Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 260 - 279)



  260. Why is that?
  (Ms Herklots) They provide help to older and disabled people in carrying out repairs and adaptations to their homes. Handyperson schemes also provide the sort of smaller repairs or adaptations that you might need, so it might be things like grab rails or those sorts of things, or indeed things like home safety checks actually to go into a person's house and see what sort of risks there might be in terms of perhaps a likelihood of falling. The issue for a lot of these schemes is actually trying to access funding. That can be a particular problem. They quite often spend quite a bit of time fund-raising, when probably they would rather be actually carrying out the work. Health and social services and housing variously fund these sorts of schemes, but in our view there are not enough of them about. For older people it is often quite small things which can make a big difference to their being able to manage at home or not, or their being at risk of needing long-term care or hospitalisation or not. So we would certainly like to see further development of that work and also further work to speed up the adaptation process. In our evidence we refer to the disabled facilities grants system which is an incredibly complex and difficult system for people to manage. The Department of Health and DTLR are currently reviewing that. We very much hope that that system is improved. The current situation is that you get a decision on whether or not you will get a grant within six months, so you wait six months before you even get a decision on whether you are going to get the grant. If you are the sort of person who needs to apply for that grant, you probably need it quite quickly to get some adaptation done, so it is a key area for improvement.

  Chairman: Can I ask a question on that point. From the constituency cases I have had I have come across a problem that has appeared on a number of occasions where the means-testing takes account of the full income of the entire family, and where you have, say, young people living at home in their late teens or early twenties, the amount of contribution under the current scheme has led in a number of instances that I have dealt with to families saying that whereas granny was actually going to remain there with them, she was actually going to go into care instead, because the family were not prepared to care in those circumstances.

  Jim Dowd: The mean so-and-sos! Instead of rewiring their house, stick her in care. That seems unreasonable to me.

  Chairman: We are talking of Yorkshire people, of course!

Julia Drown

  261. What is the difference between the social services authorities and health authorities that have been welcoming and taking on those schemes and those that have not? Is there any pattern there?
  (Ms Herklots) I do not think there is a pattern. From what we have found, I think it is just in some areas that people think more imaginatively about what can help them as workers, as people who work in health and social services. So I think that in some areas people make that connection with housing. We know, for example, some local authorities bring together the different strategies for older people, and are trying to plan in terms of developing strategies for older people and trying to plan in terms of a whole-systems approach where you are looking at the different contributions that can be made. That sort of approach does help to highlight the contribution that housing can make, and if you fund some housing work you can actually save money on your health budget or social services budget. I think that whole-systems approach is certainly one which needs encouraging, because it does lend itself to some more creative solutions around that area.

  262. Where you are putting in bath rails and things like that, do you still have to wait for an official OT assessment for those kinds of things?
  (Ms Herklots) Yes, there is a shortage of OTs, and the problem is waiting for OT assessments.

  263. Do you think it is appropriate always to ask OTs for that assessment? Again, in constituency caseloads you have the carers who say, "I can tell you need a bath rail, why do I have to wait three months for somebody to come along and tell you you need a bath rail?" There is a lot of commonsense there, is there not?
  (Ms Herklots) Yes. I think we need to weigh the balance between where somebody actually does need that professional expertise, because I think we all think we know where we can put the bath rail, but put it in the wrong place and we can actually do more damage. There are projects which are fast-track systems, which have been very successful, so you get the OT involved within the project and you do not get involved in a very long waiting process, you fast-track that and people get some help.

  264. So it is a fast-track system that might help. Would Carers UK like to speak about that issue? I saw you were nodding. Also what do you think can be done to develop domiciliary services, particularly where carers could work and that might help either to defer or avoid hospital admissions?
  (Ms Whitworth) I have said this before already, the whole area of domiciliary care is poorly funded. It is very often actually quite simple measures that need to be taken in order to make life easier or indeed to make care possible. It is not rewiring a house; it is actually something like putting down a few non-slip things under mats, putting up a few rails, putting in a ramp, and life immediately becomes possible. So I would absolutely echo what Helena said.

  265. Would you echo that it may be dangerous not to go through the OT route, because the rail might be put in the wrong place?
  (Ms Whitworth) I think I would be cautious about allowing that. I certainly would not want to advise somebody on where to put a rail myself. These are no doubt the frustrations that people face which should be dealt with.

