Examination of Witnesses (Questions 340
WEDNESDAY 20 MARCH 2002
340. And you mentioned the availability of IT
systems, and this really comes down to the quality of information
that we are getting, which I think all of you have condemned.
How can that quality of information be improved?
(Professor Swift) If we can get electronic patient
records right, and we can actually make this single assessment
something which is governable and workable, I think there really
is mileage in that.
341. Could I ask you, Professor Swift, on this
issue, I asked a question of witnesses, possibly last week, where
I had been given some information by somebody who works in a hospital
in the West Yorkshire area, where I am from, and they were talking
about, I think, four different bar codes for an individual patient
within the same hospital, is that parallel with your experience,
is that common, that kind of problem?
(Professor Swift) At its worst, quite often, is the
342. So it is quite a common problem, it is
a key issue in this area?
(Professor Swift) Yes, very much so.
343. The reliability of the figures comes back
to just the figures that Andy was talking about with the delayed
discharges in the North West, because they certainly do not mirror
my experience at all. And even the NHS league tables give you
such huge, wide ranges that the quality of the information that
they rest on is very questionable; any ways of improving this,
other than just the wholesale development of IT?
(Mr Dolan) One of the most disturbing figures I have
read for some years was from Professor Aiden Halligan, of the
clinical governance support team, who said the NHS collects five
times more data than the Pentagon. The problem is, and when we
have done reviews in different hospitals, the data is lousy, it
is terrible stuff, you do not know how long the patient has waited
in A&E departments, how long they are going to be waiting
for diagnostics, how long they are going to wait, we just about
know how long they are waiting in the bed, and often after the
event; so, actually, asking the right questions, and probably
fewer of them, might give a richer understanding. But I think
the problem is, what we do is create data for its own sake, what
we do not do is follow the patient's journey through the health
system. One of the questions Mr Burnham asked was about capacity
and numbers; one of the things, and this may be political, or
not, but when we opened so many day case units there was an assumption
made, "Well, we don't need as many hospital beds, because
we have got all this day surgery now." Well, mobility is
changing, demography is changing, the majority of patients need
medical interventions rather than surgical interventions; well,
wiping out the best part of 200,000 beds over a 10-year period
was not going to address the medical care needs. So, in a way,
that was informed by poor information. And Professor Swift was
absolutely right, once we have the electronic patient records,
that will greatly assist the collection of proper data, because
too often patients are waiting for assessments and nobody knows
they are there.
(Dr Dearden) If I can just go back, a whole systems
approach actually needs a whole systems assessment, and one of
the problems, there are two types of assessment, there is the
acute query medical, where there might be a medical problem, and
I will often refer to a consultant for a consultant's opinion
and he will assess medically, but with an older person there is
sometimes the social aspect, there is the nursing aspect, there
is the therapy aspect, and I am not the best person to do that.
And, in Cardiff, we have a thing called ECAS, which is, you send
the person in and they are assessed by a consultant physician,
they are assessed by a physiotherapist, by a social worker, and
the whole thing is talked through and a plan is made up that covers
all their needs. And one of the things that that does is that
we can then say, "Well that person needs acute care,"
or social care, or an intermediate-type thing, or a home-based
one; but the point is that they are assessed by a whole systems
assessment, and so that is a very important part. Now the single
assessment process is fraught with difficulties at the moment,
and I will just highlight one thing, and that is about shared
records; there is no point having four different people doing
four different parts of that assessment if they cannot actually
read what the other person has done.
344. So rather than discharge them, (? you were
more admission priming you say ?), or you did not say that?
(Dr Dearden) I do not like the term admission avoidance,
but you can actually avoid an inappropriate admission, if the
proper assessment is done at stage one, but not just at stage
one but halfway through as well, because when they go into a nursing
or residential home that is often the end of the assessment.
345. Yes, they are stuck in the system?
(Dr Dearden) We need to be assessing them three months
and six months down the line, to see can we bring them back out.
And the other concern about the sharing of information is read
codes; if you type in "myocardial infarction", or heart
attack, you can come up with a list of 10 or 12 different options,
well, you are bound to have 10 or 12 different read codes and
it is going to give you different amounts of information. And
so, quite right, there is a question about the electronic patient
record, which will only be useful when primary care can talk to
all aspects of primary care, secondary care can talk to all aspects
of secondary care, and we can all talk to one another, so A&E
can access it, the information it needs, but a pharmacist can;
and our estimation is that we are five or 10 years away from that
kind of computerisation within the NHS, at the moment. Any other
organisation this size, with the poor degree of IT development
we have now, would have been bankrupted by now.
