Examination of Witnesses (Questions 540
WEDNESDAY 8 MAY 2002
MR J RANSFORD
540. Getting behind why we are where we are,
in terms of a pecking order of problems, you talk about local
authority finance. Would you say that is the single biggest cause?
(Dr Morgan) No, they are all inter-linked. The biggest
issue is about the alternatives to admission. It is about the
point at which somebody makes a decision to put somebody in a
hospital and it is how we manage that better. Some of that is
within the control of the NHS, it is within the control of GPs,
or hospitals' A&E or ambulances. There is an issue about how
we manage those more effectively, not to put places where the
tendency would be to admit.
541. Do you mean that people are being admitted
to the system who really should not be?
(Dr Morgan) Absolutely. Every audit we carry out suggest
there are people who, if the alternatives were available, could
be managed without the type of care that goes on in an acute hospital.
It is developing the alternatives which would allow you to have
a range of decisions.
542. How many people do you believe are coming
into the system who never should? What kind of numbers? Is it
possible to put a figure on that?
(Dr Morgan) General practice would probably have some
figures. I have seen some audits.
(Dr James) There was a paper in the BMJ in about 1998
which looked at a few across the country. They were suggesting
that of emergency admissions about 20 per cent were avoidable.
543. Is that a consultant referring into A&E?
(Dr James) No, it is referrals into hospital, admissions
into hospital. It is very difficult to draw any big conclusions
from this but the same study showed that about 50 per cent of
bed stays were potentially avoidable.
544. This is suggesting that the problem of
delayed discharges is not principally one of resources or of organisation,
it is one of poor decisions on the ground. Is that what you are
(Dr James) It is probably a symptom of lack of ability
to care for a patient in an holistic way. We have a referral process
and only a few destinations for referrals such that if someone
has a problem, typically an elderly person, that is then medicalised,
even if it is a social problem, which means it is a medical admission
and they go on from there and get disadvantaged from that point.
545. Has there been any success in bearing down
on that figure? If you are saying this is the single biggest problemit
is the first I have really heard of itsurely you would
expect that a lot of attention would have gone into bringing down
those inappropriate referrals. Has there been any success?
(Dr James) I know of very little success. There are
some successes in admission avoidance, there are some good rapid
response teams down in the community particularly with the elderly,
but there are still many services and many health economies which
do not have the range of alternatives such that people are admitted
546. You have used the term "medicalised"
for problems, which is a very interesting term. How much do you
feel that has occurred as a consequence of the difference in investment
in the Health Service as compared with local authorities' social
(Dr James) I am not sure. It is a matter of the difference
in investments. It is still a matter of the way we work independently
of each other. I am talking about health service and social services.
If a health worker, say a GP, at one o'clock in the morning is
called to a patient who has fallen, then their training and response
is a medical one. We do not yet have sufficient joining up of
our services to say that it is actually a social problem and we
can refer it straight to the social services who can arrange district
nurses to care or look after or put this person back to bed. In
the end it turns out that they get admitted.
547. Do you think that the concept of care trusts
might take us some way in that direction? As some of you know,
I have long argued for full integration between NHS and social
services. That position may not be supported all round this table
but do you think care trusts are an option? What are your views
on whether that might address the "medicalisation" concept
that you have floated?
(Dr James) Theoretically care trusts give you the
potential to address and sort this problem out. If there is sufficient
incentive to do this and look at that particularly, then there
is a good chance. Hearing evidence from Northern Ireland, where
they have a single stream of funding for social services and health,
this issue still is not particularly well addressed.
548. As I understand it, they have a single
organisation but separate streams of funding. I am advised they
still have separate budgets.
(Mr Ransford) You and I have discussed this before.
There are two distinct concepts here. One is care trusts and the
other is integration between health and social care. The second
is absolutely essential and the first is one means of delivering
the second. It is absolutely essential that we integrate our effort
to create what has been called here a whole systems approach and
we work towards creating a healthy society and that is much wider
than health and social care. It brings in housing, it brings in
education, it brings in transport, it brings in a healthier environment,
a whole series of different things, which we must align and integrate
to ensure that the citizen in our language gets the right deal.
There is a whole series of ways of doing that. It seems to me
that the flexibilities allowed for bringing local government and
health budgets together used imaginatively can achieve exactly
what we are looking for. If in a local arrangement, a care trust
is seen as the best way of delivering that, that seems to me fine,
but there are other alternatives because the creation of the care
trust, which is part of the NHS, takes it into one organisation
and not the other and loses perhaps some of the benefits of partnership.
There are all the alignment issues which have to be taken into
account as you reorganise. You can achieve that integration in
many ways and we are seeing them coming through now.
(Mr Leadbetter) To give an idea of what is available,
Essex encompasses within its boundaries 11 primary care organisations.
We have chosen in partnership with four of those primary care
organisations to have a single manager, matrix, accountability
to manage health and social care for all elderly people's services
in those four primary care organisations. We have also chosen,
though it is only one eleventh of the solution, to go for a care
trust for older people, also including the district council so
we can encompass sheltered housing, but that is just one solution
of very many and in a proportionate sense it is just one eleventh.
We can explore these options because Essex is a big county. The
thrust is towards integration, partnership, shared workforce planning,
shared budgets, partnership trustswe have two in mental
healthbut not a one-size-fits-all solution.
549. You do not feel that the care trust concept
clouds the debate and restricts you on developing various options?
You still feel that there are options available to explore locally
and you have the freedom to do that presumably.
(Mr Leadbetter) Absolutely.
