Select Committee on Health Minutes of Evidence


Examination of Witnesses (Questions 220 - 239)

WEDNESDAY 13 MARCH 2002

MS HELENA HERKLOTS, MS TESSA HARDING, MS DIANA WHITWORTH AND MRS JANICE ROBINSON

Julia Drown

  220. Before we move on to intermediate care, can I go back to some of the points Age Concern were raising about the lower level services (which is the way you described it) things like housing adaptations which might stop people going into hospital in the first place. Is there any evidence that that is efficient? Clearly it is a better quality of life for the people concerned but have any studies been done to show it would be a better use of public money to provide the service in the first place?
  (Ms Herklots) Proving prevention is always the big question, is it not? There has been some work. The Department of Health itself when it was introducing prevention grants did some work on good practice and evaluating that. There is also a task group that Anchor Trust set up—the Prevention Task Group—which in particular looked at trying to assess which services were effective in prevention and looking at both the value to the older person using them and to the health and social care system. We would like to see the Department of Health itself fund and carry out a sustained piece of research that really looked at the different forms of preventative services and at the real cost of those. The problem has been that in some of the evaluations in individual services we might have looked at the cost in relation to social services or to the health services, without taking into account the impact on housing or the impact on benefits, the whole range. There have been some small studies in looking at good practice but it is an area which requires further research.

  221. There is no conclusive evidence yet that we as a Committee could point to on this?
  (Ms Herklots) There is certainly evidence of effectiveness of different types of services but they tend to have been studies of those particular services. We can certainly make available to the Committee what we have on that. I am not sure that the sort of evidence you are suggesting does exist, unless colleagues know.
  (Ms Harding) Can I just add one thing to it. I very much agree with what Helena has said and there really is a need for a comprehensive look at costing the benefits and doing a real cost-benefit analysis around early intervention and preventative services, which has not yet been done. Help the Aged is about to publish a study by the University of Leicester on the way that six different local authorities have gone about organising and funding and providing care services for older people and they show, as you would expect, immense variation. They are all subject to funding restraints. Some of them have been able to be more creative than others and that study will be published shortly and we will be happy to make that available. It is not, strictly speaking, about prevention but there are some elements of that in the study.

  222. We would particularly appreciate your ideas in terms of what should be studied, perhaps a list things that might prove fruitful.
  (Mrs Robinson) It is worth mentioning that although there is not so much research in this country, there is masses of research in the US and I think Canada on the financial benefits and outcomes of that very targeted approach to prevention I was talking about, which is largely done by the insurance companies, where you can see by putting in those intensive care packages for high users of the service it reduces the use and improves quality of life. There is quite a lot of trans-Atlantic research on this.
  (Ms Whitworth) If you are starting from such a low level of support in the community, there is an issue about how people just struggle to carry on. That is certainly true amongst carers and there is an issue around quality of life as well as around prevention. Whilst I absolutely agree with what everybody is saying, if you are going to talk about financial benefits or the whole issue of the pressures on the Health Service, I think you need to accept that in all of that there is an issue about people's dignity and about quality of life that needs to be added into any research that you were looking at.

  223. Thank you. Moving to intermediate care I want to ask Age Concern about some of the issues that they raise in the evidence. On the issue of time limited care which we raised earlier, have you come across that as a problem or is it a hypothetical problem that has not yet happened? I am sure you will appreciate why it has been time limited otherwise when, for example, we talk about beds it would be about the provision of more hospital beds. If you support the policy of intermediate care, how would you manage it differently?
  (Ms Herklots) Again, we have had evidence from people in social services who have contacted us and people in Age Concern who are involved in provision of intermediate care services. To give you one example, one Age Concern that works very well with health and social services and provides intermediate care services which seems to be very successful and users are pleased with it, has found in that particular area there is a higher than average rate of readmissions, and those seem to be occurring at about the time intermediate care ends. For us it is an issue of that period and that transition. It is almost saying you need another step down service after intermediate care, because although some of the medical problems may apparently have been dealt with, regaining your confidence is a much more complex thing, it is about psychological support, it is about social support, and where intermediate care needs to be improved is by looking at that sort of transition, looking at what happens after those four or six weeks or one or two weeks. One or two Age Concerns are involved in projects that have done that. For example, they might provide a "forget me not" service at the end of that time, which is a visiting and befriending service which helps to monitor whether the older person is getting on okay and getting the services they need. I can see the sense of having an intensive period of care but people must not be left on their own after that. Of course, some people will take longer than six weeks and will have needed to have made a number of adjustments, first from hospital to an intensive period of help and then from that intensive period of help to the next stage. I think it is that where there are potential problems at the moment. We need to look carefully in monitoring intermediate care at what happens after six weeks and whether that is leading to readmissions.