Jim Dowd

  266. On the handyperson scheme, does this apply to minor repairs, fuses, tap washers, that kind of thing, which are not part of the infrastructure but the kind of things people do need to work to keep older people living on their own?
  (Ms Herklots) It can do. They vary quite a lot in what they cover. That would be part of the agreement on what the services are there to do. Some schemes will provide that sort of help that people need to fix things and make things work and that kind of thing. They do vary. Most of them are more geared to making sure that the person can maintain independence. It is quite difficult to maintain independence if your water does not work or you cannot turn your tap on. So those sorts of things do get included.
  (Ms Whitworth) This issue of simplicity of the solution is really quite important. It is going back to the discussion we were having earlier about personal care. People spend a lot of time talking about personal care and the need to provide personal care in the home, but the family and the person being looked after generally would prefer to provide that personal care themselves. It is other practical things that need to be done—the gardening, washing the nets, the ironing, those things—in order to make it possible to provide the personal care. In thinking about the costing of some of this, it is thinking about what it is that people really want rather than what professionals think people need which is important.


  267. Can I ask witnesses about the issue of advances in new technology and how they may assist with the problems we have been talking about. We are talking about the issue of people who have cut vision who may be discharged into a care setting. I have certainly seen schemes where it is possible to maintain them in their own homes where appropriate mechanisms are fitted that monitor their care, the issue of tele-medicine which we are looking at and on which we are taking evidence later in this inquiry. Do you have any examples of schemes of tele-medicine in the community care setting that may offer ways forward on the issues we are talking about in this inquiry?
  (Mrs Robinson) Not tele-medicine.

  268. Perhaps that is the wrong term. I have been to one particular company who are giving evidence to the Committee where they are able from a central monitoring point with terminals in the homes to maintain people in a very, very intensive way through the carers who are coming tapping into the terminals about care that has been given and they have contact with medics through that. The Committee is very much aware of the potential of these new developments. Somebody who talks about these developments is Mr Austin. He sends me e-mails and I do not get to them and so in the end he rings me up, which seems much simpler in the first place! We are aware of the potential to discharge people into a home setting with the means of monitoring them in that home setting that were not available previously.
  (Mrs Robinson) We do refer to this issue in our report on care and support workers. We are rather cautious about those developments because while on the one hand you are absolutely right, the potential of the technology looks very exciting—safe houses, smart houses, all sorts of things being done at a push of a button—the thing that we at the King's Fund are most concerned about is the surveillance features where as long as the person moves across the ray once every whatever, everything is okay. We felt rather worried about that and felt they had all the potential for being very inhumane. They are keeping a radar watch on some movements when the truth of the matter is for many, many people living on their own who need care and support, it is going to be labour-intensive. They need people with them, to put it shortly. We are cautious about it. Certainly the "smart" house developments are worth exploring but they are costly. On a cautionary note we would counsel anybody doing any of this people sitting at a bank of machines and saying, "If they are moving, everything is okay."

  Chairman: I think I gave the wrong impression. Some of us recognise the potential for future schemes to enable people to choose to be at home otherwise they would be in some form of care setting, intermediate care, or in hospitals. I was talking to somebody about the NHS and this whole area only yesterday, somebody who works in a hospital in West Yorkshire who was saying that there are four separate bar codes on patients in his hospital. It seems we have got some way to go before we start addressing this issue.

Andy Burnham

  269. In the summing up of the Committee's discussions I want to spend some time on the future solutions. We have touched on lots of solutions but there is one issue I would like to put before all the witnesses before us and that is to what extent do you think the changes in the structure of NHS that are about to come in—I am thinking particularly here of primary care trusts—will enable better systems of planning in this area? To what extent do you think it will enable the NHS to get a grip on the issue of delayed discharges and provision of care in the hospital setting? Our inquiry is about the problems which affect the NHS and yet the NHS has very few levers it can pull. These are external factors beyond its control. Do you feel that there is an opportunity with ECTs to come at this problem in a different way?
  (Mrs Robinson) Yes and no is my answer. Yes, the potential is there for primary care trusts to have most of the budget to use it in a different way, but there are huge provisos attached to that. In the short-term I fear that things will get much worse because the truth of the matter is that they are new organisations only just setting up. Most of them do not know where the current resources go. They do not have that information about where the resources are going in the Health Service. Unless they have that information they cannot make any decision about how to move it around.

