Examination of Witnesses (Questions 300-319)
17 MARCH 2005
DR STEPHEN
LADYMAN MP, MRS
ANNE MCDONALD
AND MR
CRAIG MUIR
Q300 Mr Burns: Yes, so you did not meet
the deadline.
Dr Ladyman: That I accept entirely.
However, we did complete within the deadline the same number of
cases as we knew about when the deadline was announced.
Q301 Mr Burns: That is a different issue.
Dr Ladyman: It just so happens
that by the time we reached the deadline there were several thousand
more review cases to be carried out.
Q302 Dr Taylor: Getting back to the national
frameworks and the quality of assessment, last week we did not
hear many concerns about the 28 sets of criteria. The concerns
we heard were the interpretation of these criteria, for example
the representatives from the Alzheimer's Society and from ICAS
said quite clearly that the system was not working. Again, from
the Ombudsman just a few minutes ago, we have got their statement:
"In more than half of the cases examined we found that the
assessments had not been carried out properly" with a list
of the ways that these were not carried out properly. Under the
new national framework, when you are thinking about national assessment
tools will you be recommending just one set which will fit within
the single assessment process?
Dr Ladyman: In my mind—and
we have to work with the National Health Service to identify this—the
key is the single assessment process because that is the way we
can make sure that in the future these reviews are carried out
automatically. Individual patients should not have to understand
this system in order to get their reviews; it should be a process
that is automatically triggered and automatically carried out.
The key to doing that is to have this built in to the single assessment
process. In terms of the toolkits that we provide to do this,
one of the reasons why we have started this review with the strategic
health authorities is first of all to identify best practice,
because some strategic health authorities are saying to us "we
have a system that seems to work perfectly". They may be
wrong about that; the Ombudsman may be giving them a telephone
call in the next few weeks and telling them how wrong they are
about it; but some of them believe they have a system that works
very well. Where people think that, then we obviously want to
adopt that as best practice. Whether it will be one toolkit for
everybody or several toolkits we will have to discuss, because
I am acutely aware of the difference between making assessments
in urban environments compared with rural environments in particular.
One way of doing things might not suit the entire country.
Q303 Dr Taylor: The Ombudsman was very
clear that there are examples of good practice. Is a potential
disadvantage of a robust assessment tool that it really conflicts
with professional judgment, or can you allow space for that?
Dr Ladyman: I do not know whether
my colleagues want to address that because they have been having
the direct conversations with the strategic health authorities.
My instinct is that there does need to be some room for a professional
judgment, but how we build that into an objective process which
presumably the Ombudsman will be keeping a beady eye on over the
next 10 years as well as she has over the last 10 years, is the
question that we have to address. If we can do that and still
end up with objective criteria that everybody understands, then
instinctively I would see that as being necessary. Ultimately
of course professional judgment is part of the assessment. It
needs to be the judgment of a group of professionals rather than
a single professional, but there does have to be space for that
judgment to be expressed.
Ms McDonald: Certainly some of
the SHAs have designed tools that give the general process and
approach, and then there is some room for professional judgment
based on the individual case, because obviously the circumstances
may suggest that what the tool gives you needs to be adjusted.
Q304 Dr Taylor: I was very relieved when
you said, Minister, that the aim of the assessment will be to
produce the same conclusion wherever it is carried out, so you
are aiming for fairness. In relation to timing, with the dissatisfaction
of the way the system is working at the moment, how quickly will
you be able to get the national framework through, and I gather
from one of our advisers that the single assessment process is
not being implemented in the way that was envisaged or at the
speed that the NSF anticipated. Have you any comments on that?
Dr Ladyman: The single assessment
process is being implemented very successfully around the country,
and it is available everywhere. I would have to say that my experience
is that it is working better in some places than others, but it
is a complex process and it would be surprising if, when you needed
to carry out multidisciplinary assessments, it was working perfectly
everywhere. As far as the single assessment process and NHS continuing
care is concerned, we have always made it clear that as part of
the single assessment process, indeed as part of the review for
registered nursing care, there should always be a determination
as to whether NHS continuing care is appropriate as part of that.
What I think we need to find a way of doing is ensure that all
older people undergo the single assessment process. Sometimes
what happens is that there might be ad hoc judgments that
this particular old person is not ill enough to justify going
through the process, and I wonder if that is where some of the
errors get made and people find themselves being discharged without
having gone through the single assessment process, and therefore
without an automatic triggering of the review for NHS continuing
care. That is one of the things I will be wanting us to be looking
at over the year, because as you have already identified in your
evidence, it is no good us just looking at NHS continuing care
as if it stands in isolation; we have to look at it alongside
the other issues like the registered nursing care contribution
and the single assessment process and the way assessments are
carried out in the community by social services departments.