  224. The other concern you raised was the fact that resources that were supposedly identified for intermediate care might be diverted into other things. Have you got any evidence for that?
  (Ms Herklots) Again it is anecdotal evidence that we have had from people. Social services staff contacted us and they were not clear when the intermediate care funding came through what that was for so it has been channelled to different services. Again, we have had some cases where existing services have been rebadged as intermediate care. That is something to do with accessing that funding but also being able to show that a number of intermediate plans have been developed. That is another area of slight concern we have.

  225. Are these anecdotes such that it is a widespread problem or is it individual circumstances?
  (Ms Herklots) I think the rebadging is probably a significant issue, yes.

Dr Naysmith

  226. We have talked a lot about intermediate care and there is a quotation here from the submission of SPAIN which says intermediate care "is geared to tackle only the most visible tip of the iceberg—older people occupying a hospital bed who need alternative care". Would that be a fair summary of what everybody thinks? It is dealing with short-term care in many cases when these people have got long-term problems and putting them into intermediate care and what that does to them?
  (Ms Harding) There are two issues, one is that a number of older people who would be occupying a hospital bed for one reason or another would not qualify for intermediate care in the first place, they would not be judged suitable for rehabilitation. That would include, for example, quite a high proportion of people with dementia of one kind or another. There are some people who never go into that system in the first place but, secondly, it is very much the question of you get your intensive services and what happens after that. I entirely agree with the point that was made around that. Our point in the SPAIN paper was a little bit different, which is that delayed discharge is a very visible issue in the media and in the political arena. There are waiting lists for social care and for community health services all through the system but we do not see those waiting lists, they are not visible. People who have to qualify, who have to meet the very high eligibility criteria to get access to social care still have to wait in their own homes, either for care in their own homes or for a residential care place. We are concerned also about the quality of care that people get when they do get access to services. If people are in their own homes, they get a level of care which is decided by a notional sum of money which is probably based on the cost of a residential care place to the local authority in that area and that defines the package of care. That is hardly needs-based or person-centred. So there is rationing going on in terms of the quality of care that people get, the amount of care that people get, and whether they qualify for care in the first place. There is rationing all through the system and we simply do not see that; it is hidden.
  (Ms Whitworth) I absolutely echo that. I think one of the things that the issue of delayed hospital discharge—and it is good to use that term and not that very distasteful term of "bed blocking" which has upset many of our members—is that within communities (and I have talked already about carers struggling) we know that carers' assessments are running extremely low. 21 per cent was the figure that came out of the performance framework.

Chairman

  227. Is that n terms of the numbers of carers who are receiving a separate assessment under the law? I meet carers and I ask, "Have you had a separate assessment?" and I have yet to meet one that has had a separate assessment.
  (Ms Whitworth) That is why I think 21 per cent is probably an overstatement of what the percentage is of those who ought to be receiving assessments and what they are getting. The whole area is very, very poorly resourced. We suspect that even if carers were assessed that the crisis that is going on within social care at the moment means that very few of them would be able to receive the support that they need in order to carry on caring. There has been a piecemeal approach. The National Strategy for Carers which has put in some very valuable resources to short breaks for carers has, thankfully, been ring-fenced, but it has been a very piecemeal approach to this. It has not been thought out in any real sense linking it to this wider problem that we are talking about which is the growth of older people within the population, the growing crisis there is for many of us of our generation who are working, who need to think about how we are going to provide the care and support for the older generation, whilst also bringing up children. I absolutely agree with Tessa about SPAIN's remarks on intermediate care.