  270. Do you think they offer an opportunity for more flexible thinking that is not constrained by the old NHS orthodoxies, that we can come at this problem from this way rather than that way?
  (Mrs Robinson) Potentially it does, particularly where you are getting much greater community involvement than you get with health authorities and acute trusts, but I think they are really stymied in terms of how much real flexibility they have got to use money in different ways when so much of it in the NHS is spoken for by increased prescribing charges, increased money for salaries, and so forth. Their room for flexibility is pretty much marginalised.

  271. In giving them more flexibility, are they the people to develop the financial incentives that you mentioned? I would think they would have to come from that bottom-up rather than by way of a top-down system? Do you think that is a possibility?
  (Mrs Robinson) I would be interested in your thinking on that. When I said that, I assumed it would be something government would put in place either by legislation or through instruction from the Department.

  272. When the Committee was in the United States recently we heard of a system which had been set up where hospitals had penalty payments for days patients spent in beds beyond the pre-ordained length of stay for a procedure of the kind for which they were in hospital. Just thinking laterally here, do you think that idea has any merit? Could we take something from that?
  (Mrs Robinson) I do not think I know enough about it. What I do know is that those health maintenance organisations in the States have the power, because they own the budget, to impose those penalties on the hospital system and we do not have that kind of system of managed care in this country. I think we would have to do it rather differently to achieve that bottom-up.

  273. What was interesting in the States is acute trusts had started to invest in their community services so that they could get people out of beds to meet these objectives. The interesting thing is you were saying before if you merged the budget the acute trust would raid it, but in fact it can work the other way and the acute trust starts to think "we need to invest more in the community". Do you see what I mean?
  (Mrs Robinson) That would fit very much with what I was saying about introducing the incentives so there is a penalty on either or both the local authority or the NHS if they do not do X, Y, Z and therefore it would be in their interests to do precisely what you are saying to avoid having to pay the higher charges which will then be levied because they have got someone sitting in a bed when they should not be.

  274. It is part of the problem that there is no incentive for social services to take somebody out of hospital, is it? Is that a real problem?
  (Mrs Robinson) I think that is right. As long as you can say, "If you"—the local authority—"keep that person in this bed, when everyone's agreed it's now your responsibility, and you don't suffer any financial penalty whatsoever," they do not have an incentive to have to do it. If they actually had to pay for the cost of, say, the hospital bed, and that was more than a residential care placement, I think you would find them moving and providing money from somewhere.

  275. Can I put these same issues perhaps to Ms Whitworth?
  (Ms Whitworth) I am slightly worried about penalties being imposed on organisations that are already strapped for cash. I am much more inclined to think in terms of incentives. Certainly you can see that a penalty on the PCT would probably concentrate their minds on discharging people more quickly, but I think they are already fairly concentrated on that. My concern would be about who would pick up the pieces; that actually you would have to put in place proper systems to pick them up. I am not sure that PCTs of themselves can provide the solution. They may provide a good structure within which a solution can be delivered, if resources are made available, but I think the answer is a resource problem and not so much an organisational problem. I think the idea of PCTs, particularly the new developments about patient involvement locally, does actually mean that PCTs will become much more responsive to local needs.

  276. You are not necessarily advocating a penalty system?
  (Ms Whitworth) No, no, I do not. I am engaging in a debate.

  277. I think that in the NHS there is an opportunity to get into this question of incentives, is there not?
  (Ms Whitworth) Yes.

  278. Perhaps Ms Harding would like to comment?
  (Ms Harding) I would agree that PCTs do offer the potential for improved investment in the sort of first-stage services—in social care, in primary care, in community health services—which are very important and very critical for older people. The potential is certainly there. What I think would need to be retained is a sort of breadth of vision that they did not become narrowly focussed either on national targets or on specifically medical definitions of needs and care.

  279. But do you think we might see more health money, so to speak, being spent in a community or social setting?
  (Ms Harding) Yes, we might.

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