Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 1 - 19)




  1. Colleagues, may I welcome you to this first session of our new inquiry on delayed discharges and welcome our witnesses and express the Committee's thanks to you for coming along today. We are grateful for your written evidence as well. May I ask you each to introduce yourself briefly to the Committee and say a little about the work you do so that we are aware of your contribution?

  (Professor Philp) I am National Director for Older People's Services at the Department of Health responsible for leading the work on rooting out age discrimination from the National Health Service and for implementing the National Service Framework for older people's health and social care services and one day a week I am Professor of Geriatric Medicine at the University of Sheffield.
  (Mr Humphries) Richard Humphries. I have recently been appointed as Director of the Change Agent Team within the Department of Health. This is a team which has been established to provide practical support to local authorities and health colleagues in tackling problems of delayed discharge.
  (Ms Platt) Denise Platt, Chief Inspector, Social Services Inspectorate, but here also as Director of Older People's Services at the Department of Health, a responsibility which spans both health and social care.
  (Mr Gilroy) I am David Gilroy, I am one of Denise Platt's two Deputy Chief Inspectors in the Social Services Inspectorate.
  (Ms Edwards) I am Margaret Edwards. I am Director of Performance for the Department of Health. I am responsible for managing, monitoring and hopefully improving the performance of the NHS; recently appointed, my previous background is as a Trust Chief Executive.

  2. Probably the most appropriate opening question would be: what do we mean by a delayed discharge? Who would like to spell out the terms we are using so we agree broadly that we are talking about the same thing.
  (Mr Gilroy) We do have a definition. It is a definition which is best read rather than read out. I will read it out and if I may I shall give your stenographer a copy of it. I am very happy to respond to questions on it and I may add a few comments when I have read it out. The approach the Department takes is to define a delayed transfer of care as occurring ". . . when a patient is ready for transfer from an acute hospital bed but is still occupying such a bed. A patient is ready for transfer when: (a) a clinical decision has been made that the patient is ready for transfer; (b) a multi-disciplinary team decision has been made that the patient is ready for transfer; and (c) the patient is safe to discharge or transfer. This applies to ALL patients of ALL ages who are occupying an acute bed. The delay starts immediately from the time that the decision in (a) and/or (b) is taken and (c) is satisfied". May I try to interpret that because that is the bit which is hard to do unless it is in front of you? (a) is that a clinical decision has been made that the patient is ready for transfer and (b) is that a multi-disciplinary team decision has been made that the patient is ready for transfer. The stuff about (a) or (b) is because sometimes the clinical decision is taken as a part of the multi-disciplinary team approach and then (b) is satisfied. Where a consultant makes a separate decision not joined up with the multi-disciplinary team approach, both have to be satisfied. That is what that is about.

  3. We are interested in the numbers here and we have some figures from your evidence. You did make some changes in your methods for measuring delay last April. What impact did that have on the numbers in question? What were those changes, briefly?
  (Mr Gilroy) We changed the definition basically . . . . .

  4. How.
  (Mr Gilroy) To this one.

  5. What was it before?
  (Mr Gilroy) No consistent definition was in place which was the problem.

  6. So across the country we had different people being defined as delayed discharges.
  (Mr Gilroy) We had many many different health authorities adopting their own approach to it and that was clearly not making it possible to have any monitoring of the problem.

  7. The change basically was the introduction of a consistent form of definition.
  (Mr Gilroy) Yes.

  Mr Burns: What did changing the definition to the uniform one do to the statistics you kept on the number of people who were bed blocking? Did they go up or did they go down as a result of the change in the definition?

  Chairman: Or did they vary from area to area?

Mr Burns

  8. Presumably they cannot have varied if you brought in a uniform definition throughout the country. Did the figures go up or down?
  (Mr Gilroy) They went up marginally at a national level over a period of a couple of months. Regionally and at local level, they did go up and down because people had either tighter or less tight definitions beforehand and this definition therefore impacted on them somewhat differently. There was a marginal increase nationally during the early months of this financial year.


  9. You talked about all ages. Am I right in understanding that the figures we have are just the over-75s or are they all ages? Are the figures you have given in terms of percentages in your evidence and the figures we had when we did our expenditure inquiry, where we got a figure, as I recall, of an average of 6,000 acute beds blocked in any one day, simply over-75s or all categories?
  (Mr Gilroy) The percentages you have in our memorandum relate to over-75s. The 12 per cent figure as at September last year is the rate of people over 75 who are occupying a hospital bed and who have their discharge delayed. The percentages are for over-75s.

  10. So the real figure of delayed discharges is higher than the official figure.
  (Mr Gilroy) That is correct.

  11. Presumably the difficulties in evolving packages of care subsequent to the acute phase are more acute where we are talking possibly about fitter younger people.
  (Ms Platt) I should just like to say what we understand the figures to be and then come back to your question.

  12. It is helpful at the start for us to understand that we are talking about the same issues.
  (Ms Platt) Absolutely. The figures we get are measured quarterly in the quarterly monitoring statistics collected by the NHS. In September 2001 12 per cent of over-75s in acute beds could have been placed somewhere differently and would have been more appropriately placed somewhere differently.

  13. Could you express that in terms of numbers?
  (Ms Platt) Not off the top of my head. Somebody behind me might pass me a note.