Dr Naysmith

  228. Do you think the Government is putting too much reliance on it? It is a big part of the Government programme. You can say what you like.
  (Ms Herklots) Intermediate care is an important and useful part of the system. The danger is if we see that as the only solution because I think that would be a mistake. There does need to be a coherent approach which takes into account the needs of carers, which takes into account prevention, which takes into account the need for some intensive support, but just trying to rely on intermediate care to solve the problem will not do that.
  (Ms Harding) Intermediate care is very important. I would not want to knock it at all. We had a long period where older people were simply being discharged from hospital straight into care homes with no attempt at rehabilitation, with no thought they could retain their independence with a little bit of help and input from health and social services. I would not want to detract from what is being done on intermediate care but it is only part of the problem. To put all the resources and attention on intermediate care rather than looking at the whole of the health care system as it affects older people is very much not going to do the job. It is short-sighted, it is too narrow. We need to be looking at primary care services, we need to be looking at the whole range of community health services on which older people rely a very great deal, and we need to be looking at social care as well as part of that whole spectrum. We need to look at the whole system.

  229. I think the Government would say it was doing that.
  (Mrs Robinson) I differ slightly in that I think it is absolutely right for the Government to be putting as much stress as it is on intermediate care. It is a big sector that is very under-developed in this country. We have understood that over the last few years and the money has been put up there. The thing is to implement it now. If we substitute the words "intermediate care", which is a horrible phrase, for "rehabilitation", this process is needed at different stages as people become ill and slightly more frail to help them recover and recuperate. We need a whole range of systems invested in that which are in place for people at different points in their lives. The danger is that by putting a label on it saying you will give most of the new money for that, it allows people (which colleagues have talked about) to dive in and see that as the panacea for everything and they rebadge everything from respite care to assessment centres. I even hear doctors at the King's Fund talking about intermediate care as dental services in the community; it is not. It is not a catch-all. The danger is that we will bring it into disrepute before we have even got it working. What is really important, to go back if I may to this point about short-term stays, we are learning now and we do need to learn how to identify the people who are going to benefit from intermediate care. Not everybody in a delayed discharge bed is going to. We need to select those and we know enough about how to do that. The six-week cut-off, as I understand it, is not an absolute cut-off . You merely have to make the case for why to extend it. Why people are not making the case I do not know, but I can imagine. I think it is absolutely right to keep it short. We know that something like 80 per cent of the people who have gone through intermediate care need two to four weeks maximum.
  (Ms Whitworth) There is an issue about the route that intermediate care comes through via the NHS, and there is a problem that NHS professionals tend to be less aware of the needs of families and carers than social care professionals do, and that is because the traditional role of social workers and others is to move out and work in people's homes. That is one of the issues. Another issue—and I absolutely agree, I would not want to knock it at all—that intermediate care provides a great opportunity to put in place the assessments that need to be done in order to move somebody back home. The care should be that by the time you have reached the end of that six weeks, and it may need to be longer, you are able to move back home possibly being able to be looked after by a member of your family with proper support in place. Unfortunately that is the bit that is missing out of intermediate care.

Dr Taylor

  230. I have always been confused by intermediate care. I am pleased to hear that some of you are saying we should stop using that term and use a more accurate term, for example rehabilitation services, if that is what we mean. To Diana in your evidence you say your concern has always been that carers "should not be seen as the cheap and easy solution to community care". Will intermediate care, or whatever you are going to call it, help carers, is it good news for them, or will it place more demands on them?
  (Ms Whitworth) I may already have answered that but yes it could, if it were done properly, provide a huge support. We were asked earlier a question about how much intermediate care goes into people's homes and I am trying remember but I think the Government's plan said something like 50,000 people would benefit from home care services as a result of investment in intermediate care. I have no idea whether that is true or not and how much intermediate care is done in institutions.