346. Can I ask, just on this point of shared
records, are you saying that the BMA is not only happy for records
to be shared within the NHS but is happy for records to be shared
with the social workers, with pharmacists, even if that is pharmacists
outside the NHS?
(Dr Dearden) It is not what the BMA is happy with;
this is information about patients, and our concern really is
about patient confidentiality, patients may not want all of their
information shared with all and sundry. So, for example, if a
patient in my area goes to the GU clinic, I do not know about
that, because that is their choice; so the ultimate aim here is
actually that patients have the right to say, "Well that's
confidential, I don't want my GP to know about it." And it
might be good for me to know it, but it is their right not to
have it known. Now that could be in all sorts. Now if you are
going to have electronic patient records you will have staggered
layers of accessibility, so you can access what you need and what
is appropriate for the job that you are doing for the patient.
I think, complete access to someone's information by anybody who
might be able to get to a terminal would not be acceptable to
347. I am not suggesting that.
(Dr Dearden) I am sure you were not, I am sorry.
348. I did not talk about all and sundry, sorry,
I talked about the social workers, the pharmacists, who are trying
to help in the care plan; you were talking yourself about how
you need to be able to share that information, in order to move
(Dr Dearden) I would say, to share the appropriate
information for the task in hand; so, for example, an extreme
example, if someone had syphilis when they were 25, that will
not be necessary, per se, if it is treated and gone, an
issue about where they are living, or social care. If someone
has AIDS, for example, that does not really matter where they
live. So there has to be an appropriate level of access for whatever
task is being undertaken. If a patient says, "You can have
complete access to my records and anything about me," that
is fair enough, but that is about informed consent, which is different
from consent, informed consent is, "I understand what you
need, I understand why you need it, I understand what you have,
and I agree to it." And that really is the fundamental point,
that is the thing that the BMA would want to support, not locking
people out from medical stuff because, "It's our information
and you can't have it because you're not a doctor." That
is not what the BMA supports; it is patient-informed choice about
who knows what about them.
349. It seems to me that, within the NHS, it
is expected, a patient is encouraged to give informed choice to
sharing that record between nurses and doctors, that is okay,
but sometimes there is a real reticence about the social worker
because they are outside the field. Do you think we are moving
beyond that, are there particular things that we need to do in
order to ensure that we move beyond that, because sometimes that
itself is described as an issue why people do not get together
and have meetings; and there is some nodding coming on the left,
which you might want to pick up?
(Dr Dearden) I do not know how much time you want
to spend on the issue. I am sure there is a point where doctors
will say, "That is a medical item of information." And
obviously I am bound by my GMC code, and if I were to break that
confidentiality, without patient consent, then I am hauled up
in front of the General Medical Council and asked why I broke
patient confidentiality; so actually I have a professional, contractual
and an ethical obligation to preserve that confidentiality. So
once we start to talk about electronic patient records then, if
someone has that responsibility, we are going to have to take
that into account, of sharing that information; even if I do it
inadvertently, I am still held accountable, as the doctor.
350. But does not Caldicott balance the confidentiality
issue against getting what is right for patients?
(Dr Dearden) It still comes down to patient consent.
(Mr Dolan) I would respectfully take the view that
that is a somewhat paternalistic approach to patients, and I take
the view that it is the patients' notes, not doctors' notes, not
nurses' notes, and there should be information that people should
not be ashamed of sharing. I entirely support and endorse the
view that if somebody had syphilis when they were 25 that should
not affect anything; not many people have, it has to be said.
And I think what we do, we work on the basis that we should not
share this unless we absolutely have to; and in too many instances
you have got nurses and physios and doctors having three different
sets of notes, and they get lost, and assessments get delayed
and delayed discharges happen. So there is clearly a linear process
of delaying patient discharges, because clinician behaviour actually
is thinking in terms of paternalism, as what is best for the patient,
rather than what we think is best for the patient, rather than,
let us ensure it is the patient
351. Or being scared of litigation?
(Mr Dolan) I think actually you are right. I think
there is a growing risk-aversion in clinician behaviour, which
is thinking in terms of "What impact will this have on me,"
rather than "What impact will this have on the patient,"
and that has a knock-on effect to patient care. And I think we
are in danger of assuming that we know what is better for the
patient than the patient does.
