Examination of Witnesses (Questions 220
WEDNESDAY 13 MARCH 2002
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 upthe Prevention Task
Groupwhich 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
(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
(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
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
(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
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.
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 icebergolder 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
(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 dischargeand
it is good to use that term and not that very distasteful term
of "bed blocking" which has upset many of our membersis
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
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.
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
(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
issueand I absolutely agree, I would not want to knock
it at allthat 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
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 institutionsand 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.
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,
234. Why not ?
(Mrs Robinson) I will tell you. We have such a system
in Northern Ireland.
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
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.
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 caresomebody
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.