was effective. However, when you look further in Sweden, there is still the exact same number of delayed discharges in Sweden per population as there is in England. The best we can say is that the jury is out, although the new money also needs looking at because there are different perceptions of how much that will actually be.
  (Dr Morgan) We talk to our members. What they say is that it is right to have incentives and we need joint incentives between the two organisations, but the majority view we are getting back is that people do not believe it is an effective incentive and that in places which have worked hard to have good relationships it could bring contesting back rather than partnership.

  627. It could be counterproductive.
  (Dr Morgan) It could be counterproductive.
  (Dr James) If health fining social services is the Department's answer to facilitating partnership working, then we have a long way to go.
  (Mr Ransford) I would agree with all those points. The Local Government Association was disappointed that the Secretary of State did not talk to us first before he announced the intention to legislate. We understand that it is based on a Scandinavian system with different governance, different charging regimes. We are equally committed to everyone else to ensure we get the right incentives in the system and trying out things which will make a difference, but we fear this will act as a very big perverse incentive as explained to us so far.

  Chairman: A clear thumbs down from all our witnesses.

Dr Taylor

  628. Looking at last towards the solutions, we have already heard about partnerships and whole system approaches and that they are increasing and beginning to work. The ADSS recommend health planning be refocused around 24-hour, seven-days-a-week primary care services. Can you expand on that briefly?
  (Mr Leadbetter) GPs are pivotal in this: how we engage GPs in community networks, how we make sure that we focus on the aims of the NHS, strokes, falls, dementia and intermediate care. Whether that means configuring services around GPs or asking GPs to come into community services, it needs to be a GP primary care led service. To endorse the comments other colleagues made about trying to shift the emphasis from acute, acute just swallows up resource after resource and we need it at primary care community level.

  629. Do you think GPs need to take more responsibility for what actually goes on in secondary care?
  (Mr Leadbetter) Yes.

Dr Naysmith

  630. The NHS Alliance argues that there needs to be a revised focus, less on faster acute services and more on planned patient throughput and active patient management. That has come up this afternoon from a lot of witnesses. They argue that primary care should be responsible for co-ordinating care and managing the patient through the system of care. Could all four of you comment on what you think the primary care trusts will do for what we have been talking about this afternoon? Could you particularly say what changes we need to bring about in the system to bring about what you are asking for?
  (Dr James) As an example, in Southampton we have valve replacement and coronary artery bypass grafting waiting lists managed by the PCT. They are scored by the secondary care clinicians, the PCT decides which patients within their population are called in for operations in the next quarter. That management team is now able to identify discharge problems before they are even admitted and we have delayed people for a month from going into hospital for the operation while we are discharge planning, so we know when they go in that they will come out. At the moment discharge processes are like pushing a piece of string: a series of delays. We need throughput so we are getting primary care management knowing the clinical and social circumstances, pulling people into secondary care but pulling them out again to get that throughput going. We need the intelligence on both sides, pre-admission and post-admission.

  631. Do primary care trusts help in this?
  (Dr James) I think primary care trusts are pivotal to this. GPs are important but GPs are not the only people in primary care trusts. Primary care trusts are now much wider than they were when they started becoming primary care groups. Primary care trusts, with their association with social services, are the organisation to manage not only people with their best level of independence, but once their independence is compromised, to manage the response to that, whether it is admission avoidance or getting them into hospital and back out, leaving the hospital to do the technical clever doctor stuff.
  (Mr Leadbetter) Primary care trusts are natural partners in our (joint endeavours) lives. We now have somebody locally with clout who encompasses a wide range of services to whom we can speak, have a dialogue and make joint appointments. In a large county we had nobody before. We think that the development of closer collaboration between social services and primary care trusts has to be the way forward.
  (Dr Morgan) I think primary care organisations focused at the right level, where they are close to the appropriate level of local government, offer real opportunity for innovation because they can actually put completely different things together in different packages. My only difference is that I am not entirely sure they should all be focused through the GP. Perhaps one of the ways through some of this dilemma is to be thinking much more dynamically about the whole of the workforce and thinking much more creatively about how we manage the people we know are at most risk. We know who these people are out in the community but we do not intensively manage them before they use services. There are some lessons around that which we can be much more creative about.

  632. It needs a level of organisation, which may happen in Southampton but I know it does not happen everywhere. You can still have people called in for operations and treatments who have died two or three months before and the organisation does not seem to know that. It requires a level of sophisticated communication which I suspect is lacking at the moment in many places.
  (Dr Morgan) Absolutely. To make the thing work, one of the things the NHS needs to do is bring our information systems up into the twenty-first century. We are way off. It is absolutely fundamental. Patient records which follow the patient, to stop us asking questions and doing the same test time after time on the same patients. We are nowhere near it yet.
  (Mr Ransford) If we really are going to have a citizen led service, then primary care is the way forward. The most encouraging thing I find at the moment, if you look at any of the journals where we advertise for staff, is the amount of joint branding there is. There is a huge number of posts, from chief executives through to people working directly with individuals in the community, where the primary care trust and the local authority have come together to provide that service jointly. That will deliver the sort of principles of service that the Chairman is looking for. It is happening now, you do not have to change legislation, the legislation is there. You do not have to change conditions of service, it can be done with goodwill. I think that is one of the most optimistic ways forward.

John Austin

  633. Dr Morgan, you talked about the need to develop a range of flexible options in the community and greater emphasis on prevention, stopping falls, a whole range of issues. We have had some talk about the desirability or otherwise of ring-fencing for funding for those services, but apart from that what is missing from current policies and strategies that actually prevents what you want to see happening?
  (Dr Morgan) Nothing. All the policies are there. The one thing which could be sharpened is the incentive. We do not have the incentives right to reward and celebrate success. If we could put something there, that would be good. There is a second issue which is really important, which is how to build patient choice into this. They are two important policy issues which we are not fully resolved on. If you want to make this work today, you can do it.

  634. You have also said that what we need is an effective way of responding to fluctuations in demand and the ability to turn on beds because beds mean staffing as well. How realistic is it to have that flexibility as we move towards a more acute based service?
  (Dr Morgan) If you begin to think of all the resources within your communities as the opportunity, you can turn on beds by using—a practical example of what we did in the winter—a nursing home and turning it into an early discharge place to run more intensive work and put in nursing staff to work alongside the nursing home. You could use that very rapidly and give a different level of funding. It was not nursing home care, it was an outreach and you could turn that on and off. It means thinking about everything in your community, rather than just the bits which are under your managerial control; the tendency to think in your own box, rather than thinking across the system.
  (Mr Leadbetter) A final message. Please stop doing structural change.

Julia Drown

  635. Both Mr Leadbetter and Dr Morgan have mentioned alternative ways of having incentives. Could you drop us a little line on how you would like those incentives? That would be very useful for the Committee.
  (Mr Leadbetter) Yes.

  Chairman: Are there any burning questions any of my colleagues want to ask? If not, Dr Morgan and gentlemen, may I thank you for a very interesting session? One or two of you have mentioned coming back to us with additional points. We should be very grateful for those. Thank you very much once again for your co-operation.

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