Q305 Dr Taylor: It is reassuring that
you are mentioning that it will always be an automatic process,
because we have had evidence that people who could be eligible
for continuing care are just missing out and not being assessed,
so we would welcome the automatic process.
Dr Ladyman: Anybody being discharged
from an acute ward, especially where the reimbursement system
comes into play, we have given very clear instructions that any
older person being discharged from an acute ward should have gone
through the single assessment process and should have automatically
been considered for NHS continuing care before discharge. We have
given very clear guidance to all acute hospitals along those lines
already.
Q306 Dr Taylor: How do you plan to monitor
that?
Dr Ladyman: Under the national
service framework, the National Director, Professor Philp, monitors
the implementation of the single assessment process; and of course
the healthcare commission have a responsibility to do it; and
also I would be surprised if it was not becoming self-monitoring
in that if somebody is being discharged from an acute bed, who
might be eligible for NHS continuing care, then the local council
will be picking up the bill, except for self-funders. Under those
circumstances, it is in councils' interests, if they think the
person might be eligible for NHS continuing care to make sure
that they have been assessed for NHS continuing care, because
then the council will not be paying the bills.
Q307 Dr Taylor: So this could come to
council scrutiny committees as well.
Dr Ladyman: Absolutely, and I
would encourage scrutiny committees to be looking at how the single
assessment process is working both within their authority and
within the local health service.
Q308 Dr Taylor: Can you give us any idea
how quickly you are going to be able to push the national framework
through so we have a single assessment process, national assessment
tools, agreed criteria? How quickly is it reasonable to think
we can get that through?
Dr Ladyman: You use the word "push".
I want this to be done as quickly as possible. I am worried about
pushing because this is such a complex area, and frankly it has
not been done right and people have suffered as a result of it.
I have said that before and I will say it again. I think the reason
why it happened in the past—and I am not making a political
point here and I am not blaming the previous government for it—was
because decisions were made too quickly without too much thinking.
I am loath to push decision-making. We have got to get this right
this time.
Q309 Dr Taylor: Can I change the word
to "aim"? Six months?
Dr Ladyman: My hope is that a
minister can be sitting here this time next year, explaining how
it has all been sorted out now.
Q310 Dr Taylor: Do you have plans for
a national training programme?
Dr Ladyman: Yes.
Ms McDonald: There are a number
of steps in this. There is awareness by NHS staff, and training
is an important step in that, and it is about bringing consistency
as well. The national framework will have a number of levels,
which includes both the criteria and the assessment tools, but
also a training package and consistent information for users and
patients as well so that we are improving awareness on four different
levels.
Q311 Dr Taylor: So you are aware of the
need for training.
Ms McDonald: Yes.
Q312 Mr Amess: Sadly, the husbands of
two of the constituents who came to the Alzheimer's lobby yesterday
had died, so these decisions that are made about funding are pretty
important, and primary care trust panels and their funding decisions
will be at the centre of this. I wonder what you feel about these
panels. Not all primary care trusts have them. How important do
you feel they are and how do you see them working in the future?
Dr Ladyman: Panels, by definition,
are made up of human-beings, and human-beings make errors and
judgments, and sometimes the judgments are not where you want
them to be. We have to aim for a framework that everybody understands
and aim for systems that can make assessments that are open and
people can see what is happening, and ensure that there is an
understanding by those people who have to go through the system
as to what is going on. Do I think all the panels involved in
these judgments meet those criteria at the moment? No, I do not.
That is where we have to be, and that is what the next year has
to be about—identifying how we get to a position where we
meet those criteria.
Q313 Mr Amess: Will your review address
the role of constitution of these review panels?
Dr Ladyman: Yes, I think everything
is on the table.
Q314 Mr Amess: All up for consideration.
Dr Ladyman: Yes.
Q315 Mr Amess: Can we then move to mental
health. It is a very, very difficult area for us all to consider,
but at the moment it appears that under the current criteria a
great deal of emphasis is put on the physical aspects of disease.
This certainly disadvantages people with dementia. This was highlighted
in the Ombudsman case by Barbara Pointon. Will new criteria take
this into account?
Dr Ladyman: Let us just step back
a second from what you have said. NHS continuing care should become
available to you if you need the involvement on a regular basis
of healthcare professionals in your treatment. That is the criteria.
It is not diagnosis-specific. It does not say, "you have
cancer; you can have NHS continuing care" or "you have
got dementia, you cannot have". People with dementia are
as entitled to NHS continuing care as anybody else. However, the
judgment has to be whether they need, in order to maintain their
condition or to improve their condition the regular involvement
of healthcare professionals. If somebody with dementia does not
need that regular involvement of healthcare professionals, then
they will fall outside the criteria for NHS continuing care. If
they do require the involvement of healthcare professionals, they
will come inside the criteria and they will get their NHS continuing
care, as was the case with Mrs Pointon. She did get for her husband
NHS continuing care. I just take slight issue with you in the
implication of what you are saying, that one type of condition
rather than another benefits from this, whether you have a mental
health problem, whether it is dementia, whether it is a physical
problem, the criteria needs to be around how much involvement
you need from healthcare professionals in order to support your
condition.