352. I want to move back again to intermediate
care, where, again, there are going to be difficulties about definitions,
because we know that the NHS Plan requires there to be, all care
communities have got to develop a strategic approach to intermediate
care. Now I want to ask Mr Webster, because I am just going to
quote, in a minute, from what was submitted by the Audit Commission,
as you say in your evidence, intermediate care is about much more
than intermediate care beds, and district audit has uncovered
a hugely diverse range of intermediate care schemes across England
and Wales, with an emphasis on inventiveness and problem-solving
at a local level; so what is intermediate care?
(Mr Webster) This is a very difficult thing, is it
not; it has caused quite a lot of confusion.
353. That is why we have got experts like you
(Mr Webster) I think you have also heard evidence
from other places that there is some suspicion that things are
being rebadged as intermediate care, that existed in other forms
before. I think you need to counterbalance that with the fact
that we did discover quite a wide range of different approaches,
many of which were genuinely multi-disciplinary, a lot of which
were very small and genuinely focused on individual patients.
So I think there is some really good work going on out there,
in terms of preventing hospital admission and enabling people
to be more independent. Probably, the definition offered by Ian
Philp, who I think gave evidence to this Committee, is the clearest
one around, which is patient-centred, about rehabilitation and
allowing people to get good, long-term care, being active, I think
being time-limited is very important, if it is intermediate it
has got to be from somewhere to somewhere, has it not, rather
than ongoing, and, as we have already been debating, part of the
whole system. I think that there are some risks in here about
people regarding it just as something for old people, a kind of
ageist sort of service, and possibly that it belongs to a particular
profession, that it is something that only nurses do, for example,
or just somewhere to place people because an acute hospital is
too expensive a place to have them. So I think there are some
risks. But I think our evidence is suggesting that there are some
quite creative models out there, that should be captured, could
be married up with the sort of vision that is set out in a framework.
354. Captured and married up; what do words
like that mean? The Government is putting quite a lot of money
into this; how is it going to identify what are the best kinds
of systems to use, and obviously you say you have studied lots
of different kinds?
(Mr Webster) Some of the work that we are doing clearly
will contribute to that, and we are going to continue doing that;
we are looking at whole system issues and the support for older
people, it is something we continue to work on, we will continue
to report on, so we certainly will contribute to that. But I think
one of the big issues for these things, there seems
355. Are there any approaches that work better
(Mr Webster) There are clearly things that work better
than others in some places. A universal prescription saying, "If
everybody did what they are doing in north Devon . . ." that
will not work, but you can establish that the re-ablement team
in north Devon seems to be getting real outputs, which are good.
(Dr Dearden) Could I make a comment on the electronic
records, just briefly, because we have recently done a piece of
work on data management, which I think has been supplied to you,
which suggests that there are some real data quality issues in
the NHS and that, if electronic patient records by 2005 is going
to be part of the solution, it is a pretty big challenge for a
lot of people who have not really yet started on it.
356. We have got the message already.
(Mr Webster) So I think that we should not put too
much hope in those systems. I put more hope in the capability
of local people to invent good solutions around these sorts of
values that are set out in the intermediate care strategy.
357. Perhaps Dr Dearden can give us what he
was going to say about definitions of intermediate care?
(Dr Dearden) I think the King's Fund had a very good
one, which is relatively simple, which basically said it is moving
from what they describe as "medical dependence" to functional
independence; in other words, becoming functionally as independent
as that person can be. But some people have broken it down that
it is maybe in three areas, that there is a preventative element
to it, there is a pre-hospital element to it and a post-hospital
element to it, and so those are just sort of general areas where
intermediate care can be done. In our conference on Monday, and
I will send you some information, Dr Gillian Parker came and presented
some evidence of the studies, actual, controlled studies, that
have been done on intermediate care, and some of the things that
have been successful and some of the things that have not been,
and actually the number of published studies is fairly low, although
there is lots of very good practice. I think we have made this
point before, that it is quite fragmented; where it works well,
it works exceptionally well, where it has not worked,
358. Where what works well?
(Dr Dearden) Where intermediate-type schemes, sorry,
359. Such as?
(Dr Dearden) For example, things like acute response
teams, which were mentioned before. If someone goes in with a
DVT, a blood clot in your leg, the old things was, you went into
hospital, you were there for five or six days, they gave you heparin
injections, you came out on warfarin; now what happens is, you
go in, you have an assessment, you go out, and a nurse comes to
your home and does those kinds of things. There are also intermediate
care schemes around rehabilitation, which are very much therapist-led,
so not even doctor- or nurse-led. Where those are being done,
and, as I said, I will send you the information on those, actually
the evidence for it is actually still fairly limited, because
it is a fairly new area as well, so we have to take that into
account. But a lot of this is gut feeling on where the needs of