  231. Would that be largely rehabilitation services going into their own homes?
  (Ms Whitworth) What do we mean about rehabilitation? We mean enabling people to live independently, so it means whatever needs to be put in place to enable that to happen. If you put intermediate care in that sort of way as well as in terms of bricks and mortar and institutions—and that is a problem always with the NHS which tends to see things in terms of putting people inside an institution for rehabilitation, which is an interesting contradiction, whereas, of course, a lot of this rehabilitation can go on in the home with the right support. I think there are great opportunities. This is a very exciting initiative. In evaluating it I think it will be very important to ensure that you include some assessment of how families and carers have been involved in the process of intermediate care as well as just the patient.

Chairman

  232. I am conscious that there may be a Division in a few minutes. Can I move to another area which is something which has always interested me which is the division between social and nursing care. Mrs Robinson, you talked in your evidence about the reluctance of health and care agencies to work together. I wondered what your views was and what the other witnesses' views were about the steps that have been taken to try and engender a much closer co-operation? The other issue, which this Committee addressed in the last Parliament, is complete integration. What are your views on bringing the two service organisations completely together? We recommended it in our report last time. The Government so far have not accepted our recommendation but we are hopeful that we can keep pressing them.
  (Mrs Robinson) I am not keen.

  233. You are not keen?
  (Mrs Robinson) Not for organisational integration, no.

Mr Burns

  234. Why not ?
  (Mrs Robinson) I will tell you. We have such a system in Northern Ireland.

Chairman

  235. Not quite.
  (Mrs Robinson) Okay, but we have something similar in Northern Ireland and we have all sorts of boundary problems there and we have the problem of the acute sector raiding the budgets for what they need. It is not a solution, it simply is not; it just creates other boundaries. We have the same tensions between the acute health service and the community health and social care services within the same organisation. So I do not see it as a quick-fix and a solution, quite honestly.

  236. In your evidence you have itemised 22 per cent as relating to social services and NHS failing to agree funding. If that is the same budget for a kick off, that would be helpful?
  (Mrs Robinson) I do not think that is in our evidence although I noticed it in the summary. That is a very interesting figure. What I would want to do is unpick what is going on. We need to look at who those people are and my hunch would be that they are people who have very high, complex health needs as well as social care needs. I would put a lot of money on the fact they are probably people with dementia with a range of complex, chronic conditions where the NHS does have a strong responsibility for care. They may be people with terminal illness. We know that the numbers of those people are increasing. I was quite shocked when I saw that figure.

  237. So you can offer a definition between health and social care?
  (Mrs Robinson) No I cannot.

  238. I do not know how you can defend separate organisations when you cannot define who slots into what organisation. It is beyond me.
  (Mrs Robinson) There are certainly enormous difficulties when you look at individual cases, but you can see there is a whole range of people who can live very well in the community with social care support, home care, day centres, and so forth, with their general practitioner help, and there is not much of a dispute. Where there is a dispute is where there are really heavy and complex health needs as well as social care needs. Maybe we need some other system which is not about having continuing care guidance—

  Chairman: Can I suggest the Committee now adjourns for ten minutes for us to vote. We hope not to detain you for too much longer when we come back.

  The Committee suspended from 17.27 to 17.38 for a division in the House.

Chairman

  239. I am sure I can continue my discussion with Mrs Robinson on this interesting subject. We were discussing the way in which we have two separate departments dealing with the issue of discharges, one that deals with health and one that deals with social care. You accepted that, to be honest, you cannot really distinguish between the two, so how can we ever come up with a policy that is coherent, if you cannot define who does what within the current arrangements?
  (Mrs Robinson) I am going to stand my ground. That is what I am going to do. I think that the real clash and the difficulty of disentangling the two is around personal care—somebody who is going and cleaning your house, or doing your shopping, or helping you with various support activities in a day centre. We probably would not call it health care, even though it is improving people's health and well-being.


 
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