Q316 Jim Dowd: This was a point raised
with us yesterday during the lobby, when I am sure most Members
around the table met with constituents. The problem with dementia
is that they need assistance with things that do not require healthcare
professionals, with some of the simpler means of just staying
alive. This would not qualify as healthcare professional assistance,
but because of the nature, as a condition, they fall into that
bracket.
Dr Ladyman: That is right. They
certainly need help with personal care—there is no question
about that. Personal care however, under the current system—and
we will talk about this later no doubt—is a means-tested
service. For the poorest people in society, about a third of them,
we pay all of the costs of their personal care. For another third
we pay some of the costs of their personal care. Another third
we expect to meet the cost of their personal care because they
are people on significant incomes. The alternative is to go down
a route of free personal care. Let me emphasise—I am sorry
that there are no Liberal Democrats here—
Q317 Jim Dowd: Why?
Dr Ladyman: Because I like to
be rude to them to their faces rather than when they are not present.
They deliberately mislead the public and people with Alzheimer's
about what their policy is. Free personal care is not the same
as if you go into residential care or a nursing home having your
fees paid for you. You still have to pay your board and lodging,
and in Scotland you still have to pay your board and lodging.
I suspect if you were to do a poll of all those people from the
Alzheimer's Society who came to see you yesterday, you will find
a large proportion of them think that free personal care and free
long-term care are synonymous. That is, frankly, a callous misinterpretation
of policies on free personal care. Indeed, let me just say that
one of the things we have done in England—when people go
into a care home people say they have to sell their own home to
pay their fees. In England, nobody has had to do that since 2001
because we have given every single council the money to put a
charge on their property to be sold after their death. I am not
saying all councils tell people about it and that all councils
have made it as freely available as they ought to have done, but
it is there. In fact, that is one of the things that would have
to be scrapped in order to pay for free personal care, so under
a system of free personal care more people will end up selling
their homes in order to pay for their care. Secondly, the only
comparative system we have in the UK to compare this with—if
you are receiving care in your own home, once the cost of that
care reaches a point where it is cheaper to put you in a care
home, you are put in a care home. When your care in a care home
reaches the point where it is more expensive to put you in a long-stay
hospital, you are put in a long-stay hospital. NHS continuing
care is not an issue in those parts of the United Kingdom because
it does not exist, because you cannot receive the support Mrs
Pointon got to stay in your own home anywhere else in the United
Kingdom. Mrs Pointon's husband would be in a hospital—end
of story, no argument, no caveats to it. That is one of the ways
that people have misled the lobby and the Alzheimer's Society
about what free personal care means.
Q318 Chairman: In relation to personal
care, particularly with people who have Alzheimer's and dementia,
would you accept that if a person may not necessarily need care
by a registered nurse—would you accept that 25 years ago
a person with those needs would probably be in hospital getting
care?
Dr Ladyman: Yes.
Q319 Chairman: Something very interesting
happened. I am the only politician around the table who is not
standing for re-election, so I am trying to make a genuinely objective
point, that successive governments over a period of 25 years have
allowed a quite profound change that has taken place where people
would have received free nursing care, where they now have to
pay for that nursing care that may indeed be provided by somebody
who is not a registered nurse. Would you accept that that is a
fair point?
Dr Ladyman: I accept there is
a debate around that. In parts of the United Kingdom the long-stay
hospitals have been retained, so they do not need NHS continuing
care. NHS continuing care was introduced as a concept to deal
with the fact that in England policy was to remove the long-stay
hospitals. This was a policy of the previous government which
I happen to agree with—for once. I do not think hospital
is the right place for older people if they can be supported in
the community. Most older people tell me, by a huge, huge majority,
that they want to stay in their own homes for as long as possible.
When they cannot stay in their own homes, they still want to stay
in environments that are close to being like their own homes,
and where they can maintain their independence and dignity. We
will be saying a great deal more about that in the Green Paper
next week. You are right: if you keep the long-stay hospitals,
if you keep a policy that says we are going to institutionalise
old people as soon as they have care needs or as soon as they
become a bit expensive, then you do not need NHS continuing care
and you do not need to be having these complicated debates. Frankly,
I do not think it is an election winner.
Chairman: I am not disagreeing
with you about the models at all; I entirely agree with you. But
if I put to my Yorkshire constituents the issue that 25 years
ago they would receive a form of care for absolutely nothing and
now they are paying for it, one or two people feel a bit aggrieved
about that. That is the point I was making.
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