  14. If somebody could pass you that at some point that would be very, very helpful.
  (Ms Platt) 12 per cent of over-75s in acute beds were inappropriately placed in September. That figure has come down progressively since 1997. We are making inroads into this problem although very slowly. 6 per cent of acute beds—not people—were occupied by people of all ages who could have been moved somewhere else. Yes, there might be trickier and complex resource issues about younger people, because we are very often in the arena of people who have had severe accidents, head injuries, those sorts of issues. Our concern about the over-75s is that the delayed discharges here are a symptom that we need to do something about the totality of the system for older people. Actually just homing in on the issue of delayed discharges is concealing that there is a systems issue. That would be our concern.

  15. Can we look at the cost here? I am interested in the welcome initiatives announced by the Government in October: £300 million for councils, building up care capacity through cash-for-change grants. In December there was the additional £425 million which takes us to £725 million. Interestingly, we did a calculation, and it may be a back-of-the-envelope job and I cannot guarantee how accurate it is, but from our expenditure survey, the figure we extrapolated from the information given by the Department of Health was that the average cost of an acute bed per year was £120,000, that according to the information we were given then—and I believe it was for October—6,000 beds were blocked. Multiplied that seemed to be roughly the amount of money that the Government had put in to deal with the problem. Would you accept that?
  (Ms Edwards) I am sorry, I missed part of the question.

  16. We are trying to establish first of all the definition. Mr Gilroy has given us some very helpful information, so we understand what we are talking about. The figures relate partly to the over-75s and partly to all ages. We understand the distinction there. What I am concerned to establish in an attempt to look at the best use of our resources is what it is costing the Health Service to have these people blocking beds. The figure we came up with, a rough calculation from what was provided by the Department in October/November on our expenditure survey, was that at that stage 6,000 beds were blocked, the figure given was that the cost of each bed was £120,000 per year, multiplied that comes to roughly the amount of money the Government has put in to deal with the problem. My concern is, and we are looking at the best use of resources, that it is costing a significant amount of money not to unravel this problem. What I am trying to establish—and I appreciate you may need to take advice on this—is the Department's estimate of the cost of this problem. If we work out the costs, I would humbly suggest the solutions might possibly be a good deal cheaper.
  (Ms Edwards) The principle you are putting forward is correct in the sense that this is not an appropriate use of NHS resources. It does not necessarily always follow in our experience that the actual alternatives are cheaper. What we are working through at the moment is some quite interesting work looking at as you build up intermediate care, as you build up alternatives, the costing not being the main driver. The main driver is appropriateness of care. The biggest issue for us is that we do not want to be creating additional elective capacity and emergency capacity in acute hospitals to keep people who should not be there in them. It is not a financial issue at the moment. Our plan is estimating at the moment a cost neutral shift on the whole of moving these patients into other facilities. What is important is making sure that we get the right facility so we do not build additional acute beds when we do not need them.

  17. I do not want to over-generalise and I fully take the point you are making that there are very different costs involved here. In my area one of the two local authorities I cover has a maximum £250 per week home care package, so we have people stuck in hospital beds because the local authority are not prepared, without all sorts of deliberations, to pay more than £250. We are paying more through the public sector for them to be stuck in hospital. Frankly to me that does not add up. I think we need to do some serious calculation about how we are utilising our money.
  (Ms Edwards) Yes; I accept that.

  18. We may come onto the common budget question in due course. If you are able to come up with some figures, I should be very interested, even if it is after this session.
  (Ms Edwards) Yes, we can do that.
  (Ms Platt) We know the money we have put into social services from the building capacity grant is only tackling the symptom of what we currently have. It was only for two years. As part of the spending review, we clearly have to negotiate for a broader range of resources which can generate the capacity in all local communities, which is not forcing people into boxes just because they exist, but is providing a range of services which support their very different needs. Some of those resources might be utilised to prevent people getting into hospital in the first place. We are doing some of that work in the Department at this minute as part of our spending review proposals and are just finalising them with the Secretary of State. If you asked whether the Department of Health knows how much resolving this problem will cost, we would say to you at this minute that we could give you a variety of models of care which would resolve it, but we know that to resolve it will generate demand for more resources across community health and social care. If you are talking about pooled budgets and looking at money which is locked up in the acute sector at present and redeploying it differently, part of another problem we are trying to solve is by getting older people—and we are talking predominantly here older people—in the right place at the right time we release occupancy in the acute sector which is necessary to deal with the admissions through A&E, the cancelled operations and all those sorts of problem which are elsewhere in the system. It is not "if you take it from here and put it there you do it differently", it is quite a complex whole systems issue.

  19. We understand that. What we should like to do is really lift the debate a little bit on what the full costs are because I am certainly well aware, in fact I have scribbled down on my notes here, that there is an economic cost of a waiting list. Here we are talking about people occupying beds and preventing others coming into hospital, preventing people earning a living, we understand fully that the economic cost has to be estimated.
  (Ms Platt) That is absolutely right. May I just say something about the economic cost to the local authorities that you know very well? An episode of care can be a short period in a hospital in the acute sector. A package of care, whether that is in the community, domiciliary care, residential care or whatever, can be a package which lasts two or three years. Actually the investment you are asking the local authority to make is not just a unit cost on the day and those are the things we are needing to look at.

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