Examination of Witnesses (Questions 620
WEDNESDAY 8 MAY 2002
MR J RANSFORD
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 statisticsfor us this is the
biggest gap in the statistical analysisof 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
(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.
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
(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.
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
629. Do you think GPs need to take more responsibility
for what actually goes on in secondary care?
(Mr Leadbetter) Yes.
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
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
(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.
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 usinga practical example of what we did in the wintera
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
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.