550. On inappropriately referred patients, is
it a logical step to say that the majority of people who are delayed
discharges are the same people who are inappropriately referred?
Am I right to make that link, that the system does not know how
to cope with people who have fallen between the cracks and there
is no place for them? Is that right?
(Dr Morgan) There will be an overlap because for the
patient who falls over late at night and has no-one to lift them
up, the rational decision, if you are the clinician who cannot
get out of hours cover because of the way the resources are currently
focused, is to admit. Those are going to be the same people who
do not have support networks in the community at the point you
reach the end of the process. These are linked. They are not identical
groups but there is a very strong overlap. The way this links
back into the issue about a whole systems approach and the use
of resources is that the more we use the resources at the other
end, about delayed discharges, getting people out of hospital,
the less we are able to use the resources to put in schemes which
prevent people getting into hospital at the beginning. The problem
with things like delayed discharge on a clinical basis is that
we know the longer we keep somebody in hospital, the less socially
able they are to function at discharge, they are institutionalised.
551. You talk of the lack of capacity in the
community, lack of capacity in the independent sector. Is the
NHS in partnership with local government increasingly looking
at developing its own step-down, intermediate care or even residential
care capacity so that you are more masters of your own destiny,
so that you can move people through the system? Is that something
which is coming?
(Dr Morgan) Yes, there is a lot of debate about intermediate
care and what that really means. People are experimenting with
a range of different models, some of which are at the front end,
stopping people getting into hospital and some of which are about
getting people out at an earlier stage in recovery to allow them
to recover in places without the high-tech sorts of things you
get in an acute hospital which is not the place if you are recovering.
It is fine when you are ill: it is not when you are not ill. All
of those have to be done jointly. Some of the most innovative
schemes are not actually about health and social care, they are
about being able to put aids to daily living into a house very
rapidly, they are about the range of housing options which are
available to people, they are about a range of support systems
which might come from the voluntary sector, about how you help
people maintain their independence. They are quite complex because
you need a mixture of all those things together.
552. You would be relaxed about health resources
being spent on things like that.
(Dr Morgan) It is perfectly appropriate and that is
what primary care organisations are already looking at because
we know that the big place we spend money is the acute sector
and if we want to develop things which actually prevent and manage
things, then getting money out of being spent in the acute sector
is the best place for patients and for the service. You will not
find the NHS has a problem with that. All we have a problem with
is how you link all these complex things together at a local level
when you never have the money to double run. At the heart of this
is the issue about how you get professional confidence. At the
end of the day, once you have got the facilities you have to have
professionals who make decisions and feel safe in making a decision
about an alternative in a world which is increasingly litigious
and things like that. You have to have the services there, demonstrate
they work, teach, learn, gain professional confidence before you
get the big wins. None of the systems has enough of the spare
capacity to allow us to do that in a systematic way. What you
have is 1,000 flowers blooming out there and virtually every community
can take you to half a dozen innovative schemes, but they are
not properly evaluated, they are not linked in yet to a whole-system
approach because of the difficulties in pulling all the different
bits of resources together in a systematic way. It is a complex
553. It was depressing to read in the submission
from the NHS Alliance about the ongoing problems of definition
of delayed discharge. We are all aware that the Department of
Health tried to get over this by laying down a definition which
was supposed to be applicable from April. From your evidence that
is clearly not being used, so you could tell us a bit more about
that perhaps and what you see as an alternative definition. I
have to say I have a concern about trying to pursue other definitions
because you just keep on talking about problems and definitions
rather than getting on and delivering for people. In particular
you say one of the issues was people defining what a multi-disciplinary
team really is. Is that not just people arguing about it for the
sake of it and not getting on delivering the services that everybody
would agree people need?
(Dr James) It is something which can be argued about
and therefore can cause delay if people wish to argue about it.
554. So what is the solution? Surely it is not
about creating an alternative definition, it is about just getting
on and delivering.
(Dr James) My issue with definitions is on two levels.
One is the technical definition itself in that the definition
is well set out in the guidance about situation reports, but there
are local interpretations of that and local differences from that.
The example I gave was of a health authority, which, even though
it reports on a seven-calendar-day wait for social services assessment,
actually allows seven working days to be more reasonable. That
is then compared with another neighbouring local authority which
does not do that. There is disagreement about the readiness to
discharge, disagreement about the health and social needs on discharge
and there is disagreement about what constitutes the multi-disciplinary
team which has to say the patient no longer requires the acute
The Committee suspended from 4.56 pm to 5.08
pm for a division in the House
555. In responding on these issues on definitions
is the definition you are referring to the same as the Department
of Health one, which I know does not seem to refer to seven days
and you are referring to seven days in your definition?
(Dr James) The definition I have been mentioning is
the one where targets are set, where numbers are counted and reports
are made to health authorities and they are collated nationally
as far as I know.
556. Surely it has to be on the Department of
(Dr James) Yes, I should like to think it is.
557. That does not mention seven days.
(Dr James) Ho-hum.
558. We are not going to resolve this today,
are we, unless anybody else can help us?
(Dr Morgan) I am not aware of the seven day figure.
I would have to go back and check.
559. But Dr James uses it in his definition.
(Dr James) The other difficulty is how these figures
are collated. My understanding is that these situation reports
which have to be given to health authorities are collated at health
authority level in terms of the acute trusts. So health authorities
count which hospitals have delayed discharges and they do not
count as a delayed discharge until they have been awaiting social
services assessment for more than seven days. The national collation
is at commissioner level. Nationally you see by primary care trust,
by commissioner, the number of delayed discharges. It is all very
confusing and cloudy.